Incidence of Complications Associated With Lipectomy Techniques and Patient Body Mass Index: An Institutional and National Analysis Using the Tracking Operations and Outcomes for Plastic Surgeons.

INTRODUCTION: An evaluation of complication rates in different abdominal lipectomy techniques with relationship to body mass index (BMI) and other risk factors. METHODS: We identified patients who underwent an abdominal lipectomy at our institution from January 2015 to July 2020. Those with concurrent hernia repair were excluded. Patients were classified into 2 groups: (1) horizontal lipectomy with or without umbilical translocation and (2) inverted-T lipectomy with translocation. Demographics, operative details, and postoperative complications were collected for 1 year postoperatively. Bivariate analyses were conducted to determine factors associated with type of procedure and complications. Crude and stratum-specific (based on BMI) odds ratios for complications were calculated for the inverted T as compared with the horizontal group. A replicate analysis using the national Tracking Operations and Outcomes for Plastic Surgeons (TOPS) as a single cohort was performed. RESULTS: At our institution, 362 patients (group 1 = 196, group 2 = 166) were included. A total of 40.9% of patients experienced at least one complication at 1 year postoperatively with the complication rate decreasing to 28.0% when analyzed at the 30-day postoperative period. Specifically, wound disruption rates were highest in group 2 (39.8%) compared with group 1 (15.6%; P < 0.0001). The odds of experiencing a complication were greater in the inverted-T group overall and within each stratum of BMI. When dividing the cohort based on BMI class (normal weight, overweight, class I, class II, and class III obesity), the incidence of wound disruption increased as did BMI (2.6%, 22.2%, 27.2%, 48.2%, and 56.3%, respectively; P < 0.0001). The TOPS data set included 23,067 patients and showed an overall complication rate of 13.1% at 30-day postop. Overall, wound disruption rate was 4.6%. Compared with normal weight patients, the odds of experiencing a complication trended higher with each stratum of BMI. Other factors associated with complications included BMI, tobacco use, diabetes, American Society of Anesthesiology, prior massive weight loss, and LOS. CONCLUSIONS: The increasing complication rate within each BMI stratum of the large sample size of the TOPS patient cohort, in addition to our similar institutional trends, suggests that a staged procedure may be more appropriate for higher BMI patients. Surgical technique modification with limited flap undermining in patients undergoing inverted-T lipectomy to preserve flap perfusion may also decrease overall complication rates.

Clinical and Financial Implications of Positive Margins After Nonmelanoma Skin Cancer Resection: A Longitudinal Evaluation.

BACKGROUND: Management of positive margins after nonmelanoma skin cancer (NMSC) excision is debated in the literature. The purpose of this study is to determine the rate of residual tumor in reexcised NMSC specimens after previous excision with positive margins, to determine the rate of recurrence in patients who had positive margins but did not undergo reexcision, and to define the financial burden of negative reexcisions. METHODS: An Institutional Review Board-approved retrospective review was conducted on all patients with NMSC excision over a 15-year period. Patients who met inclusion criteria and underwent initial NMSC excision with negative frozen section margins, but had positive permanent section margins were divided into 2 groups: those who underwent reexcision for clearance of tumor (n = 161) or those who did not undergo further reexcision (n = 105). Variables collected include demographics, previous skin cancer, tumor location, cancer subtype, excision measurements, and time between first and second excisions. For those patients who did not undergo reexcision, charts were examined for recurrence. RESULTS: Two hundred sixty-six patients met inclusion criteria with mean follow-up of 60 months. Eighty-three (52%) of 161 patients with positive margins on initial excision had no evidence of residual cancer upon reexcision. Residual tumor on permanent section was confirmed in 48% of patients. Patients with a previous history of basal cell carcinoma were more likely to have a true-positive margin after reexcision (P = 0.02). Larger reexcisions were more likely to harbor residual cancer (5.9 cm2, P = 0.04). Patients with positive margins that did not undergo reexcision, only 7 of 105 patients (6.6%) had recurrence. No mortalities were reported from NMSC recurrence. US $247,672 was spent in reexcision for negative margins in 98 patients for an average cost of US $2984 per case. CONCLUSIONS: Forty-eight percent of NMSC patients with positive margins had residual tumor upon reexcision. There were 6.6% of the patients who did not undergo resection after positive margins developed recurrence of disease at 5 years. Patients requiring larger reexcisions or those with a prior history of BCC were more likely to have residual cancer upon reexcision. This study suggests that observation is an appropriate option of care for certain patients with residual NMSC on permanent pathology.

Impact of Postoperative Antibiotic Prophylaxis Duration on Surgical Site Infections in Autologous Breast Reconstruction.

BACKGROUND: Although some surgeons prescribe prolonged postoperative antibiotics after autologous breast reconstruction, evidence is lacking to support this practice. We used the Tracking Operations and Outcomes for Plastic Surgeons database to evaluate the association between postoperative antibiotic duration and the rate of surgical site infection (SSI) in autologous breast reconstruction. STUDY DESIGN: The intervention of interest for this study was postoperative duration of antibiotic prophylaxis: either discontinued 24 hours after surgery or continued beyond 24 hours. The primary outcome variable of interest for this study was the presence of SSI within 30 days of autologous breast reconstruction. Cohort characteristics and 30-day outcomes were compared using χ² and Fischer exact tests for categorical variables and Student t tests for continuous variables. Multivariate logistic regression was used to control for confounders. RESULTS: A total of 1036 patients met inclusion criteria for our study. Six hundred fifty-nine patients (63.6%) received antibiotics for 24 hours postoperatively, and 377 patients (36.4%) received antibiotics for greater than 24 hours. The rate of SSI did not differ significantly between patients given antibiotics for only 24 hours and those continued on antibiotics beyond the 24-hour postoperative time period (5.01% vs 2.92%, P = 0.109). Furthermore, antibiotic duration was not predictive of SSI in multivariate regression modeling. CONCLUSIONS: We did not find a statistically significant difference in the rate of SSI in patients who received 24 hours of postoperative antibiotics compared to those that received antibiotics for greater than 24 hours. These findings held for both purely autologous reconstruction as well as latissimus dorsi reconstruction in conjunction with an implant. Thus, our study does not support continuation of postoperative antibiotics beyond 24 hours after autologous breast reconstruction.

Tissue Expander Complications Predict Permanent Implant Complications and Failure of Breast Reconstruction.

BACKGROUND: Two-stage tissue expander-based breast reconstruction is the most commonly used reconstructive modality following mastectomy. We sought to determine if patients who experienced complications during the expansion phase were at increased risk for complications or reconstructive failure after the exchange procedure. METHODS: A retrospective review of tissue expander-based breast reconstructions was performed from January 2007 through December 2011. Variables evaluated included age, presence of cancer, tobacco use, body mass index, comorbidities, use of acellular dermal matrix, chemotherapy, radiation, timing of reconstruction (delayed/immediate), intraoperative tissue expander fill, complications, and explantation or salvage of the reconstruction by means of debridement and closure or myocutaneous flap. RESULTS: A total of 196 patients underwent mastectomy with 304 tissue expander reconstructions. Tobacco use (active and remote), hypertension, and radiation were associated with complications. Patients with a salvaged tissue expander complication were 3 times more likely to have a complication after placement of a permanent implant and 9 times more likely to fail permanent implant reconstruction (ie, require explantation). CONCLUSIONS: Women with complications after placement of a tissue expander are at significantly increased risk for both complications and reconstructive failure after placement of a permanent implant. Consideration for earlier autologous reconstruction as a salvage should be strongly considered in patients with a tissue expander complication, particularly in smokers and those undergoing radiation therapy.

The use of patient registries in breast surgery: a comparison of the tracking operations and outcomes for plastic surgeons and national surgical quality improvement program data sets.

BACKGROUND: The National Surgical Quality Improvement Program (NSQIP) and the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) registries gather outcomes for plastic surgery procedures. The NSQIP collects hospital data using trained nurses, and the TOPS relies on self-reported data. We endeavored to compare the TOPS and NSQIP data sets with respect to cohort characteristics and outcomes to better understand the strengths and weakness of each registry as afforded by their distinct data collection methods. STUDY DESIGN: The 2008 to 2011 TOPS and NSQIP databases were queried for breast reductions and breast reconstructions. Propensity score matching identified similar cohorts from the TOPS and NSQIP databases. Shared 30-day surgical and medical complications rates were compared across matched cohorts. RESULTS: The TOPS captured a significantly greater number of wound dehiscence occurrences (4.77%-5.47% vs 0.69%-1.17%, all P<0.001), as well as more reconstructive failures after prosthetic reconstruction (2.82% vs 0.26%, P<0.001). Medical complications were greater in NSQIP (P<0.05). Other complication rates did not differ across any procedure (all P>0.05). CONCLUSIONS: The TOPS and NSQIP capture significantly different patient populations, with TOPS' self-reported data allowing for the inclusion of private practices. This self-reporting limits TOPS' ability to identify medical complications; surgical complications and readmissions, however, were not underreported. Many surgical complications are captured by TOPS at a higher rate due to its broader definitions, and others are not captured by NSQIP at all. The TOPS and NSQIP provide complementary information with different strengths and weakness that together can guide evidence-based decision making in plastic surgery.

The Evolution of Organized Plastic Surgery in the United States and Its Role as a Global Partner.

The medical environment in the United States is evolving rapidly and the stresses that plastic surgeons face are mounting. These changes and stresses are not unique to the United States but rather are impacting our specialty globally. In order to help its members meet these challenges and to remain relevant, organized plastic surgery in the United States must evolve. In addition, as the nation whose plastic surgery organizations have the largest infrastructure to support their membership, organized plastic surgery in the United States could make a significant contribution to helping our international colleagues. Various challenges facing plastic surgeons in the United States and throughout the world are discussed as well as possible roles that organized plastic surgery can play to support practicing surgeons around the globe.

Impact of Injury Mechanisms on Patterns and Management of Facial Fractures.

Mechanisms causing facial fractures have evolved over time and may be predictive of the types of injuries sustained. The objective of this study is to examine the impact of mechanisms of injury on the type and management of facial fractures at our Level 1 Trauma Center. The authors performed an Institutional Review Board-approved review of our network's trauma registry from 2006 to 2010, documenting age, sex, mechanism, Injury Severity Score, Glasgow Coma Scale, facial fracture patterns (nasal, maxillary/malar, orbital, mandible), and reconstructions. Mechanism rates were compared using a Pearson χ2 test. The database identified 23,318 patients, including 1686 patients with facial fractures and a subset of 1505 patients sustaining 2094 fractures by motor vehicle collision (MVC), fall, or assault. Nasal fractures were the most common injuries sustained by all mechanisms. MVCs were most likely to cause nasal and malar/maxillary fractures (P < 0.01). Falls were the least likely and assaults the most likely to cause mandible fractures (P < 0.001), the most common injury leading to surgical intervention (P < 0.001). Although not statistically significant, fractures sustained in MVCs were the most likely overall to undergo surgical intervention. Age, number of fractures, and alcohol level were statistically significant variables associated with operative management. Age and number of fractures sustained were associated with operative intervention. Although there is a statistically significant correlation between mechanism of injury and type of facial fracture sustained, none of the mechanisms evaluated herein are statistically associated with surgical intervention. Clinical Question/Level of Evidence: Therapeutic, III.

Combining abdominal and cosmetic breast surgery does not increase short-term complication rates: a comparison of each individual procedure and pretreatment risk stratification tool.

BACKGROUND: Combined abdominal and breast surgery presents a convenient and relatively cost-effective approach for accomplishing both procedures. OBJECTIVES: This study is the largest to date assessing the safety of combined procedures, and it aims to develop a simple pretreatment risk stratification method for patients who desire a combined procedure. METHODS: All women undergoing abdominoplasty, panniculectomy, augmentation mammaplasty, and/or mastopexy in the TOPS database were identified. Demographics and outcomes for combined procedures were compared to individual procedures using χ(2) and Student's t-tests. Multiple logistic regression provided adjusted odds ratios for the effect of a combined procedure on 30-day complications. Among combined procedures, a logistic regression model determined point values for pretreatment risk factors including diabetes (1 point), age over 53 (1), obesity (2), and 3+ ASA status (3), creating a 7-point pretreatment risk stratification tool. RESULTS: A total of 58,756 cases met inclusion criteria. Complication rates among combined procedures (9.40%) were greater than those of aesthetic breast surgery (2.66%; P < .001) but did not significantly differ from abdominal procedures (9.75%; P = .530). Nearly 77% of combined cases were classified as low-risk (0 points total) with a 9.78% complication rates. Medium-risk patients (1 to 3 points) had a 16.63% complication rate, and high-risk (4 to 7 points) 38.46%. CONCLUSIONS: Combining abdominal and breast procedures is safe in the majority of patients and does not increase 30-day complications rates. The risk stratification tool can continue to ensure favorable outcomes for patients who may desire a combined surgery. LEVEL OF EVIDENCE: 4 Risk.

"Monitoring Postoperative Weight Changes Following Reduction Mammoplasty in Adolescents".

BACKGROUND: Macromastia can limit women's ability to exercise. Reduction mammoplasty has been reported to subjectively improve exercise capability and stimulate weight loss. Considering the lack of published quantitative data, we sought to examine change in weight and body mass index (BMI) in adolescent women following reduction mammoplasty. METHODS: Retrospective chart review was performed of patients under 21 years of age that underwent reduction mammoplasty at our institution from 2015 through 2019. RESULTS: Fifty-six patients with follow-up weight measurements were included in analysis. Median follow-up time of our sample was 46.0 months. Only 22 (39.3%) experienced a decrease in BMI at final follow-up compared to baseline. Patients classified as healthy weight preoperatively (BMI 18.5-24.9kg/m) experienced a significant increase in BMI at 2-year, 3-year, 5-year, and final postoperative follow-up compared to baseline. Patients classified as overweight (25.0-29.99kg/m) or obese (≥30kg/m) did not experience significant BMI change at final postoperative follow-up. CONCLUSIONS: BMI and weight trended upwards postoperatively regardless of BMI classification. Reduction mammoplasty alone is not sufficient to stimulate weight loss. Healthy lifestyle changes should be encouraged to help prevent weight gain in adolescent women following reduction mammoplasty.

Developing an International Framework for Informed Consent in Plastic Surgery: A Focus on Cosmetic Breast Augmentation.

Background: Informed consent is a fundamental pillar of patient rights and is an essential part of good clinical practice. In 2019, the International Confederation of Plastic Surgery Societies launched a survey to collect feedback on informed consent practices, with an aim to develop an international guideline for cosmetic surgery. Methods: A 15-question survey was sent to delegates of the International Confederation of Plastic Surgery Societies for dissemination to their national society members. The survey comprised a range of quantitative and qualitative questions. Descriptive and thematic analysis was performed. Results: There were 364 respondents. Over half of the respondents reported no local informed consent policy, whereas others noted national society, specialist college, or government policies. The majority of respondents believed that the performing surgeon should be responsible for obtaining informed consent with at least two face-to-face consultations. Most respondents agreed with a cooling-off period (duration based on procedure type and use of high-risk devices). Regarding cosmetic breast augmentation, the majority of respondents felt that the performing surgeon should be responsible for postoperative management, including cases that occur as part of surgical tourism. Some respondents incorporate financial consent as part of their informed consent practice. Most supported the development of an international informed consent guideline. Conclusions: Informed consent should result from face-to-face consultations with the performing surgeon. There should be a minimum cooling-off period. Postoperative surveillance should be available in all settings. The findings of this survey will help inform an international standardized informed consent guideline for cosmetic surgery.

The Rates of Postmastectomy Immediate Breast Reconstruction during the Initial Months of the COVID-19 Pandemic.

Background: Coronavirus disease 2019 (COVID-19) pandemic-related changes may have led to changes in immediate breast reconstruction (IBR) rates. We aimed to evaluate these changes before, during, and after the initial wave of COVID-19. Methods: We retrospectively reviewed women who underwent mastectomy with or without IBR from January 1 to September 30, 2019 and from January 1 to September 30, 2020, and compared demographic, clinical, and surgical variables between defined time periods. Results: A total of 202 mastectomies were included. Fewer patients underwent IBR during the initial surge of COVID-19 (surge period) compared with the months before (presurge period; 38.46% versus 70.97%, P = 0.0433). When comparing the postsurge period with a year before (postsurge control), fewer patients underwent reconstruction even after the initial surge had passed (53.13% versus 81.25%, P = 0.0007). Those who underwent IBR were older than the year before (59.34 versus 53.06, P = 0.0181). The median number of postoperative visits in the postsurge period was 8.50 (interquartile range: 6-12) compared with 14 (interquartile range: 8-20.50) in the year before (P = 0.0017). The overall incidences of complications and unanticipated resource utilization were also significantly lower in the postsurge period compared with the year before [5.88% versus 30.77% (P = 0.0055), and 14.71% versus 28.85% (P = 0.0103), respectively]. Conclusions: IBR rates were lower even after the initial surge than at the year before. Furthermore, during the pandemic, IBR patients were older, had fewer follow-up visits, and fewer reported complications.

Reduction mammaplasty trends: a quality and fiscal analysis update.

BACKGROUND: Reduction mammaplasty remains one of the most common procedures performed by plastic surgeons today. The national health care quality and fiscal environments continue to evolve, with increasing emphasis on outpatient procedures and reduced lengths of stay (LOS). This study was designed to analyze the trends in reduction mammaplasty at our institution during the last 10 years with particular attention to LOS, complication rate, and readmission. We also evaluated the institutional fiscal implications with regard to reimbursement in the changing health care environment. MATERIALS AND METHODS: Institutional review board approval was obtained for this retrospective chart review. An analysis of all reduction mammaplasties during the last 10 years was undertaken. Admission status [same day surgery (SDS), outpatient ambulatory, observation, and inpatient], LOS, mortality, morbidity, and readmissions were documented. A financial analysis was also performed comparing trends in hospital revenue and operating income. Revenue was defined as the amount that the hospital received from all sources, whereas operating income was the revenue reduced by all costs incurred to provide services. RESULTS: In this population, 1779 patients were identified (SDS, 499; outpatient ambulatory or observational, 694; and inpatient, 586). Twenty patients were readmitted within 30 days. The all-cause 30-day readmission rate was 11.24 per 1000 patients. The disease-specific readmission rate was 5.06 per 1000 patients (n=9). Only 1 patient with disease-specific complication requiring readmission had been classified as SDS. No cases of nipple compromise were identified in our study. Revenue per case was highly variable throughout the study period. In general, operating income has decreased during the last decade, despite a small increase for those patients who were truly inpatient. CONCLUSIONS: Reduction mammaplasty is a common procedure that is safe when performed on an outpatient basis. Institutional operating income, except in the case of inpatients, continues to decrease and could pose a challenge in the future should present trends continue.

The Impact of Telehealth on Primary Care Physician Panel Sizes: A Modeling Study.

INTRODUCTION: Most research on the use of telehealth in lieu of in-office visits has focused on its growth, its impact on access, and the experience of physicians and patients. One important issue that has not gotten much attention is the potential for telehealth to significantly increase physician capacity by reducing nonvalue adding activities and patient no-shows. We explore this in this article. METHODS: We use data from the electronic health records of 2 health care systems and information gathered from family medicine physician focus groups to develop estimates of visit durations and no-show rates for tele-visits. We use these in a simulation model to determine how patient panel sizes could be increased while maintaining high levels of access by substituting tele-visits for in-person visits. RESULTS: We found that tele-visits reduce the nonvalue-added time physicians spend with patients as well as patient no-shows. At current levels of tele-visit utilization, the use of tele-visits may translate into more than a 10% increase in patient panel sizes assuming a modest reduction in visit durations and no-shows, and as much as a 30% increase assuming that half of all visits could be effectively conducted virtually and result in a greater reduction in visit durations and no-shows. DISCUSSION: Our study provides evidence that a major benefit of using telehealth for many routine encounters is a reduction in wasted physician time and a substantial increase in the number of patients that a primary care physician can care for without jeopardizing access to care.

Hidradenitis Suppurativa: A Comparison of Institutional Experience and the Tracking Operations and Outcomes for Plastic Surgeons Registry.

BACKGROUND: Hidradenitis suppurativa is a chronic inflammatory dermatologic condition occurring most commonly in areas with large numbers of apocrine sweat glands. Surgical excision and wound reconstruction are indicated for severe or refractory disease. This study aims to explore institutional reconstructive outcomes following hidradenitis suppurativa excision and compare these to the nationally recognized Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database to determine best-practice guidelines. METHODS: A retrospective chart review of all patients with surgically treated hidradenitis suppurativa from January of 2004 to January of 2016 was performed. Data on patient characteristics, reconstructive methods, and outcomes were collected. Outcomes for each reconstructive method were analyzed and associations between reconstruction and complications were determined. These results were compared to TOPS data. RESULTS: A total of 382 operative sites for 101 individual patients were reviewed. Overall complication rates were 80, 68.3, and 59.6 percent for simple, intermediate, and complex closure, respectively; 68.3 percent for adjacent soft-tissue rearrangement; and 100 percent for split-thickness skin grafts and perforator flaps. Statistical significance was identified between superficial wound dehiscence and adjacent tissue rearrangement compared to intermediate and complex closure (p = 0.0132). TOPS data revealed similar wound breakdown rates for primary closure methods but much lower rates with negative-pressure wound therapy, split-thickness skin grafts, and muscle flaps. CONCLUSIONS: Primary closure techniques for hidradenitis suppurativa wound reconstruction possess high complication rates, whereas improved outcomes are observed with negative-pressure wound therapy, split-thickness skin grafts, and muscle flaps. The correlation in outcomes between our experience and that reported in the TOPS database provides a level of validation to this national database.

Plastic Surgery Training across Seven Continents: Results from the First Global Trainee Survey.

Little is known about the demographics and ambitions of plastic surgery trainees and if these differ between regions. This study sought opinion from current and recently graduated plastic surgery trainees to map demographics, training structure, and ambitions of plastic surgery trainees worldwide. Methods: A cross-sectional study was designed and administered by the international trainee organization International Confederation of Societies of Plastic Surgery Trainees. A questionnaire of 45 questions was distributed digitally through several international channels using the REDCap platform. Results: A total of 290 junior plastic surgeons, of whom 124 (42.8%) were women, from all seven International Confederation of Societies of Plastic Surgery regions, participated in this study. Of the trainees, 21% have emigrated, and 75% expressed a desire to undertake a part of their training abroad. The most common length of training in plastic surgery is 5 years. There is a difference in working hours between regions, where more than 80-hour work weeks are most common in Asia (24.1%), and work weeks of less than 40 hours are most common in Middle East (30.8%). A majority of trainees (85%) reported a research interest, and we found a negative correlation between the extent of research ambition and reported clinical workload. Conclusions: We present here the first international investigation of trainee experiences of plastic surgery training. We show that training structure and organization vary between institutions, and that plastic surgery trainees report a strong interest in international training as well as in research.

Establishing a comprehensive networkwide pressure ulcer identification process.

BACKGROUND: Pressure ulcers (PUs) are a critical concern, endangering patients and requiring significant resources for treatment in Stage II/IV. The Centers for Medicare & Medicaid Services (CMS) denies reimbursement in cases where a more complex diagnosis-related group (DRG) is assigned as a result of hospital-acquired conditions such as a PU that could have been reasonably prevented. IMPLEMENTATION: An interdisciplinary PU present-on-admission (POA) team developed an algorithm to support the early identification of PUs for units participating in the process. This approach standardized work, resulting in consistent (1) skin assessment, (2) physician notification, (3) reporting of findings in the patient safety reporting system, and (4) communication to receiving units. Computer-entry tools were developed and completed for six months by the patient care services unit-based process improvement councils; these councils made possible immediate "loop closure" for either positive feedback or needed reeducation with the nursing staff. RESULTS: The total number of PUs recognized and reported after implementation of the process improvement initiative--from April 1, 2008, to March 31, 2009--increased to 1,103--an increase of 36.3% in PU reporting when compared with the same period the year before. This initiative has yielded 100% effectiveness in identifying Stage III/IV PUs POA and in preventing hospital-acquired Stage III/IV PUs. The success of the project has helped to ensure high-quality patient care and protection of precious fiscal resources. CONCLUSIONS: The data suggest that the identification of all PUs that are present at time of admission is clinically feasible.

Impact of automobile restraint device utilization on facial fractures and fiscal implications for plastic surgeons.

In 2009, the National Highway Traffic Safety Administration projected that 33,963 people would die and millions would be injured in motor vehicle collisions (MVC). Multiple studies have evaluated the impact of restraint devices in MVCs. This study examines longitudinal changes in facial fractures after MVC as result of utilization of restraint devices. The Pennsylvania Trauma Systems Foundation-Pennsylvania Trauma Outcomes Study database was queried for MVCs from 1989 to 2009. Restraint device use was noted, and facial fractures were identified by International Classification of Diseases-ninth revision codes. Surgeon cost data were extrapolated. More than 15,000 patients sustained ≥1 facial fracture. Only orbital blowout fractures increased over 20 years. Patients were 2.1% less likely every year to have ≥1 facial fracture, which translated into decreased estimated surgeon charges. Increased use of protective devices by patients involved in MVCs resulted in a change in incidence of different facial fractures with reduced need for reconstructive surgery.

An observational study to develop a scoring system and model to detect risk of hospital admission due to COVID-19.

BACKGROUND: COVID-19 has caused an unprecedented global health emergency. The strains of such a pandemic can overwhelm hospital capacity. Efficient clinical decision-making is crucial for proper healthcare resource utilization in this crisis. Using observational study data, we set out to create a predictive model that could anticipate which COVID-19 patients would likely be admitted and developed a scoring tool that could be used in the clinical setting and for population risk stratification. METHODS: We retrospectively evaluated data from COVID-19 patients across a network of 6 hospitals in northeastern Pennsylvania. Analysis was limited to age, gender, and historical variables. After creating a variable importance plot, we chose a selection of the best predictors to train a logistic regression model. Variable selection was done using a lasso regularization technique. Using the coefficients in our logistic regression model, we then created a scoring tool and validated the score on a test set data. RESULTS: A total of 6485 COVID-19 patients were included in our analysis, of which 707 were hospitalized. The biggest predictors of patient hospitalization included age, a history of hypertension, diabetes, chronic heart disease, gender, tobacco use, and chronic kidney disease. The logistic regression model demonstrated an AUC of 0.81. The coefficients for our logistic regression model were used to develop a scoring tool. Low-, intermediate-, and high-risk patients were deemed to have a 3.5%, 26%, and 38% chance of hospitalization, respectively. The best predictors of hospitalization included age (odds ratio [OR] = 1.03, confidence interval [CI] = 1.02-1.03), diabetes (OR = 2.08, CI = 1.69-2.57), hypertension (OR = 2.36, CI = 1.90-2.94), chronic heart disease (OR = 1.53, CI = 1.22-1.91), and male gender (OR = 1.32, CI = 1.11-1.58). CONCLUSIONS: Using retrospective observational data from a 6-hospital network, we determined risk factors for admission and developed a predictive model and scoring tool for use in the clinical and population setting that could anticipate admission for COVID-19 patients.

Surgical and financial implications of genetic counseling and requests for concurrent prophylactic mastectomy.

Risk assessment evaluation and breast cancer (BRCA) testing can occur in situations where a woman considers herself to be at increased risk for developing breast cancer or her physicians, either during routine evaluation or after diagnosis of unilateral breast cancer, consider her to be at risk for harboring a genetic predisposition to breast malignancy. This study examined the impact of risk assessment counseling on trends in breast surgery and cost of care. A retrospective chart review was performed from January 1, 1999 to December 31, 2008 for women older than 18 years who underwent breast surgery for malignancy or prophylaxis, had at least 1-year follow-up, and underwent genetic counseling. From the total number of women treated at our institution who underwent unilateral or bilateral mastectomy, we identified 102 women who underwent genetic counseling and selected 199 patients who did not undergo counseling to create a 4:1 retrospective case-control study. Patients who underwent BRCA gene testing and/or counseling were compared with patients who did not (controls). The study was powered at 70%, and alpha was set at 0.05. Counseled patients were >9 times more likely to undergo bilateral mastectomies (odds ratio = 9.18). They were younger (46.4 vs. 61.8) and incurred higher total costs ($10,810 vs. $7,266) (P < 0.002). The same trend was observed in each group. In counseled and control groups, younger women chose bilateral mastectomies (mean 44.4; 55.5), whereas older women chose unilateral procedures (mean 49.8; 63.02) (P < 0.014). Total cost for bilateral mastectomies was greater than unilateral mastectomies for both groups. Of 55 counseled patients undergoing mastectomies (85 breasts), 78 (92%) breasts were reconstructed, whereas 113 (49%) of 230 breasts were reconstructed in the control group. There was a statistically significant association between counseling with BRCA testing and decision to undergo bilateral as opposed to unilateral mastectomies. Younger women were also more likely to choose bilateral mastectomies whether or not they underwent counseling. Furthermore, a greater proportion of counseled women who underwent reconstruction opted to have bilateral implants. At our institution, younger women tend to choose costlier options.