1
|
Eregha N, Villalvazo Y, De La Cruz C. Disparities in Breast Reconstruction: An Analysis of Treatment Choices. Ann Plast Surg 2024; 92:S223-S227. [PMID: 38556678 DOI: 10.1097/sap.0000000000003862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
BACKGROUND Breast reconstruction methods vary based on factors such as medical history, breast size, and personal preferences. However, disparities in healthcare exist, and the role race plays in accessing to different reconstruction methods is unclear. This study aimed to investigate the influence of race and/or ethnicity on the type of breast reconstruction chosen. METHODS This retrospective cohort study analyzed the University of Pittsburgh Medical Center Magee Women's Hospital database, including patients who underwent breast cancer surgery from 2011 to 2022. Multivariate analysis examined race, reconstruction, and reconstruction type (P < 0.05). RESULTS The database included 13,260 women with breast cancer; of whom 1763 underwent breast reconstruction. We found that 91.8% of patients were White, 6.8% Black, and 1.24% were of other races (Asian, Chinese, Filipino, Vietnamese, unknown). Reconstruction types were 46.8% implant, 30.1% autologous, and 18.7% combined. Among Black patients, autologous 36.3%, implant 32.2%, and combined 26.4%. In White patients, autologous 29.5%, implant 48%, and combined 18.2%. Among other races, autologous 36.3%, implant 40.9%, and combined 22.7%. In patients who underwent breast reconstruction, 85.2% underwent unilateral and 14.7% of patients underwent bilateral. Among the patients who had bilateral reconstruction, 92.3% were White, 6.1% were Black, and 1.5% were of other ethnicities. CONCLUSIONS Our analysis revealed differences in breast reconstruction methods. Autologous reconstruction was more common among Black patients, and implant-based reconstruction was more common among Whites and other races. Further research is needed to understand the cause of these variations.
Collapse
Affiliation(s)
- Nicole Eregha
- From the Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | | |
Collapse
|
2
|
Gombaut C, Bakovic M, Tran HV, Goldman J, Wallace S, Ranganath B. Simultaneous Free Flap Breast Reconstruction Combined With Contralateral Mastopexy or Breast Reduction: A Propensity-Matched National Surgical Quality Improvement Program Study on Postoperative Outcomes. Ann Plast Surg 2024; 92:S234-S240. [PMID: 38556680 DOI: 10.1097/sap.0000000000003816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
BACKGROUND Simultaneous free flap breast reconstruction combined with contralateral mastopexy or breast reduction can increase patient satisfaction and minimize the need for a second procedure. Surgeon concerns of increases in operative time, postoperative complications, and final breast symmetry may decrease the likelihood of these procedures being done concurrently. This study analyzed postoperative outcomes of simultaneous contralateral mastopexy or breast reduction with free flap breast reconstruction. METHODS By using the American College of Surgeons National Surgical Quality Improvement Program database (2010-2020), we analyzed 2 patient cohorts undergoing (A) free flap breast reconstruction only and (B) free flap breast reconstruction combined with contralateral mastopexy or breast reduction. The preoperative variables assessed included demographic data, comorbidities, and perioperative data. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 602 free flap breast reconstruction patients and 621 with concurrent contralateral operation patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort. RESULTS We identified 11,308 cases who underwent microsurgical free flap breast reconstruction from the American College of Surgeons National Surgical Quality Improvement Program database from the beginning of 2010 to the end of 2020. A total of 621 patients underwent a free flap breast reconstruction combined with contralateral mastopexy or breast reduction. After propensity score matching, there were no significant differences in patient characteristics, perioperative variables or postoperative medical complications between the 2 cohorts. CONCLUSIONS Simultaneous free flap breast reconstruction combined with contralateral mastopexy or breast reduction can be performed safely and effectively without an increase in postoperative complication rates. This can improve surgeon competence in offering this combination of procedures as an option to breast cancer survivors, leading to better patient outcomes in terms of symmetrical and aesthetically pleasing results, reduced costs, and elimination of the need for a second operation.
Collapse
Affiliation(s)
- Cindy Gombaut
- From the George Washington School of Medicine and Health Sciences, Washington, DC
| | | | | | | | | | | |
Collapse
|
3
|
Rochlin D, Matros E, Lee C, Sheckter C. The Financial Impact of S Code Termination for Autologous Breast Reconstruction: Considerations for Patient Access. Plast Reconstr Surg 2024; 153:658e-660e. [PMID: 37566527 PMCID: PMC10858972 DOI: 10.1097/prs.0000000000010983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Affiliation(s)
- Danielle Rochlin
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Clara Lee
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus, OH
| | - Clifford Sheckter
- Division of Plastic and Reconstructive Surgery and S-SPIRE Center, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
4
|
Peterson MN, Giblon RE, Achenbach SJ, Davis JM, TerKonda SP, Crowson CS. The Incidence and Outcomes of Breast Implants Among 1696 Women over more than 50 Years. Aesthetic Plast Surg 2023; 47:2268-2276. [PMID: 37580563 PMCID: PMC10841363 DOI: 10.1007/s00266-023-03535-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/19/2023] [Indexed: 08/16/2023]
Abstract
OBJECTIVE To investigate the incidence of women with breast implants in 1964-2017 MATERIALS AND METHODS: All women with breast implants in Olmsted County, MN between January 1, 1992 and December 31, 2017 were identified, and a comprehensive review of individual medical records was performed, adding to a previously identified cohort of women with breast implants in 1964-1991. Incidence rates were calculated and were age- and sex-adjusted to the US white female 2010 population. RESULTS In 1992-2017, 948 women with breast implants were identified, totaling 1696 Olmsted County, MN women with breast implants in 1964-2017. Overall incidence was 63.3 (95% CI 60.2-66.4) per 100,000 women, but incidence varied significantly over time. Women in 1964-1991 were more likely to have implants for cosmetic reasons and more likely to have silicone implants compared to the 1992-2017 cohort. The overall standardized mortality ratio was 1.17 (95% CI 0.99-1.38) in 1964-1991 and 0.94 (95% CI 0.66-1.29) in 1992-2017. In 1992-2017, breast reconstruction patients had a significantly elevated risk of implant rupture and implant removal versus breast augmentation patients. CONCLUSION The incidence of breast implants among women in Olmsted County, MN has varied drastically over the past five decades, with significant changes in the trends for implant type and reason. The findings of this study may provide further insight regarding how risks associated with implants may vary over time. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Collapse
Affiliation(s)
- Madeline N Peterson
- Division of Rheumatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Rachel E Giblon
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Sara J Achenbach
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - John M Davis
- Division of Rheumatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sarvam P TerKonda
- Division of Plastic and Reconstructive Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Cynthia S Crowson
- Division of Rheumatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
5
|
Malekpour M, Malekpour F, Wang HTH. Breast reconstruction: Review of current autologous and implant-based techniques and long-term oncologic outcome. World J Clin Cases 2023; 11:2201-2212. [PMID: 37122510 PMCID: PMC10131028 DOI: 10.12998/wjcc.v11.i10.2201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/13/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Implant-based reconstruction is the most common method of breast reconstruction. Autologous breast reconstruction is an indispensable option for breast reconstruction demanding keen microsurgical skills and robust anatomical understanding. The reconstructive choice is made by the patient after a discussion with the plastic surgeon covering all the available options. Advantages and disadvantages of each technique along with long-term oncologic outcome are reviewed.
Collapse
Affiliation(s)
- Mahdi Malekpour
- Department of Plastic and Reconstructive Surgery, University of Texas Health San Antonio, San Antonio, TX 78229, United States
| | - Fatemeh Malekpour
- Department of Plastic and Reconstructive Surgery, University of Texas Health San Antonio, San Antonio, TX 78229, United States
| | - Howard Tz-Ho Wang
- Department of Plastic and Reconstructive Surgery, University of Texas Health San Antonio, San Antonio, TX 78229, United States
| |
Collapse
|
6
|
Shammas RL, Gordee A, Lee HJ, Sergesketter AR, Scales CD, Hollenbeck ST, Phillips BT. Complications, Costs, and Healthcare Resource Utilization After Staged, Delayed, and Immediate Free-Flap Breast Reconstruction: A Longitudinal, Claims-Based Analysis. Ann Surg Oncol 2023; 30:2534-2549. [PMID: 36474094 PMCID: PMC9735033 DOI: 10.1245/s10434-022-12896-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/15/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND There is a lack of consensus detailing the optimal approach to free-flap breast reconstruction when considering immediate, delayed, or staged techniques. This study compared costs, complications, and healthcare resource utilization (HCRU) across staged, delayed, and immediate free-flap breast reconstruction. PATIENTS AND METHODS Retrospective study using MarketScan databases to identify women who underwent mastectomies and free-flap reconstructions between 2014 and 2018. Complications, costs, and HCRU [readmission, reoperation, emergency department (ED) visits] occurring 90 days after mastectomy and 90 days after free flap were compared across immediate, delayed, and staged reconstruction. RESULTS Of 3310 women identified, 69.8% underwent immediate, 11.7% underwent delayed, and 18.5% underwent staged free-flap reconstruction. Staged reconstruction was associated with the highest rate (57.8% staged, 42.3% delayed, 32.0% immediate; p < 0.001) and adjusted relative risk [67% higher than immediate (95% CI: 49-87%; p < 0.001)] of surgical complications. Staged displayed the highest HCRU (staged 47.9%, delayed, 38.4%, immediate 25.2%; p < 0.001), with 16.5%, 30.7%, and 26.5% of staged patients experiencing readmission, reoperation, or ED visit, respectively. The adjusted probability of HCRU was 206% higher (95% CI: 156-266%; p < 0.001) for staged compared with immediate. Staged had the highest mean total cost (staged $106,443, delayed $80,667, immediate $76,756; p < 0.001) with regression demonstrating the adjusted mean cost for staged is 31% higher (95% CI: 23-39%; p < 0.001) when compared with immediate. CONCLUSIONS Staged free-flap reconstruction is associated with increased complications, costs, and HCRU, while immediate demonstrated the lowest. The potential esthetic benefits of a staged approach should be balanced with the increased risk for adverse events after surgery.
Collapse
Affiliation(s)
- Ronnie L Shammas
- Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, NC, USA
| | - Alexander Gordee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Amanda R Sergesketter
- Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, NC, USA
| | - Charles D Scales
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Scott T Hollenbeck
- Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brett T Phillips
- Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, NC, USA.
| |
Collapse
|
7
|
The Insurance Landscape for Implant- and Autologous-based Breast Reconstruction in the United States. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4818. [PMID: 36817274 PMCID: PMC9937099 DOI: 10.1097/gox.0000000000004818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/07/2022] [Indexed: 02/19/2023]
Abstract
Insurance coverage of postmastectomy breast reconstruction is mandated in America, regardless of reconstructive modality. Despite enhanced patient-reported outcomes, autologous reconstruction is utilized less than nonautologous reconstruction nationally. Lower reimbursement from Medicare and Medicaid may disincentivize autologous-based reconstruction. This study examines the impact of insurance and sociodemographic factors on breast reconstruction. Methods A retrospective analysis of the Healthcare Cost and Utilization Project National Inpatient Sample Database from 2014 to 2017 was performed. International Classification of Diseases Clinical Modification and Procedure Coding System codes were used to identify patients for inclusion. De-identified sociodemographic and insurance data were analyzed using χ 2, least absolute shrinkage and selection operator regression analysis, and classification trees. Results In total, 31,468 patients were identified for analysis and stratified by reconstructive modality, sociodemographics, insurance, and hospital characteristics. Most patients underwent nonautologous reconstruction (63.2%). Deep inferior epigastric perforator flaps were the most common autologous modality (46.7%). Least absolute shrinkage and selection operator regression identified Black race, urban-teaching hospitals, nonsmoking status, and obesity to be associated with autologous reconstruction. Publicly-insured patients were less likely to undergo autologous reconstruction than privately-insured patients. Within autologous reconstruction, publicly-insured patients were 1.97 (P < 0.001) times as likely to obtain pedicled flaps than free flaps. Black patients were 33% (P < 0.001) less likely to obtain free flaps than White patients. Conclusions Breast reconstruction is influenced by insurance, hospital demographics, and sociodemographic factors. Action to mitigate this health disparity should be undertaken so that surgical decision-making is solely dependent upon medical and anatomic factors.
Collapse
|
8
|
Correlation between Relative Value Units and Operative Time for Flap-Based Reconstruction Procedures. Plast Reconstr Surg 2023; 151:299e-307e. [PMID: 36696331 DOI: 10.1097/prs.0000000000009859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Procedures performed by plastic surgeons tend to generate lower work relative value units (RVUs) compared to other surgical specialties despite their major contributions to hospital revenue. The authors aimed to compare work RVUs allocated to all free flap and pedicled flap reconstruction procedures based on their associated median operative times and discuss implications of these compensation disparities. METHODS A retrospective analysis of deidentified patient data from the American College of Surgeons National Surgical Quality Improvement Program was performed, and relevant CPT codes for flap-based reconstruction were identified from 2011 to 2018. RVU data were assessed using the 2020 National Physician Fee Schedule Relative Value File. The work RVU per unit time was calculated using the median operative time for each procedure. RESULTS A total of 3991 procedures were included in analysis. With increased operative time and surgical complexity, work RVU per minute trended downward. Free-fascial flaps with microvascular anastomosis generated the highest work RVUs per minute among all free flaps (0.114 work RVU/minute). Free-muscle/myocutaneous flap reconstruction generated the least work RVUs per minute (0.0877 work RVU/minute) among all flap reconstruction procedures. CONCLUSIONS Longer operative procedures for flap-based reconstruction were designated with higher work RVU. Surgeons were reimbursed less per operative unit time for these surgical procedures, however. Specifically, free flaps resulted in reduced compensation in work RVUs per minute compared to pedicled flaps, except in breast reconstruction. More challenging operations have surprisingly resulted in lower compensation, demonstrating the inequalities in reimbursement within and between surgical specialties. Plastic surgeons should be aware of these discrepancies to appropriately advocate for themselves.
Collapse
|
9
|
Narang G, Kellner D, Krambeck A, Humphreys M. Reimbursement of surgical procedures for benign prostatic hyperplasia: are we disincentivizing complex care? Curr Opin Urol 2022; 32:318-323. [PMID: 35249967 DOI: 10.1097/mou.0000000000000978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of how surgical benign prostatic hyperplasia (BPH) procedures are compensated in the United States and the implications of the current reimbursement system on the care of patients. RECENT FINDINGS The resource-based relative value care system is Medicare's current reimbursement model. There is strong evidence that the current system does not adequately account for complex care. Consequently, for BPH surgical procedures, treatment options best suited for complex patients are not adequately reimbursed which may have implications on healthcare delivery and outcomes. SUMMARY Inadequate reimbursement for certain BPH procedures may disincentivize the care of complex patients. Procedures such a holmium laser enucleation of the prostate are well suited for complex patients but have a steep learning curve. The incentive to learn and offer such procedures to complex patients may be unfairly influenced by reimbursement levels, which in the end penalizes patients and the treatments available to them.
Collapse
Affiliation(s)
- Gopal Narang
- Mayo Clinic Arizona Department of Urology, Phoenix, Arizona
| | | | - Amy Krambeck
- Northwestern Department of Urology, Chicago, Illinois, USA
| | | |
Collapse
|
10
|
Is There a Difference in the Diagnosis and Prognosis of Local Recurrence between Autologous Tissue and Implant-Based Breast Reconstruction? Breast J 2022; 2022:9029528. [PMID: 35711889 PMCID: PMC9187269 DOI: 10.1155/2022/9029528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/04/2022] [Accepted: 03/18/2022] [Indexed: 12/03/2022]
Abstract
Introduction Breast reconstruction has become common after total mastectomy; however, certain types of breast reconstruction may be associated with delayed local recurrence or poor survival. Here, we investigated whether there are differences in the diagnosis and prognosis of local recurrence between autologous reconstruction and implant reconstruction. Materials and Methods A retrospective analysis was performed on patients undergoing breast cancer surgery with autologous tissue or immediate implant reconstruction in a single center (January 2003-December 2017). Patient data including the period from cancer surgery to local recurrence diagnosis, tumor size at the time of recurrence, and survival time after cancer surgery and recurrence detection were analyzed. Results There was a significant difference (p = 0.021) in the time from surgery to recurrence between the autologous tissue (1,246 days) and implant (909 days) groups. Recurrence tumor size did not differ (autologous: 1.00 cm2 vs. implant: 0.90 cm2; p = 0.813). Survival time after surgery (p = 0.63) and recurrence detection (p = 0.74) did not statistically significant. Conclusions Statistical difference in the detection time was observed between autologous tissue and implant group. On the other hand, there is no difference in recurrence tumor size or survival time. A further study is necessary to identify the different detection time of local recurrence.
Collapse
|
11
|
Variation in Payment per Work Relative Value Unit for Breast Reconstruction and Nonbreast Microsurgical Reconstruction: An All-Payer Claims Database Analysis. Plast Reconstr Surg 2021; 147:505-513. [PMID: 33587555 DOI: 10.1097/prs.0000000000007679] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Commercial payments for implant-based breast reconstruction have increased within the past decade, whereas reimbursements have stagnated for microsurgical techniques. The physician payment-to-work relative value unit ratio allows for standardization when comparing procedures of differing complexity. This study aimed to characterize payment per work relative value unit for common breast and nonbreast microsurgical procedures. METHODS The Massachusetts All-Payer Claims Database was queried from 2010 to 2014 for Current Procedural Terminology (CPT) codes related to microsurgical and breast reconstruction. International Classification of Diseases codes were further used to categorize procedures by anatomical region, including head and neck, breast, trunk, and extremities. Physician payments, both commercial and governmental, were aggregated by anatomical region and CPT code. Payment distributions were described with means and medians and compared using statistical tests. RESULTS Among 3435 commercial claims, distributions of physician payments per work relative value unit for microsurgical and common breast procedures differed only for breast free flaps billed through S codes (p < 0.001). Microsurgical breast procedures (CPT code 19364) had significantly greater median payments per work relative value unit compared to microsurgery of the head and neck, trunk, and upper extremities (p = 0.004). Payment per work relative value unit for common breast and nonbreast microsurgical procedures did not differ significantly among governmental claims (p = 0.103). CONCLUSIONS Adjustment of physician payments by work relative value units did not show significant variability across common breast procedures, except for S codes, suggesting that payments are mostly driven by differences in work relative value units and individual contractual negotiations. Lower payments per work relative value unit for other regions compared to breast suggests an opportunity for negotiation with commercial payers.
Collapse
|
12
|
Sisk GC, Chao AH. Advances in Autologous Breast Reconstruction. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-020-00280-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
13
|
Li Y, Wang X, Thomsen JB, Nahabedian MY, Ishii N, Rozen WM, Long X, Ho YS. Research trends and performances of breast reconstruction: a bibliometric analysis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1529. [PMID: 33313274 PMCID: PMC7729324 DOI: 10.21037/atm-20-3476] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background The need for postmastectomy breast reconstruction surgery has increased dramatically, and significant progress has been made both in implant and autologous based breast reconstruction in recent decades. In this paper, we performed a bibliometric analysis with the aim of providing an overview of the developments in breast reconstruction research and insight into the research trends. Methods We searched the Science Citation Index Expanded database and the Web of Science Core Collection for articles published between 1991 to 2018 in the topic domain, using title, abstract, author keywords, and KeyWords Plus. Four citation indicators TCyear, Cyear, C0 and CPPyear were employed to help analyse the identified articles. Results The number of scientific articles in breast reconstruction in this period steadily increased. It took most articles nearly a decade to hit a plateau in terms of citation counts. Plastic and Reconstructive Surgery, Annals of Plastic Surgery, and Journal of Plastic Reconstructive and Aesthetic Surgery published the largest number of articles on breast reconstruction. Nine of the top ten most prolific publications were based in the USA. The research highlights related to breast reconstruction were implant-based breast reconstruction, deep inferior epigastric perforator (DIEP) flap breast reconstruction, and superficial inferior epigastric artery (SIEA) flap breast reconstruction. Conclusions This bibliometric analysis yielded data on citation number, publication outputs, categories, journals, institutions, countries, research highlights and tendencies. It helps to picture the panorama of breast reconstruction research, and guide the future research work.
Collapse
Affiliation(s)
- Yunzhu Li
- Department of Plastic Surgery, Peking Union Medical College (PUMC) Hospital, PUMC and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaojun Wang
- Department of Plastic Surgery, Peking Union Medical College (PUMC) Hospital, PUMC and Chinese Academy of Medical Sciences, Beijing, China
| | - Jørn Bo Thomsen
- Department of Plastic Surgery, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Denmark
| | - Maurice Y Nahabedian
- Department of Plastic Surgery, Virginia Commonwealth University, Inova Branch, Falls Church, Virginia, USA
| | - Naohiro Ishii
- Department of Plastic and Reconstructive Surgery, International University of Health and Welfare Hospital, Japan
| | - Warren M Rozen
- Department of Plastic and Reconstructive Surgery, Frankston Hospital, Australia
| | - Xiao Long
- Department of Plastic Surgery, Peking Union Medical College (PUMC) Hospital, PUMC and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuh-Shan Ho
- Trend Research Centre, Asia University, Taichung, Taiwan
| |
Collapse
|
14
|
Abstract
The practice of plastic surgery has become more complex. As plastic surgeons face the postgraduate realities of contracts, negotiations, and health system employment, they are frequently unprepared to effectively manage these challenges. Furthermore, many plastic surgery training programs do not emphasize real-world business and policy concerns in residency training. Plastic and Reconstructive Surgery endeavors to provide robust conceptual education and guidance in business and policy to help both private practice and academic plastic surgeons participate in, lead, and shape the future of health care.
Collapse
|
15
|
Immediate versus secondary DIEP flap breast reconstruction: a multicenter outcome study. Arch Gynecol Obstet 2020; 302:1451-1459. [PMID: 32895743 PMCID: PMC7584555 DOI: 10.1007/s00404-020-05779-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/28/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE Immediate breast reconstruction (IBR) at the time of mastectomy is gaining popularity, as studies show no negative impact on recurrence or patient survival, but better aesthetic outcome, less psychological distress and lower treatment costs. Using the largest database available in Europe, the presented study compared outcomes and complications of IBR vs. delayed breast reconstruction (DBR). METHODS 3926 female patients underwent 4577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups according to the time of reconstruction: an IBR and a DBR group. Surgical complications were accounted for and the groups were then compared. RESULTS Overall, the rate of partial-(1.0 versus 1.2 percent of cases; p = 0.706) and total flap loss (2.3 versus 1.9 percent of cases; p = 0.516) showed no significant difference between the groups. The rate of revision surgery was slightly, but significantly lower in the IBR group (7.7 versus 9.8 percent; p = 0.039). Postoperative mobilization was commenced significantly earlier in the IBR group (mobilization on postoperative day 1: 82.1 versus 68.7 percent; p < 0.001), and concordantly the mean length of hospital stay was significantly shorter (7.3 (SD3.7) versus 8.9 (SD13.0) days; p < 0.001). CONCLUSION IBR is feasible and cannot be considered a risk factor for complications or flap outcome. Our results support the current trend towards an increasing number of IBR. Especially in times of economic pressure in health care, the importance of a decrease of hospitalization cannot be overemphasized.
Collapse
|
16
|
Is Our Effort Appropriately Valued? An Analysis of Work Relative Value Units in Immediate Breast Reconstruction. Plast Reconstr Surg 2020; 146:502-508. [DOI: 10.1097/prs.0000000000007054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
17
|
Momoh AO, Griffith KA, Hawley ST, Morrow M, Ward KC, Hamilton AS, Shumway D, Katz SJ, Jagsi R. Postmastectomy Breast Reconstruction: Exploring Plastic Surgeon Practice Patterns and Perspectives. Plast Reconstr Surg 2020; 145:865-876. [PMID: 32221191 PMCID: PMC8099170 DOI: 10.1097/prs.0000000000006627] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Within the multidisciplinary management of breast cancer, variations exist in the reconstructive options offered and care provided. The authors evaluated plastic surgeon perspectives on important issues related to breast cancer management and reconstruction and provide some insight into factors that influence these perspectives. METHODS Women diagnosed with early-stage breast cancer (stages 0 to II) between July of 2013 and September of 2014 were identified through the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries. These women were surveyed and identified their treating plastic surgeons. Surveys were sent to the identified plastic surgeons to collect data on specific reconstruction practices. RESULTS Responses from 134 plastic surgeons (74.4 percent response rate) were received. Immediate reconstruction (79.7 percent) was the most common approach to timing, and expander/implant reconstruction (72.6 percent) was the most common technique reported. Nearly one-third of respondents (32.1 percent) reported that reimbursement influenced the proportion of autologous reconstructions performed. Most (82.8 percent) reported that discussions about contralateral prophylactic mastectomy were initiated by patients. Most surgeons (81.3 to 84.3 percent) felt that good symmetry is achieved with unilateral autologous reconstruction with contralateral symmetry procedures in patients with small or large breasts; a less pronounced majority (62.7 percent) favored unilateral implant reconstructions in patients with large breasts. In patients requiring postmastectomy radiation therapy, one-fourth of the surgeons (27.6 percent) reported that they seldom recommend delayed reconstruction, and 64.9 percent reported recommending immediate expander/implant reconstruction. CONCLUSIONS Reconstructive practices in a modern cohort of plastic surgeons suggest that immediate and implant reconstructions are performed preferentially. Respondents perceived a number of factors, including surgeon training, time spent in the operating room, and insurance reimbursement, to negatively influence the performance of autologous reconstruction.
Collapse
Affiliation(s)
- Adeyiza O Momoh
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Kent A Griffith
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Sarah T Hawley
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Monica Morrow
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Kevin C Ward
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Ann S Hamilton
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Dean Shumway
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Steven J Katz
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| | - Reshma Jagsi
- From the Section of Plastic Surgery, the School of Public Health, Center for Cancer Biostatistics, the Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, the Department of Internal Medicine, and the Department of Health Management and Policy, University of Michigan; Ann Arbor U.S. Department of Veterans Affairs Health Services Research and Development; the Department of Surgery, Memorial Sloan Kettering Cancer Center; the Department of Epidemiology, Emory University, Rollins School of Public Health; and the Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| |
Collapse
|
18
|
Discussion: Postmastectomy Breast Reconstruction: Exploring Plastic Surgeon Practice Patterns and Perspectives. Plast Reconstr Surg 2020; 145:877-878. [PMID: 32221192 DOI: 10.1097/prs.0000000000006628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
19
|
Impact of Physician Payments on Microvascular Breast Reconstruction: An All-Payer Claim Database Analysis. Plast Reconstr Surg 2020; 145:333-339. [PMID: 31985616 DOI: 10.1097/prs.0000000000006453] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction. METHODS The Massachusetts All-Payer Claims Database was queried for women undergoing immediate autologous or implant breast reconstruction from 2010 to 2014. Univariate analyses compared demographic and clinical characteristics between different reconstructive approaches. Logistic regression explored the relative impact of insurance type and physician payments on breast reconstruction modality. RESULTS Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001). CONCLUSIONS Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
Collapse
|
20
|
Is Bigger Better?: The Effect of Hospital Consolidation on Index Hospitalization Costs and Outcomes Among Privately Insured Recipients of Immediate Breast Reconstruction. Ann Surg 2019; 270:681-691. [PMID: 31356269 DOI: 10.1097/sla.0000000000003481] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To examine the relationship between hospital market competition and inpatient costs, procedural markup, inpatient complications, and length of stay among privately insured patients undergoing immediate reconstruction after mastectomy. METHODS A retrospective cross-sectional analysis of privately insured female patients undergoing immediate breast reconstruction in the 2009 to 2011 Nationwide Inpatient Sample was performed. The Herfindahl-Hirschman index was used to describe hospital market competition; associations with outcomes were explored via hierarchical models adjusting for patient, hospital, and market characteristics. RESULTS A weighted total of 42,411 patients were identified; 5920 (14.0%) underwent free flap reconstruction. In uncompetitive markets, 6.8% (n=857) underwent free flap reconstruction, compared with 13.6% (n=2773) in highly competitive markets and 24.6% (n=2290) in moderately competitive markets. For every 5 additional hospitals in a market, adjusted costs were 6.6% higher (95% CI: 2.8%-10.5%), for free flap reconstruction, and 5.1% higher (95% CI: 2.0%-8.4%) for nonfree flap reconstruction. Similarly, higher procedural markup was associated with increased hospital market competition both for nonfree flap reconstruction (5.5% increase, 95% CI: 1.1%-10.1%) and for free flap reconstruction (8.2% increase, 95% CI: 1.8%-15.0%). Notably, there was no association between incidence of inpatient complications or extended length of stay and hospital market competition among either free flap or nonfree flap reconstruction patients. CONCLUSIONS Decreasing market competition was associated with lower inpatient costs and equivocal clinical outcomes. This suggests that some of the economies of scale, access to capital and care delivery efficiencies gained from increased market power following hospital mergers are passed onto payers and consumers as lower costs.
Collapse
|
21
|
The Influence of Physician Payments on the Method of Breast Reconstruction: A National Claims Analysis. Plast Reconstr Surg 2019; 143:1311e-1312e. [PMID: 30907802 DOI: 10.1097/prs.0000000000005659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Reply: The Influence of Physician Payments on the Method of Breast Reconstruction: A National Claims Analysis. Plast Reconstr Surg 2019; 143:1312e-1313e. [PMID: 30907795 DOI: 10.1097/prs.0000000000005660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|