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Berlin NL, Momoh AO. Reconstruction of Chest Wall Defects in Resource-Constrained Settings. Ann Surg Oncol 2024; 31:3572-3574. [PMID: 38498090 DOI: 10.1245/s10434-024-15154-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 02/20/2024] [Indexed: 03/19/2024]
Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Adeyiza O Momoh
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
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2
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Mirza HN, Berlin NL, Sugg KB, Chen JS, Chung KC, Momoh AO. The Impact of Timing of Delayed Autologous Breast Reconstruction following Postmastectomy Radiation Therapy on Postoperative Morbidity. J Reconstr Microsurg 2024; 40:318-328. [PMID: 37751883 DOI: 10.1055/a-2182-1440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND The ideal time to perform reconstruction after the completion of postmastectomy radiation therapy (PMRT) in patients with locally advanced breast cancer is currently unknown. We evaluate the association between the timing of delayed autologous breast reconstruction following PMRT and postoperative complications. METHODS Patients who underwent mastectomy, PMRT, and then delayed autologous breast reconstruction from 2009 to 2016 were identified from the Truven Health MarketScan Research Databases. Timing of reconstruction following PMRT was grouped 0-3, 3-6, 6-12, 12-24, and after 24 months. Multivariable models were used to assess associations between timing of reconstruction following PMRT and key measures of morbidity. RESULTS A total of 1,039 patients met inclusion criteria. The rate of any complications for the analytic cohort was 39.4%, including 13.3% of patients who experienced wound complications and 11.3% of patients requiring additional flaps. Unadjusted rates of complications increased from 23.4% between 0 and 3 months to 49.4% between 3 and 6 months and decreased thereafter. Need for additional flaps was highest within 3 to 6 months (14.0%). Multivariate analysis revealed higher rates of any complications when reconstruction was performed between 3 and 6 months (odds ratio [OR]: 3.04, p < 0.001), 6 and 12 months (OR: 2.66, p < 0.001), or 12 and 24 months (OR: 2.13, p = 0.001) after PMRT. No difference in complications were noted in reconstructions performed after 24 months compared with those performed before 3 months (p > 0.05). However, rates of wound complications were least likely in reconstructions after 24 months (OR: 0.34, p = 0.035). CONCLUSION These findings suggest plastic surgeons may consider performing autologous breast reconstruction early for select patients, before 3 months following PMRT without increasing postoperative morbidity.
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Affiliation(s)
- Humza N Mirza
- Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Nicholas L Berlin
- Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kristoffer B Sugg
- Department of Surgery, St. Joseph's Mercy Hospital, Ann Arbor, Michigan
| | - Jung-Shen Chen
- Center for Artificial Intelligence Research in Medicine, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kevin C Chung
- Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
| | - Adeyiza O Momoh
- Section of Plastic and Reconstructive Surgery, University of Michigan, Ann Arbor, Michigan
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Hider AM, Gomez-Rexrode AE, Agius J, MacEachern MP, Ibrahim AM, Regenbogen SE, Berlin NL. Association of bundled payments with spending, utilization, and quality for surgical conditions: A scoping review. Am J Surg 2024; 229:83-91. [PMID: 38148257 DOI: 10.1016/j.amjsurg.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/17/2023] [Accepted: 12/09/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVES To assess the body of literature examining episode-based bundled payment models effect on health care spending, utilization, and quality of care for surgical conditions. BACKGROUND SUMMARY Episode-based bundled payments were developed as a strategy to lower healthcare spending and improve coordination across phases of healthcare. Surgical conditions may be well-suited targets for bundled payments because they often have defined periods of care and widely variable healthcare spending. In bundled payment models, hospitals receive financial incentives to reduce spending on care provided to patients during a predefined clinical episode. Despite the recent proliferation of bundles for surgical conditions, a collective understanding of their effect is not yet clear. METHODS A scoping review was conducted, and four databases were queried from inception through September 27, 2021, with search strings for bundled payments and surgery. All studies were screened independently by two authors for inclusion. RESULTS Our search strategy yielded a total of 879 unique articles of which 222 underwent a full-text review and 28 met final inclusion criteria. Of these studies, most (23 of 28) evaluated the impact of voluntary bundled payments in orthopedic surgery and found that bundled payments are associated with reduced spending on total care episodes, attributed primarily to decreases in post-acute care spending. Despite reduced spending, clinical outcomes (e.g., readmissions, complications, and mortality) were not worsened by participation. Evidence supporting the effects of bundled payments on cost and clinical outcomes in other non-orthopedic surgical conditions remains limited. CONCLUSIONS Present evaluations of bundled payments primarily focus on orthopedic conditions and demonstrate cost savings without compromising clinical outcomes. Evidence for the effect of bundles on other surgical conditions and implications for quality and access to care remain limited.
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Affiliation(s)
- Ahmad M Hider
- University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Josh Agius
- University of Michigan, Ann Arbor, MI, USA
| | - Mark P MacEachern
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
| | - Andrew M Ibrahim
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Scott E Regenbogen
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA.
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Berlin NL, Albright BB, Moss HA, Offodile AC. Catastrophic health expenditures, insurance churn, and non-employment among women with breast cancer. JNCI Cancer Spectr 2024; 8:pkae006. [PMID: 38331405 PMCID: PMC11003299 DOI: 10.1093/jncics/pkae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/19/2024] [Accepted: 01/25/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Breast cancer treatment and survivorship entails a complex and expensive continuum of subspecialty care. Our objectives were to assess catastrophic health expenditures, insurance churn, and non-employment among women younger than 65 years who reported a diagnosis of breast cancer. We also evaluated changes in these outcomes related to implementation of the Affordable Care Act. METHODS The data source for this study was the Medical Expenditure Panel Survey (2005-2019), which is a national annual cross-sectional survey of families, providers, and insurers in the United States. To assess the impact of breast cancer, comparisons were made with a matched cohort of women without cancer. We estimated predicted marginal probabilities to quantify the effects of covariates in models for catastrophic health expenditures, insurance churn, and non-employment. RESULTS We identified 1490 respondents younger than 65 years who received care related to breast cancer during the study period, representing a weight-adjusted annual mean of 1 062 129 patients. Approximately 31.8% of women with breast cancer reported health expenditures in excess of 10% of their annual income. In models, the proportion of women with breast cancer who experienced catastrophic health expenditures and non-employment was inversely related to increasing income. During Affordable Care Act implementation, mean number of months of uninsurance decreased and expenditures increased among breast cancer patients. CONCLUSIONS Our study underscores the impact of breast cancer on financial security and opportunities for patients and their families. A multilevel understanding of these issues is needed to design effective and equitable strategies to improve quality of life and survivorship.
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Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin B Albright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - Haley A Moss
- Division of Gynecologic Oncology, Duke University School of Medicine, Durham, NC, USA
| | - Anaeze C Offodile
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Agbafe V, Waljee JF, Berlin NL. A stakeholder model for prioritization and distribution of elective surgery for population health. Am J Surg 2024:S0002-9610(24)00119-3. [PMID: 38378351 DOI: 10.1016/j.amjsurg.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 02/22/2024]
Affiliation(s)
- Victor Agbafe
- University of Michigan Medical School, Ann Arbor, MI, USA; Yale Law School, New Haven, CT, USA.
| | - Jennifer F Waljee
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
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Baglien BD, Ganesh Kumar N, Berlin NL, Hawley ST, Jagsi R, Momoh AO. Financial Toxicity in Breast Reconstruction: The Role of the Surgeon-Patient Cost-of-Care Discussion. Semin Plast Surg 2024; 38:39-47. [PMID: 38495060 PMCID: PMC10942833 DOI: 10.1055/s-0043-1778040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The financial burden of breast cancer treatment and reconstruction is a significant concern for patients. Patient desire for preoperative cost-of-care counseling while navigating the reconstructive process remains unknown. A cross-sectional survey of women from the Love Research Army was conducted. An electronic survey was distributed to women over 18 years of age and at least 1 year after postmastectomy breast reconstruction. Descriptive statistics and multivariable modeling were used to determine desire for and occurrence of cost-of-care discussions, and factors associated with preference for such discussions. Secondary outcomes included the association of financial toxicity with desire for cost discussions. Among 839 women who responded, 620 women (74.1%) did not speak to their plastic surgeon and 480 (57.4%) did not speak to a staff member regarding costs of breast reconstruction. Of the 550 women who reported it would have been helpful to discuss costs, 315 (57.3%) were not engaged in a financial conversation initiated by a health care provider. A greater proportion of women who reported financial toxicity, compared to those who did not, would have preferred to discuss costs with their plastic surgeon (65.2% vs. 43.5%, p < 0.001) or a staff member (75.5% vs. 59.3%, p < 0.001). Among women with financial toxicity, those who had some form of insurance (private, Medicaid, Medicare, "other") were significantly more likely to prefer a cost-of-care discussion ( p < 0.001, p = 0.02, p = 0.05, p = 0.01). Financial discussions about the potential costs of breast reconstruction seldom occurred in this national cohort. Given the reported preference and unmet need for financial discussions by a majority of women, better cost transparency and communication is needed.
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Affiliation(s)
- Brigit D. Baglien
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Nishant Ganesh Kumar
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Nicholas L. Berlin
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Sarah T. Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, Michigan
- Ann Arbor VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Adeyiza O. Momoh
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Berlin NL, Kirch M, Singer DC, Solway E, Malani PN, Kullgren JT. Preoperative Concerns of Older US Adults and Decisions About Elective Surgery. JAMA Netw Open 2024; 7:e2353857. [PMID: 38289606 PMCID: PMC10828908 DOI: 10.1001/jamanetworkopen.2023.53857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/07/2023] [Indexed: 02/01/2024] Open
Abstract
This cross-sectional study examines the preoperative concerns among US adults aged 50 to 80 years who considered elective surgery.
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Affiliation(s)
| | - Matthias Kirch
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Dianne C. Singer
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor
| | - Erica Solway
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Preeti N. Malani
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Jeffrey T. Kullgren
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- School of Public Health, University of Michigan, Ann Arbor
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Berlin NL, Kamdar N, Syrjamaki J, Sears ED. Health-Care Patterns for Three Common Elective Surgeries: Implications for Bundled Payment Models. J Surg Res 2023; 291:414-422. [PMID: 37517349 DOI: 10.1016/j.jss.2023.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 06/08/2023] [Accepted: 06/25/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION The study objectives were to assess the timing, duration, and nature of health-care service utilization before and after three common elective surgical procedures not currently included in federal episode-based bundled payment programs. METHODS We performed a retrospective cohort study of patients undergoing one of three low-risk surgical procedures (breast reduction, upper extremity nerve decompression, and panniculectomy) between 2010 and 2017 using a private insurer's national claims database. All professional and facility billing claims for health-care services were identified during the 12-mo preoperative and 12-mo postoperative periods for each patient. We compared trends in monthly utilization of health-care services to estimate surgery-related utilization patterns with interrupted time series analyses. RESULTS The cohort included 7885 patients receiving breast reduction, 99,404 patients receiving upper extremity nerve decompression, and 955 patients receiving panniculectomy. The mean monthly encounters gradually increased before each procedure, with a gradual decline in services postoperatively. Claims in the preoperative period for all procedures were primarily diagnostic testing and outpatient evaluation and management. There was limited use of postacute care services across the surgical procedures. There were notable differences in service utilization between the three surgeries, including differing inflection points for preoperative services (approximately 7 mo for breast reduction and panniculectomy, compared with at least 9 mo for nerve decompression) and postoperative services (up to 3 mo for panniculectomy and 4 mo for nerve decompression, compared with 6 mo for breast reduction). CONCLUSIONS This study highlights important differences in utilization of health-care services by type of surgery. These findings suggest that prior to expanding episode-based bundled payment models to surgical conditions with limited utilization of postacute care services and fewer complications, the Centers for Medicare and Medicaid Services and private payers should consider tailoring the timing and duration of clinical episodes to individual surgical procedures.
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Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - John Syrjamaki
- Blue Health Intelligence, Blue Cross Blue Shield, Chicago, Illinois
| | - Erika D Sears
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan; Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.
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Kennedy SH, Bekele M, Berlin NL, Ranganathan K, Hamill JB, Haileselassie E, Oppong J, Newman LA, Momoh AO. A Prospective Evaluation of the Quality of Life and Mental Health Implications of Mastectomy Alone on Women in sub-Saharan Africa. Ann Surg 2023; 278:e1080-e1086. [PMID: 37144388 DOI: 10.1097/sla.0000000000005891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
OBJECTIVE Assess quality of life and mental health implications of mastectomy for breast cancer on sub-Saharan African women. BACKGROUND Mortality rates amongst women diagnosed with breast cancer in sub-Saharan Africa (SSA) are high, with disparities in survival relative to women in high income countries partly attributed to advanced disease at presentation. Fears of the sequelae of mastectomy are a prominent reason for presentation delays. There is a critical need to better understand the effects of mastectomy on women in SSA to inform preoperative counseling and education for women with breast cancer. METHODS Women with breast cancer in Ghana and Ethiopia undergoing mastectomy were followed prospectively. Breast related quality-of-life and mental health measures were evaluated preoperatively, 3 and 6 months postoperatively, using BREAST-Q, PHQ-9, and GAD-7. Bivariate and logistic regression analyses evaluated changes in these measures for the total cohort and between sites. RESULTS A total of 133 women from Ghana and Ethiopia were recruited. The majority of women presented with unilateral disease (99%) and underwent unilateral mastectomy (98%) with axillary lymph node dissection. Radiation was more common in Ghana ( P <0.001). Across most BREAST-Q subscales, women from both countries reported significantly decreased scores at 3 months postoperative. At 6 months, the combined cohort reported decreased scores for breast satisfaction (mean difference, -3.4). Women in both countries reported similar improvements in anxiety and depression scores postoperatively. CONCLUSIONS Women from Ghana and Ethiopia who underwent mastectomy experienced a decline in breast-related body image while also experiencing decreased levels of depression and anxiety.
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Affiliation(s)
- Sarah H Kennedy
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Mahteme Bekele
- Department of Surgery, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Kavitha Ranganathan
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jennifer B Hamill
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Etsehiwot Haileselassie
- Department of Surgery, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Joseph Oppong
- Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Lisa A Newman
- Department of Surgery, Weill Cornell Medicine, New York, NY
| | - Adeyiza O Momoh
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
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Lane M, Berlin NL, Chung KC, Waljee JF. Strengthening Association through Causal Inference. Plast Reconstr Surg 2023; 152:899-907. [PMID: 37768861 DOI: 10.1097/prs.0000000000010305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
SUMMARY Understanding causal association and inference is critical to study health risks, treatment effectiveness, and the impact of health care interventions. Although defining causality has traditionally been limited to rigorous, experimental contexts, techniques to estimate causality from observational data are highly valuable for clinical questions in which randomization may not be feasible or appropriate. In this review, the authors highlight several methodologic options to deduce causality from observational data, including regression discontinuity, interrupted time series, and difference-in-differences approaches. Understanding the potential applications, assumptions, and limitations of quasi-experimental methods for observational data can expand our interpretation of causal relationships for surgical conditions.
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Affiliation(s)
- Megan Lane
- From the Section of Plastic and Reconstructive Surgery, University of Michigan Health System
| | - Nicholas L Berlin
- From the Section of Plastic and Reconstructive Surgery, University of Michigan Health System
| | - Kevin C Chung
- the Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School
| | - Jennifer F Waljee
- From the Section of Plastic and Reconstructive Surgery, University of Michigan Health System
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Berlin NL, Matros E. Discussion: Extended Venous Thromboembolism Chemoprophylaxis following Microsurgical Breast Reconstruction: Analysis of Trends in Postoperative Anticoagulation. Plast Reconstr Surg 2023; 152:28-30. [PMID: 37382916 DOI: 10.1097/prs.0000000000010189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Affiliation(s)
| | - Evan Matros
- Division of Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center
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Metz AK, Berlin NL, Yost ML, Cheng B, Kerr E, Nathan H, Cuttitta A, Henderson J, Dossett LA. Comprehensive History and Physicals are Common Before Low-Risk Surgery and Associated With Preoperative Test Overuse. J Surg Res 2023; 283:93-101. [PMID: 36399802 DOI: 10.1016/j.jss.2022.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/21/2022] [Accepted: 10/16/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The Centers for Medicare and Medicaid Services (CMS) recently eliminated the requirement for preoperative history and physicals (H&Ps) prior to ambulatory surgery. We sought to assess variations in separately billed preoperative H&P utilization prior to low-risk ambulatory surgery, describe any relationship with preoperative testing, and identify independent predictors of these consultations prior to this policy change to help characterize the potential unnecessary utilization of these consultations and potential unnecessary preoperative testing prior to low-risk surgery. MATERIALS AND METHODS A retrospective cohort study was performed using claims data from a hospital value collaborative in Michigan from January 2015 to June 2019 and included patients undergoing one of three ambulatory procedures: breast lumpectomy, laparoscopic cholecystectomy, and laparoscopic inguinal hernia repair. Rates of preoperative H&P visits within 30 d of surgical procedure were determined. H&P and preoperative testing associations were explored, and patient-level, practice-level, and hospital-level determinants of utilization were assessed with regression models. Risk and reliability-adjusted caterpillar plots were generated to demonstrate hospital-level variations in utilization. RESULTS 50,775 patients were included with 50.5% having a preoperative H&P visit, with these visits being more common for patients with increased comorbidities (1.9 ± 2.2 vs 1.4 ± 1.9; P < 0.0001). Preoperative testing was associated with H&P visits (57.2% vs 41.4%; P < 0.0001). After adjusting for patient case-mix and interhospital and intrahospital variations in H&P visits, utilization remained with significant associations in patients with increased comorbidities. CONCLUSIONS Preoperative H&P visits were common before three low-risk ambulatory surgical procedures across Michigan and were associated with higher rates of low-value preoperative testing, suggesting that preoperative H&P visits may create clinical momentum leading to unnecessary testing. These findings will inform strategies to tailor preoperative care before low-risk surgical procedures and may lead to reduced utilization of low-value preoperative testing.
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Affiliation(s)
- Allan K Metz
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan; National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Monica L Yost
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Bonnie Cheng
- Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan
| | - Eve Kerr
- Michigan Program on Value Enhancement, Ann Arbor, Michigan; VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan; Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Hari Nathan
- National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan; Michigan Value Collaborative, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Anthony Cuttitta
- Michigan Program on Value Enhancement, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - James Henderson
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Lesly A Dossett
- Michigan Program on Value Enhancement, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Shammas RL, Sisk GC, Coroneos CJ, Offodile AC, Largo RD, Momeni A, Berlin NL, Hanson SE, Momoh AO, Nelson JA, Matros E, Rezak K, Phillips BT. Textbook outcomes in DIEP flap breast reconstruction: a Delphi study to establish consensus. Breast Cancer Res Treat 2023; 197:559-568. [PMID: 36441271 PMCID: PMC9892240 DOI: 10.1007/s10549-022-06820-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/16/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Composite measures, like textbook outcomes, may be superior to individual metrics when assessing hospital performance and quality of care. This study utilized a Delphi process to define a textbook outcome in DIEP flap breast reconstruction. METHODS A two-round Delphi survey defined: (1) A textbook outcome, (2) Exclusion criteria for a study population, and (3) Respondent opinion regarding textbook outcomes. An a priori threshold of ≥ 70% agreement among respondents established consensus among the tested statements. RESULTS Out of 85 invitees, 48 responded in the first round and 41 in the second. A textbook outcome was defined as one that meets the following within 90 days: (1) No intraoperative complications, (2) Operative duration ≤ 12 h for bilateral and ≤ 10 h for unilateral/stacked reconstruction, (3) No post-surgical complications requiring re-operation, (4) No surgical site infection requiring IV antibiotics, (5) No readmission, (6) No mortality, (7) No systemic complications, and (8) Length of stay < 5 days. Exclusion criteria for medical and surgical characteristics (e.g., BMI > 40, HgbA1c > 7) and case-volume cut-offs for providers (≥ 21) and institutions (≥ 44) were defined. Most agreed that textbook outcomes should be defined for complex plastic surgery procedures (75%) and utilized to gauge hospital performance for microsurgical breast reconstruction (77%). CONCLUSION This Delphi study identified (1) Key elements of a textbook outcome for DIEP flap breast reconstruction, (2) Exclusion criteria for future studies, and (3) Characterized surgeon opinions regarding the utility of textbook outcomes in serving as quality metric for breast reconstruction care.
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Affiliation(s)
- Ronnie L Shammas
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC, USA
| | - Geoffroy C Sisk
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC, USA
| | | | - Anaeze C Offodile
- Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rene D Largo
- Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, Ca, USA
| | - Nicholas L Berlin
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Summer E Hanson
- Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, USA
| | - Adeyiza O Momoh
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jonas A Nelson
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Evan Matros
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kristen Rezak
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC, USA
| | - Brett T Phillips
- Division of Plastic, Maxillofacial, and Oral Surgery, Duke University, Durham, NC, USA.
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14
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Shashikumar SA, Gulseren B, Berlin NL, Hollingsworth JM, Joynt Maddox KE, Ryan AM. Association of Hospital Participation in Bundled Payments for Care Improvement Advanced With Medicare Spending and Hospital Incentive Payments. JAMA 2022; 328:1616-1623. [PMID: 36282256 PMCID: PMC9597389 DOI: 10.1001/jama.2022.18529] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 09/20/2022] [Indexed: 11/14/2022]
Abstract
Importance Bundled Payments for Care Improvement Advanced (BPCI-A) is a Centers for Medicare & Medicaid Services (CMS) initiative that aims to produce financial savings by incentivizing decreases in clinical spending. Incentives consist of financial bonuses from CMS to hospitals or penalties paid by hospitals to CMS. Objective To investigate the association of hospital participation in BPCI-A with spending, and to characterize hospitals receiving financial bonuses vs penalties. Design, Setting, and Participants Difference-in-differences and cross-sectional analyses of 4 754 139 patient episodes using 2013-2019 US Medicare claims at 694 participating and 2852 nonparticipating hospitals merged with hospital and market characteristics. Exposures BPCI-A model years 1 and 2 (October 1, 2018, through December 31, 2019). Main Outcomes and Measures Hospitals' per-episode spending, CMS gross and net spending, and the incentive allocated to each hospital. Results The study identified 694 participating hospitals. The analysis observed a -$175 change in mean per-episode spending (95% CI, -$378 to $28) and an aggregate spending change of -$75.1 million (95% CI, -$162.1 million to $12.0 million) across the 428 670 episodes in BPCI-A model years 1 and 2. However, CMS disbursed $354.3 million (95% CI, $212.0 million to $496.0 million) more in bonuses than it received in penalties. Hospital participation in BPCI-A was associated with a net loss to CMS of $279.2 million (95% CI, $135.0 million to $423.0 million). Hospitals in the lowest quartile of Medicaid days received a mean penalty of $0.41 million; (95% CI, $0.09 million to $0.72 million), while those in the highest quartile received a mean bonus of $1.57 million; (95% CI, $1.09 million to $2.08 million). Similar patterns were observed for hospitals across increasing quartiles of Disproportionate Share Hospital percentage and of patients from racial and ethnic minority groups. Conclusions and Relevance Among US hospitals measured between 2013 and 2019, participation in BPCI-A was significantly associated with an increase in net CMS spending. Bonuses accrued disproportionately to hospitals providing care for marginalized communities.
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Affiliation(s)
- Sukruth A Shashikumar
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Baris Gulseren
- School of Public Health, University of Michigan, Ann Arbor
- Center for Evaluating Health Reform, University of Michigan, Ann Arbor
| | - Nicholas L Berlin
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor
| | | | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
- Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St Louis, Missouri
- Associate Editor, JAMA
| | - Andrew M Ryan
- School of Public Health, Brown University, Providence, Rhode Island
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15
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Berlin NL, Chopra Z, Bryant A, Agius J, Singh SR, Chhabra KR, Schulz P, West BT, Ryan AM, Kullgren JT. Individualized Out-of-Pocket Price Estimators for "Shoppable" Surgical Procedures: A Nationwide Cross-Sectional Study of US Hospitals. Ann Surg Open 2022; 3:e162. [PMID: 36936723 PMCID: PMC10013173 DOI: 10.1097/as9.0000000000000162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/12/2022] [Indexed: 11/25/2022] Open
Abstract
To estimate the nationwide prevalence of individualized out-of-pocket (OOP) price estimators at US hospitals, characterize patterns of inclusion of 14 specified "shoppable" surgical procedures, and determine hospital-level characteristics associated with estimators that include surgical procedures. Background Price transparency for shoppable surgical services is a key requirement of several recent federal policies, yet the extent to which hospitals provide online OOP price estimators remains unknown. Methods We reviewed a stratified random sample of 485 U.S. hospitals for the presence of a tool to allow patients to estimate individualized OOP expenses for healthcare services. We compared characteristics of hospitals that did and did not offer online price estimators and performed multivariable modeling to identify facility-level predictors of hospitals offering price estimator with and without surgical procedures. Results Nearly two-thirds (66.0%) of hospitals in the final sample (95% confidence interval 61.6%-70.1%) offered an online tool for estimating OOP healthcare expenses. Approximately 58.5% of hospitals included at least one shoppable surgical procedure while around 6.6% of hospitals included all 14 surgical procedures. The most common price reported was laparoscopic cholecystectomy (55.1%), and the least common was recurrent cataract removal (20.0%). Inclusion of surgical procedures varied by total annual surgical volume and health system membership. Only 26.9% of estimators explicitly included professional fees. Conclusions Our findings highlight an ongoing progress in price transparency, as well as key areas for improvement in future policies to help patients make more financially informed decisions about their surgical care.
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Affiliation(s)
- Nicholas L. Berlin
- From the National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Zoey Chopra
- University of Michigan Medical School, Ann Arbor, MI
- University of Michigan, Ann Arbor, MI
| | - Arrice Bryant
- University of Michigan Medical School, Ann Arbor, MI
| | | | - Simone R. Singh
- School of Public Health, University of Michigan, Ann Arbor, MI
| | | | - Paul Schulz
- Institute for Social Research, University of Michigan, Ann Arbor, MI
| | - Brady T. West
- Institute for Social Research, University of Michigan, Ann Arbor, MI
| | - Andrew M. Ryan
- School of Public Health, University of Michigan, Ann Arbor, MI
| | - Jeffrey T. Kullgren
- School of Public Health, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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16
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Agbafe V, Berlin NL, Butler CE, Hawk E, Offodile Ii AC. Prescriptions for Mitigating Climate Change-Related Externalities in Cancer Care: A Surgeon's Perspective. J Clin Oncol 2022; 40:1976-1979. [PMID: 35333584 DOI: 10.1200/jco.21.02581] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Victor Agbafe
- University of Michigan Medical School, Ann Arbor, MI
| | | | - Charles E Butler
- Department of Plastic and Reconstructive Surgery, UT MD Anderson Cancer Center, Houston, TX
| | - Ernest Hawk
- Division of Cancer Prevention and Population Sciences, UT MD Anderson Cancer Center, Houston, TX
| | - Anaeze C Offodile Ii
- Department of Plastic and Reconstructive Surgery, UT MD Anderson Cancer Center, Houston, TX.,Baker Institute for Public Policy, Rice University, Houston, TX
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17
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Berlin NL, Abrahamse P, Momoh AO, Katz SJ, Jagsi R, Hamilton AS, Ward KC, Hawley ST. Perceived financial decline related to breast reconstruction following mastectomy in a diverse population-based cohort. Cancer 2022; 128:1284-1293. [PMID: 34847259 PMCID: PMC8882150 DOI: 10.1002/cncr.34048] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/19/2021] [Accepted: 11/12/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite mandated insurance coverage for breast reconstruction following mastectomy, health care costs are increasingly passed on to women through cost-sharing arrangements and high-deductible health plans. In this population-based study, the authors assessed perceived financial and employment declines related to breast reconstruction following mastectomy. METHODS Women with early-stage breast cancer (stages 0-II) diagnosed between July 2013 and May 2015 who underwent mastectomy were identified through the Surveillance, Epidemiology, and End Results registries of Georgia and Los Angeles and were surveyed. Primary outcome measures included patients' appraisal of their financial and employment status after cancer treatment. Multivariable models evaluated the association between breast reconstruction and primary outcomes. RESULTS Among 883 patients with breast cancer who underwent mastectomy, 44.2% did not undergo breast reconstruction, and 55.8% underwent reconstruction. Overall, 21.9% of the cohort reported being worse off financially since their diagnosis (25.8% with reconstruction vs 16.6% without reconstruction; P = .002). Women who underwent reconstruction reported higher out-of-pocket medical expenses (32.1% vs 15.6% with expenses greater than $5000; P < .001). Reconstruction was independently associated with a perceived decline in financial status (odds ratio, 1.92; 95% confidence interval, 1.15-3.22; P = .013). Among women who were employed at the time of their diagnosis, there was no association between reconstruction and a perceived decline in employment status (P = .927). CONCLUSIONS In this diverse cohort of women who underwent mastectomy, those who elected to undergo reconstruction experienced higher out-of-pocket medical expenses and self-reported financial decline. Patients, providers, and policymakers should be aware of the potential financial implications related to reconstruction despite mandatory insurance coverage.
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Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan.,National Clinician Scholars Program, Institute for Health Policy and Innovation, Ann Arbor, Michigan
| | - Paul Abrahamse
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Adeyiza O Momoh
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven J Katz
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Kevin C Ward
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.,Health Care Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan
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18
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Bredbeck BC, Baskin AS, Wang T, Sinco BR, Berlin NL, Shubeck SP, Mott NM, Greenup RA, Nathan H, Hughes TM, Dossett LA. Incremental Spending Associated with Low-Value Treatments in Older Women with Breast Cancer. Ann Surg Oncol 2022; 29:1051-1059. [PMID: 34554342 DOI: 10.1245/s10434-021-10807-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/31/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND In most women ≥ 70 years old with hormone-receptor-positive breast cancer, axillary staging and adjuvant radiotherapy provide no survival advantage over surgery and hormone therapy alone. Despite recommendations for their omission, sentinel lymph node biopsy (SLNB) and adjuvant radiotherapy rates remain high. While treatment side effects are well documented, less is known about the incremental spending associated with SLNB and adjuvant radiotherapy. METHODS Using a statewide multipayer claims registry, we examined spending associated with breast cancer treatment in a retrospective cohort of women ≥ 70 years old undergoing surgery. RESULTS 9074 women ≥70 years old underwent breast cancer resection between 2012 and 2019, with 78% (n = 7122) receiving SLNB and/or adjuvant radiotherapy within 90 days of surgery. Women undergoing SLNB were more likely to receive radiation (51% vs. 28%; p < 0.001 and OR = 2.68). Average 90-day spending varied substantially based upon treatment received, ranging from US$10,367 (breast-conserving surgery alone) to US$27,370 (mastectomy with SLNB and adjuvant radiotherapy). The relative increases in 90-day treatment spending in the breast-conserving surgery cohort was 65% for SLNB, 82% for adjuvant radiotherapy, and 120% for both treatments. CONCLUSIONS SLNB and adjuvant radiotherapy have significant spending implications in older women with breast cancer, even though they are unlikely to improve survival.
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Affiliation(s)
- Brooke C Bredbeck
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA
| | - Alison S Baskin
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Ton Wang
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA
| | - Brandy R Sinco
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA
| | - Nicholas L Berlin
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA
| | - Sarah P Shubeck
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole M Mott
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | | | - Hari Nathan
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA
| | - Tasha M Hughes
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA.
- Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, MI, USA.
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19
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Hughes TM, Ellsworth B, Berlin NL, Sinco B, Bredbeck B, Baskin A, Wang T, Nathan H, Dossett LA. Statewide Episode Spending Variation of Mastectomy for Breast Cancer. J Am Coll Surg 2022; 234:14-23. [PMID: 35213456 DOI: 10.1097/xcs.0000000000000005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Centralizing complex cancer operations, such as pancreatectomy and esophagectomy, has been shown to increase value, largely due to reduction in complications. For high-volume operations with low complication rates, it is unknown to what degree value varies between facilities, or by what mechanism value may be improved. To identify possible opportunities for value enhancement for such operations, we sought to describe variations in episode spending for mastectomy with a secondary aim of identifying patient- and facility-level determinants of variation. STUDY DESIGN Using the Michigan Value Collaborative risk-adjusted, price-standardized claims data, we evaluated mean spending for patients undergoing mastectomy at 74 facilities (n = 7,342 patients) across the state of Michigan. Primary outcomes were 30- and 90-day episode spending. Using linear mixed models, facility- and patient-level factors were explored for association with spending variability. RESULTS Among 7,342 women treated across 74 facilities, mean 30-day spending by facility ranged from $11,129 to $20,830 (median $14,935). Ninety-day spending ranged from $17,303 to $31,060 (median $23,744). Patient-level factors associated with greater spending included simultaneous breast reconstruction, bilateral surgery, length of stay, and readmission. Among women not undergoing reconstruction, variation persisted, and length of stay, bilateral surgery, and readmission were all associated with increased spending. CONCLUSION Michigan hospitals have significant variation in spending for mastectomy. Reducing length of stay through wider adoption of same-day discharge for mastectomy and reducing the frequency of bilateral surgery may represent opportunities to increase value, without compromising patient safety or oncologic outcomes.
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Affiliation(s)
- Tasha M Hughes
- From the Department of Surgery (Hughes, Berlin, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
| | - Brandon Ellsworth
- the University of Michigan School of Medicine, Ann Arbor, MI (Ellsworth, Baskin)
| | - Nicholas L Berlin
- From the Department of Surgery (Hughes, Berlin, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
| | - Brandy Sinco
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
| | - Brooke Bredbeck
- From the Department of Surgery (Hughes, Berlin, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
| | - Alison Baskin
- the University of Michigan School of Medicine, Ann Arbor, MI (Ellsworth, Baskin)
| | - Ton Wang
- From the Department of Surgery (Hughes, Berlin, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
| | - Hari Nathan
- From the Department of Surgery (Hughes, Berlin, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
| | - Lesly A Dossett
- From the Department of Surgery (Hughes, Berlin, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
- the Center for Healthcare Outcomes and Policy (Hughes, Berlin, Sinco, Bredbeck, Wang, Nathan, Dossett), Michigan Medicine, Ann Arbor, MI
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20
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Hughes TM, Berlin NL, Ellsworth B, Sinco BR, Wang T, Bredbeck B, Dossett LA. Variations in Episode Spending for Breast Cancer Patients Undergoing Mastectomy: Results From a Statewide Value Collaborative. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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21
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Ganesh Kumar N, Berlin NL, Hawley ST, Jagsi R, Momoh AO. Financial Toxicity in Breast Reconstruction: A National Survey of Women Who have Undergone Breast Reconstruction After Mastectomy. Ann Surg Oncol 2021; 29:535-544. [PMID: 34480284 DOI: 10.1245/s10434-021-10708-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/29/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite awareness regarding financial toxicity in breast cancer care, little is known about the financial strain associated with breast reconstruction. This study aims to describe financial toxicity and identify factors independently associated with financial toxicity for women pursuing post-mastectomy breast reconstruction. METHODS A 33-item electronic survey was distributed to members of the Love Research Army. Women over 18 years of age and at least 1 year after post-mastectomy breast reconstruction were invited to participate. The primary outcome of interest was self-reported financial toxicity due to breast reconstruction, while secondary outcomes of interest were patient-reported out-of-pocket expenses and impact of financial toxicity on surgical decision making. RESULTS In total, 922 women were included (mean age 58.6 years, standard deviation 10.3 years); 216 women (23.8%) reported financial toxicity from reconstruction. These women had significantly greater out-of-pocket medical expenses. When compared with women who did not experience financial toxicity, those who did were more likely to have debt due to reconstruction (50.9% vs. 3.2%, p < 0.001). Younger age, lower annual household income, greater out-of-pocket expenses, and a postoperative major complication were independently associated with an increased risk for financial toxicity. If faced with the same decision, women experiencing financial toxicity were more likely to decide against reconstruction (p < 0.001) compared with women not experiencing financial toxicity. CONCLUSIONS Nearly one in four women experienced financial toxicity from breast reconstruction. Women who reported higher levels of financial toxicity were more likely to change their decisions about surgery. Identified factors predictive of financial toxicity could guide preoperative discussions to inform decision making that mitigates undesired financial decline.
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Affiliation(s)
- Nishant Ganesh Kumar
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Nicholas L Berlin
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA.,National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Department of Internal Medicine and Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Reshma Jagsi
- Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, University of Michigan, Ann Arbor, USA
| | - Adeyiza O Momoh
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA.
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22
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Ganesh Kumar N, Berlin NL, Hawley ST, Jagsi R, Momoh AO. ASO Visual Abstract: Financial Toxicity in Breast Reconstruction: A National Survey of Women Who Have Undergone Breast Reconstruction After Mastectomy. Ann Surg Oncol 2021. [PMID: 34462818 DOI: 10.1245/s10434-021-10722-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Nishant Ganesh Kumar
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Nicholas L Berlin
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA.,National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Sarah T Hawley
- Department of Internal Medicine and Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Reshma Jagsi
- Department of Radiation Oncology, Center for Bioethics and Social Science in Medicine, University of Michigan, Michigan, WI, USA
| | - Adeyiza O Momoh
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA.
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23
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Berlin NL, Peterson TA, Chopra Z, Gulseren B, Ryan AM. Hospital Participation Decisions In Medicare Bundled Payment Program Were Influenced By Third-Party Conveners. Health Aff (Millwood) 2021; 40:1286-1293. [PMID: 34339237 DOI: 10.1377/hlthaff.2020.01766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Bundled Payments for Care Improvement initiative Advanced Model (BPCI Advanced) is a voluntary Medicare bundled payment model in which hospitals may participate with third-party conveners-private consulting firms that share in the financial risk built into the program. We found that nonteaching and for-profit status was associated with a higher probability of hospital partnership with third-party conveners in BPCI Advanced. Among hospitals participating in at least one inpatient clinical episode, hospitals that partnered with third-party conveners were more likely to select episodes with higher target prices: A $1,000 increase in episode target price was associated with a 1.66-percentage-point increase in the probability of episode participation in BPCI Advanced compared with a 0.72-percentage-point increase for participating hospitals without third-party conveners. Hospitals with third-party conveners also were more likely than those without them to select inpatient clinical episodes with greater opportunities to reduce spending on postacute care and readmissions. These findings have important implications for understanding the role of private consulting firms in the program and for planning potential program modifications in the future.
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Affiliation(s)
- Nicholas L Berlin
- Nicholas L. Berlin is a National Clinician Scholar in the Institute for Healthcare Policy and Innovation, University of Michigan, in Ann Arbor, Michigan
| | - Timothy A Peterson
- Timothy A. Peterson is the population health executive for Michigan Medicine and the ACO executive of the Physician Organization of Michigan Accountable Care Organization, in Ann Arbor, Michigan
| | - Zoey Chopra
- Zoey Chopra is an MD/PhD student in economics at the University of Michigan Medical School, in Ann Arbor, Michigan
| | - Baris Gulseren
- Baris Gulseren is a health policy analyst in the Institute for Healthcare Policy and Innovation, University of Michigan
| | - Andrew M Ryan
- Andrew M. Ryan is the UnitedHealthcare Professor of Health Care Management, Department of Health Management and Policy, University of Michigan School of Public Health, and director of the Center for Evaluating Health Reform, University of Michigan
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24
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Berlin NL, Yost ML, Cheng B, Henderson J, Kerr E, Nathan H, Dossett LA. Patterns and Determinants of Low-Value Preoperative Testing in Michigan. JAMA Intern Med 2021; 181:1115-1118. [PMID: 33999103 PMCID: PMC8129898 DOI: 10.1001/jamainternmed.2021.1653] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/11/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Nicholas L. Berlin
- Department of Surgery, University of Michigan, Ann Arbor
- National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
| | - Monica L. Yost
- Michigan Value Collaborative, University of Michigan, Ann Arbor
| | - Bonnie Cheng
- Michigan Value Collaborative, University of Michigan, Ann Arbor
| | | | - Eve Kerr
- Michigan Program on Value Enhancement, Ann Arbor
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor
- Michigan Value Collaborative, University of Michigan, Ann Arbor
| | - Lesly A. Dossett
- Department of Surgery, University of Michigan, Ann Arbor
- Michigan Program on Value Enhancement, Ann Arbor
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25
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Mavroudis CL, Landau S, Brooks E, Bergmark R, Berlin NL, Blumenthal B, Cooper Z, Hwang EK, Lancaster E, Waljee J, Wick E, Yeo H, Wirtalla C, Kelz RR. The Relationship Between Surgeon Gender and Stress During the Covid-19 Pandemic. Ann Surg 2021; 273:625-629. [PMID: 33491977 PMCID: PMC7959864 DOI: 10.1097/sla.0000000000004762] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the relationship between surgeon gender and stress during the Covid-19 pandemic. BACKGROUND Although female surgeons face difficulties integrating work and home in the best of times, the Covid-19 pandemic has presented new challenges. The implications for the female surgical workforce are unknown. METHODS This cross-sectional, multi-center telephone survey study of surgeons was conducted across 5 academic institutions (May 15-June 5, 2020). The primary outcome was maximum stress level, measured using the validated Stress Numerical Rating Scale-11. Mixed-effects generalized linear models were used to estimate the relationship between surgeon stress level and gender. RESULTS Of 529 surgeons contacted, 337 surgeons responded and 335 surveys were complete (response rate 63.7%). The majority of female respondents were housestaff (58.1%), and the majority of male respondents were faculty (56.8%) (P = 0.008). A greater proportion of male surgeons (50.3%) than female surgeons (36.8%) had children ≤18 years (P = 0.015). The mean maximum stress level for female surgeons was 7.51 (SD 1.49) and for male surgeons was 6.71 (SD 2.15) (P < 0.001). After adjusting for the presence of children and training status, female gender was associated with a significantly higher maximum stress level (P < 0.001). CONCLUSIONS Our findings that women experienced more stress than men during the Covid-19 pandemic, regardless of parental status, suggest that there is more to the gendered differences in the stress experience of the pandemic than the added demands of childcare. Deliberate interventions are needed to promote and support the female surgical workforce during the pandemic.
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Affiliation(s)
| | - Sarah Landau
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ezra Brooks
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Regan Bergmark
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | - Zara Cooper
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | | | | | - Heather Yeo
- Weill Cornell Medical College, New York, New York
| | | | - Rachel R Kelz
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Mavroudis CL, Landau S, Brooks E, Bergmark R, Berlin NL, Blumenthal B, Cooper Z, Hwang EK, Lancaster E, Waljee J, Wick E, Yeo H, Wirtalla C, Kelz RR. Exploring the Experience of the Surgical Workforce During the Covid-19 Pandemic. Ann Surg 2021; 273:e91-e96. [PMID: 33351461 PMCID: PMC7869967 DOI: 10.1097/sla.0000000000004690] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To explore the impact of the Covid-19 pandemic on the stress levels and experience of academic surgeons by training status (eg, housestaff or faculty). BACKGROUND Covid-19 has uniquely challenged and changed the United States healthcare system. A better understanding of the surgeon experience is necessary to inform proactive workforce management and support. METHODS A multi-institutional, cross-sectional telephone survey of surgeons was conducted across 5 academic medical centers from May 15 to June 5, 2020. The exposure of interest was training status. The primary outcome was maximum stress level, measured using the validated Stress Numerical Rating Scale-11 (range 0-10). RESULTS A total of 335 surveys were completed (49.3% housestaff, 50.7% faculty; response rate 63.7%). The mean maximum stress level of faculty was 7.21 (SD 1.81) and of housestaff was 6.86 (SD 2.06) (P = 0.102). Mean stress levels at the time of the survey trended lower amongst housestaff (4.17, SD 1.89) than faculty (4.56, SD 2.15) (P = 0.076). More housestaff (63.6%) than faculty (40.0%) reported exposure to individuals with Covid-19 (P < 0.001). Subjects reported inadequate personal protective equipment in approximately a third of professional exposures, with no difference by training status (P = 0.557). CONCLUSIONS During the early months of the Covid-19 pandemic, the personal and professional experiences of housestaff and faculty differed, in part due to a difference in exposure as well as non-work-related stressors. Workforce safety, including adequate personal protective equipment, expanded benefits (eg, emergency childcare), and deliberate staffing models may help to alleviate the stress associated with disease resurgence or future disasters.
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Affiliation(s)
- Catherine L Mavroudis
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah Landau
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ezra Brooks
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Regan Bergmark
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | - Zara Cooper
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | | | | | - Heather Yeo
- Weill Cornell Medical College, New York City, New York
| | - Christopher Wirtalla
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Center for Surgery and Health Economics, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Baskin AS, Wang T, Bredbeck BC, Sinco BR, Berlin NL, Dossett LA. Trends in Contralateral Prophylactic Mastectomy Utilization for Small Unilateral Breast Cancer. J Surg Res 2021; 262:71-84. [PMID: 33548676 DOI: 10.1016/j.jss.2020.12.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/01/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND For average-risk women with unilateral breast cancer, contralateral prophylactic mastectomy (CPM) offers no survival benefit and contributes to increased costs and patient harm. Despite recommendations from professional societies against CPM, utilization of this service is increasing, partly due to patients' desire for breast symmetry when undergoing mastectomy. Most women with small tumors are candidates for breast-conserving surgery (BCS) and could avoid CPM. We describe CPM utilization in women with small, unilateral tumors, and identify determinants of possible overuse. METHODS Using the National Cancer Database, we identified women with unilateral, T1 breast cancer. We evaluated utilization of BCS, unilateral mastectomy, and CPM and assessed patient, tumor, and facility factors associated with CPM. RESULTS Of 765,487 women with small, unilateral breast cancer, 69% underwent BCS and 31% chose mastectomy. Of 176,673 women ≥70 y, 75% underwent BCS and 25% chose mastectomy. CPM rates in both cohorts have increased since 2006. Decreased adjuvant radiotherapy in older women was associated with increased BCS rates. Patient factors (younger age, white race, private insurance, and breast reconstruction), tumor factors (lobular histology, higher grade, and human epidermal growth factor receptor 2 positive/estrogen receptor negative status), and facility factors (type and geographic location) were associated with increased CPM rates compared with unilateral mastectomy in multivariable models. CONCLUSIONS Most women with small unilateral breast cancer are candidates for BCS, yet one-third elects to undergo a mastectomy, of which a rising percentage opts for CPM. Tailoring deimplementation strategies to factors influencing treatment may help reduce CPM utilization and associated financial toxicity, pain, and disability.
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Affiliation(s)
| | - Ton Wang
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Brooke C Bredbeck
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Brandy R Sinco
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan
| | - Nicholas L Berlin
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lesly A Dossett
- Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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Howard R, Johnson E, Berlin NL, Fan Z, Englesbe M, Dimick JB, Telem DA. Hospital and surgeon variation in 30-day complication rates after ventral hernia repair. Am J Surg 2020; 222:417-423. [PMID: 33323274 DOI: 10.1016/j.amjsurg.2020.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/29/2020] [Accepted: 12/08/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ventral hernia repair is an extremely common operation, however the variability in patient outcomes between individual hospitals and surgeons is unclear. We analyzed variability in 30-day complication rates and identified specific complications that contributed to this variability. METHODS Retrospective, cross-sectional analysis of 30-day complication rates following ventral hernia repair across 73 hospital and 978 surgeons between January 1, 2014 and December 31, 2018. RESULTS Data were collected on 19,007 patients who underwent VIHR at 73 hospitals across 978 surgeons. Adjusted complication rate among hospitals was 6.2% (range 4.3%-12.8%) and among surgeons was 6.2% (range 3.5%-26.8%). Variation between lowest and highest quartile surgeons was greatest for acute kidney injury (0.12% vs. 1.71%, P < 0.001), superficial surgical site infection (0.33% vs. 3.62%, P < 0.001), sepsis (0.27% vs. 2.47%, P < 0.001), and catheter-associated urinary tract infection (0.02% vs. 0.30%, P < 0.001). CONCLUSION After adjusting for a number of patient-specific clinical variables, there is significant variation in 30-day complication rates after ventral hernia repair. This represents a significant opportunity to improve patient outcomes.
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Affiliation(s)
- Ryan Howard
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA; Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA
| | - Emily Johnson
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA; National Clinical Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA
| | - Zhaohui Fan
- Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA
| | | | - Justin B Dimick
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA; Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA; Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Dana A Telem
- Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA; Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA; Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI, USA.
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Berlin NL, Momoh AO, Abrahamse P, Katz SJ, Jagsi R, Hawley ST. Financial and employment toxicity related to breast reconstruction following mastectomy in a diverse population-based cohort. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
78 Background: Despite mandated private insurance coverage for breast reconstruction following mastectomy, health care costs are increasingly passed onto women who seek these procedures through cost-sharing arrangements and high-deductible health plans. In this population-based study, we sought to characterize financial and employment toxicities related to pursuing breast reconstruction following mastectomy. Methods: Women (white, African American, and Latina-English and Spanish speaking) with early stage breast cancer (stages 0-II) diagnosed between July 2013 to September 2014 and who underwent mastectomy were identified through the Georgia and Los Angeles Surveillance, Epidemiology, and End Results (SEER) registries and surveyed. Primary outcome measures included patient-reported appraisal of financial toxicity and employment status following breast cancer treatment using previously developed measures. Multivariable models evaluated the association between breast reconstruction and self-reported financial and employment status. Results: Among 868 breast cancer patients who underwent mastectomy, 43.5% (n = 378) did not undergo breast reconstruction and 56.5% (n = 490) underwent reconstruction. 43.4% of the cohort reported being worse off financially since their diagnosis (49.4% with reconstruction vs. 35.0% without reconstruction, P< .001). Among women who were employed at time of breast cancer diagnosis (n = 535), 70.2% who underwent reconstruction reported being worse off regarding employment status compared to 51.1% who did not undergo reconstruction ( P< .001). Receipt of reconstruction was independently associated with a self-reported decline in financial status (Odds Ratio (OR) 2.1, 95% Confidence Interval (CI) 1.4-3.4, P= .001). Similarly, reports of being worse off regarding employment status were also higher in those who underwent reconstruction vs. not (OR 2.2, 95% CI 1.2-3.8, P= .006). Spanish-speaking Latina women more often reported being worse off regarding employment status (OR 4.3, 95% CI 2.1-9.0, P< .001) than white women. Conclusions: In this diverse cohort of women who underwent mastectomy for early stage breast cancer, women who elected to undergo reconstruction experienced more self-reported financial and employment toxicities. Patients should be counseled regarding the potential costs related to these procedures. Policy-makers should be aware of the financial barriers for women who undergo reconstruction despite mandatory insurance coverage in the United States.
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Baskin AS, Wang T, Sinco BR, Shubeck SP, Berlin NL, Hughes TM, Dossett LA. Facility-Level Determinants of Differential Deimplementation of Low-Value Surgery in Breast Cancer. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Baskin AS, Wang T, Sinco BR, Berlin NL, Dossett LA. Determinants of Unsuccessful De-Implementation of Contralateral Prophylactic Mastectomy. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Baskin AS, Wang T, Berlin NL, Skolarus TA, Dossett LA. Scope and Characteristics of Choosing Wisely in Cancer Care Recommendations by Professional Societies. JAMA Oncol 2020; 6:1463-1465. [PMID: 32701128 PMCID: PMC7378871 DOI: 10.1001/jamaoncol.2020.2066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/21/2020] [Indexed: 11/14/2022]
Affiliation(s)
| | - Ton Wang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, University of Michigan, Ann Arbor
| | - Nicholas L. Berlin
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, University of Michigan, Ann Arbor
| | - Ted A. Skolarus
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Urology, University of Michigan, Ann Arbor
| | - Lesly A. Dossett
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, University of Michigan, Ann Arbor
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Berlin NL, Gulseren B, Nuliyalu U, Ryan AM. Target Prices Influence Hospital Participation And Shared Savings In Medicare Bundled Payment Program. Health Aff (Millwood) 2020; 39:1479-1485. [DOI: 10.1377/hlthaff.2020.00104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Nicholas L. Berlin
- Nicholas L. Berlin is a National Clinician Scholar in the Institute for Healthcare Policy and Innovation at the University of Michigan, in Ann Arbor, Michigan
| | - Baris Gulseren
- Baris Gulseren is a health policy analyst in the Institute for Healthcare Policy and Innovation, University of Michigan
| | - Ushapoorna Nuliyalu
- Ushapoorna Nuliyalu is a statistician in the Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan
| | - Andrew M. Ryan
- Andrew M. Ryan is the UnitedHealthcare Professor of Health Care Management, Department of Health Management and Policy, University of Michigan School of Public Health, and director of the Center for Evaluating Health Reform, University of Michigan
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Wang T, Mott N, Miller J, Berlin NL, Hawley S, Jagsi R, Dossett LA. Patient Perspectives on Treatment Options for Older Women With Hormone Receptor-Positive Breast Cancer: A Qualitative Study. JAMA Netw Open 2020; 3:e2017129. [PMID: 32960279 PMCID: PMC7509630 DOI: 10.1001/jamanetworkopen.2020.17129] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/07/2020] [Indexed: 12/27/2022] Open
Abstract
Importance Women aged 70 years or older with hormone receptor-positive breast cancer have an excellent prognosis, but because of their age and comorbidities, they are at higher risk for treatment-related adverse events. Despite studies demonstrating the safety of omitting previously routine therapies, including sentinel lymph node biopsy (SLNB) and postlumpectomy radiotherapy, these treatments continue to be used at high rates. Physicians cite patient preference as one factor associated with overuse. However, little is known about how women view potential de-escalation of therapies. Objective To evaluate older women's preferences for SLNB and radiotherapy in the setting of guidelines recommending them or allowing for their omission. Design, Setting, and Participants This qualitative study was performed from October 2019 to January 2020. Midwestern women aged 70 years and older who had never received a diagnosis of breast cancer were recruited online and interviewed. Guided by an interpretive description approach, interviews were analyzed to produce a thematic description. Data analysis was performed from January to March 2020. Exposures Participants were presented with hypothetical scenarios in which they received a diagnosis of low-risk, hormone receptor-positive breast cancer and were given treatment options in accordance with current guidelines. Main Outcomes and Measures The interviews elicited perspectives on breast cancer treatment, including surgery, SLNB, chemotherapy, and postlumpectomy radiotherapy. Results The median (interquartile range) age of the 30 participants was 72.0 (71.0-76.5) years. Most of the women were White (26 participants [87%]), lived in metropolitan areas (29 participants [97%]), and were college educated (20 participants [67%] had a 4-year degree or higher). Overall, women expressed the belief that age-based guidelines were appropriate on the basis of decreased recurrence risk and increased frailty in older patients. However, many participants stated that these guidelines should not apply to healthy older women with a long life expectancy. Some participants struggled to understand that the basis for treatment de-escalation in older patients is a favorable, not poor, prognosis. Women who said they would undergo SLNB (12 participants [40%]) perceived the procedure as low risk and providing peace of mind. Most participants (22 participants [73%]) expressed a preference for omitting postlumpectomy radiotherapy because of the perceived risks, lack of benefit, and inconvenience. Conclusions and Relevance Positive reframing of the excellent prognosis driving national recommendations for de-escalation may reduce breast cancer overtreatment in older women. Strategies for reducing SLNB use will likely require education on the risks vs benefits and addressing patient preferences for peace of mind. In contrast, efforts to reduce radiotherapy use may need to address clinician or organizational factors.
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Affiliation(s)
- Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Nicole Mott
- University of Michigan Medical School, Ann Arbor
| | - Jacquelyn Miller
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Nicholas L. Berlin
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Sarah Hawley
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Reshma Jagsi
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Radiation Oncology, University of Michigan, Ann Arbor
| | - Lesly A. Dossett
- Department of Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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35
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Mott N, Wang T, Miller J, Berlin NL, Hawley S, Jagsi R, Zikmund-Fisher BJ, Dossett LA. Medical Maximizing-Minimizing Preferences in Relation to Low-Value Services for Older Women with Hormone Receptor-Positive Breast Cancer: A Qualitative Study. Ann Surg Oncol 2020; 28:941-949. [PMID: 32720038 DOI: 10.1245/s10434-020-08924-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/08/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Multiple studies have demonstrated the safety of omitting therapies in older women with breast cancer. Despite de-implementation guidelines, up to 65% of older women continue to receive one or more of these low-value services. Previous work has investigated the role of both provider and patient attitudes as barriers to de-implementation; however, the importance of the patient's maximizing-minimizing preferences within this context remains unclear. METHODS In this qualitative study, we conducted 30 semi-structured interviews with women ≥ 70 years of age without a previous diagnosis of breast cancer to elicit perspectives on breast cancer treatment in relation to their medical maximizing-minimizing preferences, as determined by the single-item maximizer-minimizer elicitation question (MM1). We used an interpretive description approach in analysis to produce a thematic survey. RESULTS Participants were relatively evenly distributed across the MM1 (minimizer, n = 8; neutral, n = 13; maximizer, n = 9). Despite being told of recommendations allowing for the safe omission of sentinel lymph node biopsy and post-lumpectomy radiotherapy, maximizers consistently stated preferences for more medical intervention and aggressive therapies over minimizers and neutral individuals. CONCLUSION Medical maximizing-minimizing preferences in older women correspond with preferences for breast cancer treatment options that guidelines identify as potentially unnecessary. Increased awareness of patient-level variability in maximizing-minimizing preferences may be valuable in developing optimal intervention strategies to reduce utilization of low-value care.
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Affiliation(s)
- Nicole Mott
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ton Wang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Jacquelyn Miller
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Nicholas L Berlin
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Sarah Hawley
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Health Education and Health Behavior, University of Michigan, Ann Arbor, MI, USA.,Center for Bioethics and Social Sciences in Medicine (CBSSM), Ann Arbor, MI, USA
| | - Reshma Jagsi
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.,Center for Bioethics and Social Sciences in Medicine (CBSSM), Ann Arbor, MI, USA
| | - Brian J Zikmund-Fisher
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Department of Health Education and Health Behavior, University of Michigan, Ann Arbor, MI, USA.,Center for Bioethics and Social Sciences in Medicine (CBSSM), Ann Arbor, MI, USA
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. .,Center for Bioethics and Social Sciences in Medicine (CBSSM), Ann Arbor, MI, USA.
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Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.,National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI.,VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Eve A Kerr
- VA HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.,Michigan Program for Value Enhancement, Ann Arbor, MI.,Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Lesly A Dossett
- Michigan Program for Value Enhancement, Ann Arbor, MI.,Department of Surgery, University of Michigan, Ann Arbor, MI
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Berlin NL, Offodile AC. Leveraging Implementation Science to Improve Delivery of Oncologic Reconstructive Surgery. Ann Surg Oncol 2020; 27:2117-2119. [PMID: 32281015 DOI: 10.1245/s10434-020-08465-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Indexed: 01/27/2023]
Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA.,National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Anaeze C Offodile
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA. .,Baker Institute for Public Policy, Rice University, Houston, TX, USA. .,Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Berlin NL, Pannucci CJ, Wilkins EG. Commentary on: Oral Contraceptive Management in Aesthetic Surgery: A Survey of Current Practice Trends. Aesthet Surg J 2019; 39:NP515-NP516. [PMID: 29452337 DOI: 10.1093/asj/sjx260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Christopher J Pannucci
- Division of Plastic Surgery, Division of Health Services Research, University of Utah, Salt Lake City, UT
| | - Edwin G Wilkins
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI
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Berlin NL, Wilkins EG, Alderman AK. Addressing Continued Disparities in Access to Breast Reconstruction on the 20th Anniversary of the Women's Health and Cancer Rights Act. JAMA Surg 2019; 153:603-604. [PMID: 29800943 DOI: 10.1001/jamasurg.2018.0387] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Edwin G Wilkins
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Amy K Alderman
- The Swan Center for Plastic Surgery, Alpharetta, Georgia
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Kumar NG, Berlin NL, Qi J, Kim HM, Sagiyama K, Hamill JB, Kozlow JH, Pusic AL, Wilkins EG. Abstract 64. Plast Reconstr Surg Glob Open 2019. [PMCID: PMC6504374 DOI: 10.1097/01.gox.0000558338.34736.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Berlin NL, Wilkins EG. Commentary on: Outcomes of Acellular Dermal Matrix for Immediate Tissue Expander Reconstruction with Radiotherapy: A Retrospective Cohort Study. Aesthet Surg J 2019; 39:289-291. [PMID: 30272132 DOI: 10.1093/asj/sjy201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Edwin G Wilkins
- Division of Plastic Surgery, University of Michigan, Ann Arbor, MI
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Berlin NL, Tandon VJ, Hawley ST, Hamill JB, MacEachern MP, Lee CN, Wilkins EG. Feasibility and Efficacy of Decision Aids to Improve Decision Making for Postmastectomy Breast Reconstruction: A Systematic Review and Meta-analysis. Med Decis Making 2018; 39:5-20. [DOI: 10.1177/0272989x18803879] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. The decision-making process for women considering breast reconstruction following mastectomy is complex. Research suggests that fewer than half of women undergoing mastectomy have adequate knowledge and make treatment decisions that are concordant with their underlying values. This systematic review assesses the feasibility and efficacy of preoperative decision aids (DAs) to improve the patient decision-making process for breast reconstruction. Methods. A systematic review was performed using PubMed, Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Databases published prior to January 4, 2018. Studies that assessed the impact of a DA on patient decision making for breast reconstruction were identified. The effect of preoperative DAs on decisional conflict in randomized controlled trials (RCTs) was measured with inverse variance-weighted mean differences (mean difference [MD] ± 95% confidence interval [CI]). Results. Among 1299 unique articles identified, 1197 were excluded after reviewing titles and abstracts against selection criteria. Among the 17 studies included in this review, 11 assessed the efficacy of DAs for breast reconstruction and 6 additional studies described the development and usability of these DAs. Studies suggest that DAs reduce patient-reported decisional conflict (MD, –4.55 [95% CI, –8.65 to –0.45], P = 0.03 in the fixed-effects model and MD, –4.70 [95% CI, –10.75 to 1.34], P = 0.13 in the random-effects model). Preoperative DAs also improved patient satisfaction with information and perceived involvement in the decision-making process. Conclusions. The existing literature suggests that DAs reduce decisional conflict, improve self-reported satisfaction with information, and improve perceived involvement in the decision-making process for women considering breast reconstruction.
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Affiliation(s)
| | | | - Sarah T. Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Center for Health Communications and Research, University of Michigan, Ann Arbor, MI
| | | | - Mark P. MacEachern
- Taubman Health Sciences Library, University of Michigan School of Medicine, Ann Arbor, MI
| | - Clara N. Lee
- Department of Plastic and Reconstructive Surgery, College of Medicine, Ohio State University, Columbus, OH
- Division of Health Services Management and Policy, College of Public Health, Ohio State University, Columbus, OH
| | - Edwin G. Wilkins
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI
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Bennett KG, Berlin NL, MacEachern MP, Buchman SR, Preminger BA, Vercler CJ. The Ethical and Professional Use of Social Media in Surgery: A Systematic Review of the Literature. Plast Reconstr Surg 2018; 142:388e-398e. [PMID: 30148789 PMCID: PMC6112181 DOI: 10.1097/prs.0000000000004692] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Although certain medical societies have released guidelines on the use of social media, plastic surgery, with its inherent visual nature and potential for sensationalism, could benefit from increasing direction regarding the ethical use of social media. The authors hypothesized that although general platitudes for use exist in the literature, guidelines articulating the boundaries of professional use are nonspecific. Systematic searches of MEDLINE, Embase.com, and Cochrane Central Register of Controlled Trials were completed on January 18, 2017. Searches consisted of a combination of Medical Subject Headings terms and title and abstract keywords for social media and professionalism concepts. In addition, the authors manually searched the three highest impact plastic surgery journals (ending in October of 2017). Two authors screened all titles and abstracts. Studies related to clinical medicine, patient care, and the physician-patient relationship were included for full-text review. Articles related to surgery merited final inclusion. The initial search strategy yielded 954 articles, with 28 selected for inclusion after final review. The authors' manual search yielded nine articles. Of the articles from the search strategy, 10 were published in the urology literature, eight were published in general surgery, six were published in plastic surgery, three were published in orthopedic surgery, and one was published in vascular surgery. Key ethical themes emerged across specialties, although practical recommendations for professional social media behavior were notably absent. In conclusion, social media continue to be a domain with potential professional pitfalls. Appropriate use of social media must extend beyond obtaining consent, and plastic surgeons must adhere to a standard of professionalism far surpassing that of today's media culture.
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Affiliation(s)
- Katelyn G. Bennett
- Section of Plastic Surgery, Department of Surgery, University of Michigan
| | - Nicholas L. Berlin
- Section of Plastic Surgery, Department of Surgery, University of Michigan
| | | | - Steven R. Buchman
- Section of Plastic Surgery, Department of Surgery, University of Michigan
| | - B. Aviva Preminger
- Division of Plastic Surgery, Department of Surgery, Columbia University. Division of Medical Ethics, Department of Medicine, Weill Medical College of Cornell University
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Berlin NL, Hamill JB, Hawley ST, Qi J, Kim HM, Varon DE, Lee CN, Wilkins EG. Abstract 50. Plast Reconstr Surg Glob Open 2018. [PMCID: PMC5959596 DOI: 10.1097/01.gox.0000533915.81689.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Berlin NL, Hamill JB, Qi J, Kim HM, Pusic AL, Wilkins EG. Nonresponse bias in survey research: lessons from a prospective study of breast reconstruction. J Surg Res 2017; 224:112-120. [PMID: 29506826 DOI: 10.1016/j.jss.2017.11.058] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/05/2017] [Accepted: 11/21/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND Survey-based research is essential for evaluating the outcomes of health care in an era of patient-centered care. However, many such studies are hampered by poor response rates in completion of study questionnaires, thus limiting the generalizability of any findings. The objectives of this analysis were to identify independent variables associated with nonresponse to surveys following breast reconstruction to improve future patient-reported outcomes research. MATERIALS AND METHODS The Mastectomy Reconstruction Outcomes Consortium is a prospective cohort study involving 11 leading medical centers from the United States and Canada. Nonresponse rates for surveys assessing satisfaction with breast, satisfaction with care (BREAST-Q), depression (Patient Health Questionnaire-9), and anxiety (Generalized Anxiety Disorder-7) were measured at 1 y and 2 y postoperatively. Clinical complication rates were compared between responders and nonresponders, and multivariable models were used to assess predictors of nonresponse. RESULTS Among 2856 women in the analytic cohort, 1882 (65.9%) underwent implant-based, 817 (28.6%) received autologous, and 157 (5.5%) underwent latissimus dorsi myocutaneous flap breast reconstructions. Nonresponse rates to surveys at 1 y and 2 y were 27.8% and 34.4%, respectively. Race, ethnicity, and annual household income were associated with nonresponse to surveys. Women who underwent implant-based procedures were less likely to complete long-term surveys. CONCLUSIONS As survey-based research plays an increasingly prominent role in evaluating the outcomes of breast reconstruction, we found socioeconomic and procedure-related differences in survey response rates. Investigators must consider systematic differences in response rates among particular groups of women on the generalizability and validity of findings and perform rigorous nonresponse bias analyses.
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Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jennifer B Hamill
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ji Qi
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hyungjin M Kim
- Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Andrea L Pusic
- Division of Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Edwin G Wilkins
- Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan.
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Berlin NL, Steinbacher DM, Tuggle CT. Procedure Volume in Orthognathic Surgery: The Surgeon or the Hospital? J Oral Maxillofac Surg 2017; 75:2037. [PMID: 28735745 DOI: 10.1016/j.joms.2017.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 06/06/2017] [Indexed: 10/19/2022]
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Berlin NL, Momoh AO, Qi J, Hamill JB, Kim HM, Pusic AL, Wilkins EG. Racial and ethnic variations in one-year clinical and patient-reported outcomes following breast reconstruction. Am J Surg 2017; 214:312-317. [PMID: 28215963 DOI: 10.1016/j.amjsurg.2017.02.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 02/05/2017] [Accepted: 02/05/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Existing studies evaluating racial and ethnic disparities focus on describing differences in procedure type and the proportion of women who undergo reconstruction following mastectomy. This study seeks to examine racial and ethnic variations in clinical and patient-reported outcomes (PROs) following breast reconstruction. METHODS The Mastectomy Reconstruction Outcomes Consortium is an 11 center, prospective cohort study collecting clinical and PROs following autologous and implant-based breast reconstruction. Mixed-effects regression models, weighted to adjust for non-response, were performed to evaluate outcomes at one-year postoperatively. RESULTS The cohort included 2703 women who underwent breast reconstruction. In multivariable models, Hispanic or Latina patients were less likely to experience any complications and major complications. Black or African-American women reported greater improvements in psychosocial and sexual well-being. CONCLUSIONS Despite differences in pertinent clinical and socioeconomic variables, racial and ethnic minorities experienced equivalent or better outcomes. These findings provide reassurance in the context of numerous racial and ethnic health disparities and build upon our understanding of the delivery of surgical care to women with or at risk for developing breast cancer.
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Affiliation(s)
- Nicholas L Berlin
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Adeyiza O Momoh
- Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI, USA
| | - Ji Qi
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer B Hamill
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Hyungjin M Kim
- Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI, USA; Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Andrea L Pusic
- Division of Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Edwin G Wilkins
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA.
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Berlin NL, Cutter C, Battaglia C. Will preoperative smoking cessation programs generate long-term cessation? A systematic review and meta-analysis. Am J Manag Care 2015; 21:e623-e631. [PMID: 26735296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The aim of this review was to examine published randomized controlled trials (RCTs) and quasi-experimental studies that evaluate the association between preoperative smoking cessation programs and long-term smoking cessation at a minimum of 6 months, postoperatively. STUDY DESIGN Systematic review and meta-analysis. METHODS A systematic review was performed utilizing MEDLINE, EMBASE, CINAHL, PSYCHinfo, and COCHRANE databases. All eligible studies of smoking-cessation interventions initiated preoperatively, with cessation measured at a minimum of 6 months postoperatively, were identified. The effect of cessation interventions at 12 months postoperatively in RCTs was evaluated through meta-analyses using Mantel-Haenszel risk ratios (RRs) and 95% CIs. A fixed effects model was conducted initially; however, due to heterogeneity in study characteristics and patient cohorts, a more conservative random effects model was also performed. RESULTS Four RCTs and 4 quasi-experimental studies were included. Two RCTs demonstrated an association between interventions and cessation at 12 months, and the quasi-experimental studies showed cessation rates of 48% to 56% at 12 months, postoperatively. In a fixed effects model, interventions were associated with a greater likelihood of cessation at 12 months (RR, 1.50; 95% CI, 1.05-2.15; P = .02), although this effect was not statistically significant after applying a random effects model (RR, 1.61; 95% CI, 0.88-2.96; P = .12). CONCLUSIONS The literature suggests that preoperative smoking cessation programs will likely precipitate long-term (≥12 months) cessation. Additional studies should identify approaches that optimize preoperative cessation programs in the promotion of short-term, and long-term cessation.
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Affiliation(s)
| | | | - Catherine Battaglia
- University of Colorado School of Public Health, 13808, East 19th Ave, Mail Stop 8700, Aurora, CO 80045. E-mail:
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Berlin NL, Ferrucci LM, Cartmel B, Wang SY, Leffell DJ, McNiff JM, Mayne ST. Subsequent skin cancer in patients with early-onset basal cell carcinoma. Australas J Dermatol 2015. [PMID: 26201376 DOI: 10.1111/ajd.12338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Leah M Ferrucci
- Yale School of Public Health, New Haven, Connecticut, USA.,Yale Cancer Center, New Haven, Connecticut, USA
| | - Brenda Cartmel
- Yale School of Public Health, New Haven, Connecticut, USA.,Yale Cancer Center, New Haven, Connecticut, USA
| | - Shi-Yi Wang
- Yale School of Public Health, New Haven, Connecticut, USA.,Yale Cancer Center, New Haven, Connecticut, USA
| | - David J Leffell
- Yale Cancer Center, New Haven, Connecticut, USA.,Yale University School of Medicine, New Haven, Connecticut, USA.,Center for Food Safety and Applied Nutrition, Food and Drug Administration
| | - Jennifer M McNiff
- Yale University School of Medicine, New Haven, Connecticut, USA.,Center for Food Safety and Applied Nutrition, Food and Drug Administration
| | - Susan T Mayne
- Yale School of Public Health, New Haven, Connecticut, USA.,Yale Cancer Center, New Haven, Connecticut, USA
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Abstract
BACKGROUND The short-term outcomes of pediatric digit replantation have been derived primarily from single-center/surgeon experience. The purpose of this study was to conduct a nationwide analysis of outcomes and trends of pediatric digit replantation as compared to adult patients. METHODS Digit replantation patients were identified in the 1999-2011 Healthcare Cost and Utilization Project, Nationwide Inpatient Sample. Outcomes included in-hospital procedure-related and total complications, microvascular revision, amputation, and length of stay (LOS). Univariate and multivariate analyses were performed to compare pediatric and adult patients and to identify independent predictors of outcomes. The annual rate of replantation among pediatric digit amputation patients was evaluated over the study period. RESULTS A total of 3,010 patients who underwent digit replantation were identified, including 455 pediatric patients. For all replantations, age ≤18 years was associated with a lower likelihood of suffering a total complication (odds ratio (OR) 0.66, P = 0.006), requiring amputation (OR 0.62, P < 0.001), and experiencing LOS >5 days (OR 0.77, P = 0.019), after adjusting for comorbidity, amputation severity, digit type, number of replantations, and hospital characteristics. Similar associations were observed between patient age and replantation outcomes for single-finger replantations. The rate of pediatric replantation (range 16 to 27 %) remained consistent through the study period (incidence rate ratio 0.98, P = 0.06). CONCLUSIONS The rate of pediatric replantation has been relatively low, being 27 % at most in a given year. Importantly, short-term outcomes are better in children than for adults, supporting the indication to perform replantation in this age group when the surgeon feels that replantation is feasible and safe.
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Affiliation(s)
- Nicholas L. Berlin
- />Yale University School of Public Health, 60 College St., P.O. Box 208034, New Haven, CT 06520-8034 USA
| | - Charles T. Tuggle
- />Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, 330 Cedar Street, Boardman Building, 3rd floor, New Haven, CT 06510 USA
| | - James G. Thomson
- />Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, 330 Cedar Street, Boardman Building, 3rd floor, New Haven, CT 06510 USA
| | - Alexander Au
- />Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, 330 Cedar Street, Boardman Building, 3rd floor, New Haven, CT 06510 USA
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