Hospital volume is associated with cost and outcomes variation in 2,942 pelvic reconstructions.

BACKGROUND: Complex pelvic reconstruction is challenging for plastic and reconstructive surgeons following surgical resection of the lower gastrointestinal or genitourinary tract. Complication rates and hospital costs are variable and may be linked to the hospital case volume of pelvic reconstructions performed. A comprehensive examination of these factors has yet to be performed. METHODS: Data were retrieved for patients undergoing pedicled flap reconstruction after pelvic resections in the American National Inpatient Sample database between 2010 and 2014. Patients were then separated into three groups based on hospital case volume for pelvic reconstruction. Multivariate logistic regression and gamma regression with log-link function were used to analyze associations between hospital case volume, surgical outcomes, and cost. RESULTS: In total, 2,942 patients underwent pelvic flap reconstruction with surgical complications occurring in 1,466 patients (49.8%). Total median cost was $38,469.40. Pelvic reconstructions performed at high-volume hospitals were significantly associated with fewer surgical complications (low: 51.4%, medium: 52.8%, high: 34.8%; p < 0.001) and increased costs (low: $35,645.14, medium: $38,714.92, high: $44,967.29; p < 0.001). After regression adjustment, high hospital volume was the strongest independently associated factor for decreased surgical complications (Exp[ß], 0.454; 95% Confidence Interval, 0.346-0.596; p < 0.001) and increased hospital cost (Exp[ß], 1.351; 95% Confidence Interval, 1.285-1.421; p < 0.001). CONCLUSIONS: Patients undergoing pelvic flap reconstruction after oncologic resections experience high complication rates. High case volume hospitals were independently associated with significantly fewer surgical complications but increased hospital costs. Reconstructive surgeons may approach these challenging patients with greater awareness of these associations to improve outcomes and address cost drivers.

An Effective, Reproducible, and Cost-Effective Approach for Achieving Symmetry in Bicoronal Incisions in Pediatric Patients Undergoing Craniofacial Surgery.

SUMMARY: Bicoronal incisions are frequently used for exposure and access to the craniofacial skeleton. A zigzag design is often used to camouflage the resultant scar. Often, free-hand zigzag drawings require several correction attempts to ensure symmetry because of the need for replication of multiple limbs of the bicoronal incision that need to be similar lengths, distance, and angles from each other. The authors present a novel technique using a template that rapidly and consistently achieves symmetric zigzag bicoronal incisions. The device is a hairstyling device that is inherently geometric in its design. Retrospective results of pediatric craniofacial patients from 2010 to 2018 are presented. Patients undergoing endoscopic reconstructions and patients who had prior operations at other institutions were excluded from the study. Fifty-two patients met inclusion criteria, with age at surgery ranging from 3 to 207 months (mean, 17 months). Follow-up ranged from 1 to 66 months (mean, 26 months). Data collected included demographics, type of surgery, and operative outcomes, including incision-related complications. Using this dynamic hairstyling device in a novel application as a template results in a fast, effective, and easily reproducible symmetric bicoronal zigzag incision in all cases. This technique eliminates the need for adjusting the length and angles of bicoronal incisions, and it can be adapted across a variety of head sizes and shapes in both pediatric and adult populations.

Truth-in-Advertising Laws: Are They Working? A Cross-Sectional Analysis of a "Plastic Surgeon" Patient Search Simulation.

BACKGROUND: Non-board-certified plastic surgeons performing cosmetic procedures and advertising as plastic surgeons may have an adverse effect on a patient's understanding of their practitioner's medical training and patient safety. The authors aim to assess (1) the impact of city size and locations and (2) the impact of health care transparency acts on the ratio of board-certified and non-American Board of Plastic Surgeons physicians. METHODS: The authors performed a systematic Google search for the term "plastic surgeon [city name]" to simulate a patient search of online providers. Comparisons of board certification status between the top hits for each city were made. Data gathered included city population, regional location, practice setting, and states with the passage of truth-in-advertising laws. RESULTS: One thousand six hundred seventy-seven unique practitioners were extracted. Of these, 1289 practitioners (76.9 percent) were American Board of Plastic Surgery-certified plastic surgeons. When comparing states with truth-in-advertising laws and states without such laws, the authors found no significant differences in board-certification rates among "plastic surgery" practitioners (88.9 percent versus 92.0 percent; p = 0.170). There was a significant difference between board-certified "plastic surgeons" versus out-of-scope practitioners on Google search between large, medium, and small cities (100 percent versus 92.9 percent versus 86.5; p < 0.001). CONCLUSIONS: Non-board-certified providers tend to localize to smaller cities. Truth-in-advertising laws have not yet had an impact on the way a number of non-American Board of Plastic Surgery-certified practitioners market themselves. There may be room to expand the scope of truth-in-advertising laws to the online world and to smaller cities.

Socioeconomic Disparities in Brachial Plexus Surgery: A National Database Analysis.

BACKGROUND: Brachial plexus injuries have devastating effects on upper extremity function, with significant pain, psychosocial stress, and reduced quality of life. The aim of this study is to identify socioeconomic disparities in the receipt of brachial plexus repair in the emergent versus elective setting, and in the use of supported services on discharge. METHODS: Analysis of the Healthcare Cost and Utilization Project National Inpatient Sample Database was performed for the years 2009-2014. Adults with brachial plexus injury with or without nerve repair were identified; patient and hospital specific factors were analyzed. RESULTS: Overall, 6,618 cases of emergent brachial plexus injury were retrieved. Six hundred sixty cases of brachial plexus repair were identified in the emergency and elective settings over the study period. Of the 6,618 injured, 153 (2.3%) underwent nerve surgery during the admission. Patients undergoing repair in the elective setting were more likely to be white males with private insurance. Patients treated in the emergency setting were more likely to be African American and in the lowest income quartile. Significant differences were also seen in supported discharge: more likely males (P < 0.001), >55 years of age (P < 0.001), white (P < 0.001), with government-based insurance (P < 0.001). CONCLUSIONS: There are significant disparities in the timing of brachial plexus surgery. These relate to timing rather than receipt of nerve repair; socioeconomically advantaged individuals with private insurance in the higher income quartiles are more likely to undergo surgery in the elective setting and have a supported discharge.

Treatment of Craniosynostosis: The Impact of Hospital Surgical Volume on Cost, Resource Utilization, and Outcomes.

The authors aim to quantify the impact of hospital volume of craniosynostosis surgery on inpatient complications and resource utilization using national data. Children <12 months with nonsyndromic craniosynostosis who underwent surgery in 2012 at academic hospitals in the United States were identified from the Kids' Inpatient Database (KID) developed by the Healthcare Cost and Utilization Project (HCUP). Hospital craniosynostosis surgery volume was stratified into tertiles based on total annual hospital cases: low volume (LV, 1-13), intermediate volume (IV, 14-34), and high volume (HV, ≥35). Outcomes of interest include major complications, blood transfusion, charges, and length of stay (LOS). In 2012, 154 hospitals performed 1617 total craniosynostosis surgeries. Of these 580 cases (35.8%) were LV, 549 cases (33.9%) were IV, and 488 cases (30.2%) were HV. There was no difference in major complications between hospital volume tertiles (4.3% LV; 3.8% IV; 3.1% HV; P = 0.487). The highest blood transfusion rates were seen at LV hospitals (47.8% LV; 33.9% IV; 26.2%; P < 0.001). Hospital charges were lowest at HV hospitals ($55,839) compared with IV hospitals ($65,624; P < 0.001) and LV hospitals ($62,325; P = 0.005). Mean LOS was shortest at HV hospitals (2.96 days) compared with LV hospitals (3.31 days; P = 0.001); however, there was no difference when compared with IV hospitals (3.07 days; P = 0.282). Hospital case volume may be an important associative factor of blood transfusion rates, LOS, and hospital charges; however, there is no difference in complication rates. These results may be used to guide quality improvement within the surgical management of craniosynostosis.

The Impact of Surgical Volume on Outcomes and Cost in Cleft Repair: A Kids' Inpatient Database Analysis.

BACKGROUND: Centralization of specialist services, including cleft service delivery, is occurring worldwide with the aim of improving the outcomes. This study examines the relationship between hospital surgical volume in cleft palate repair and outcomes. METHODS: A retrospective analysis of the Kids' Inpatient Database was undertaken. Children 3 years or younger undergoing cleft palate repair in 2012 were identified. Hospital volume was categorized by cases per year as low volume (LV; 0-14), intermediate volume (IV; 15-46), or high volume (HV; 47-99); differences in complications, hospital costs, and length of stay (LOS) were determined by hospital volume. RESULTS: Data for 2389 children were retrieved: 24.9% (n = 595) were LV, 50.1% (n = 1196) were IV, and 25.0% (n = 596) were HV. High-volume centers were more frequently located in the West (71.9%) compared with LV (19.9%) or IV (24.5%) centers (P < 0.001 for hospital region). Median household income was more commonly highest quartile in HV centers compared with IV or LV centers (32.3% vs 21.7% vs 18.1%, P < 0.001). There was no difference in complications between different volume centers (P = 0.74). Compared with HV centers, there was a significant decrease in mean costs for LV centers ($9682 vs $,378, P < 0.001) but no significant difference in cost for IV centers ($9260 vs $9682, P = 0.103). Both IV and LV centers had a significantly greater LOS when compared with HV centers (1.97 vs 2.10 vs 1.74, P < 0.001). CONCLUSIONS: Despite improvement in LOS in HV centers, we did not find a reduction in cost in HV centers. Further research is needed with analysis of outpatient, long-term outcomes to ensure widespread cost-efficiency.

Indocyanine Green Angiography Use in Breast Reconstruction: A National Analysis of Outcomes and Cost in 110,320 Patients.

BACKGROUND: Indocyanine green angiography has gained popularity in breast reconstruction for its ability to assess mastectomy skin and tissue flap viability. The authors aim to analyze trends and outcomes associated with indocyanine green angiography use in breast reconstruction. METHODS: Using 2012 to 2014 data from the Healthcare Cost and Utilization Project National Inpatient Sample, Agency for Healthcare Research and Quality, the authors identified breast reconstructions performed with or without indocyanine green angiography use. Trends over time were assessed using the Cochran-Armitage test. Outcomes were assessed using logistic regression and generalized linear modeling. RESULTS: Over the study period, 110,320 patients underwent breast reconstruction: 107,005 (97.0 percent) without and 3315 (3.0 percent) with indocyanine green angiography use. Usage increased over time: 750 patients (1.9 percent) in 2012, increasing to 1275 patients (3.7 percent) in 2013 (p < 0.001). Smokers (p = 0.018), hypertensive patients (p = 0.046), obese patients (p < 0.001), and those with a higher comorbidity index (p < 0.001) were more likely to undergo indocyanine green angiography. Autologous reconstruction was more frequently combined with its use compared with tissue expander reconstruction (4.5 percent versus 2.1 percent; p < 0.001). There was a significant increase in the odds of débridement associated with its use (OR, 1.404; p < 0.001; 95 percent CI, 1.201 to 1.640). CONCLUSIONS: Indocyanine green angiography use in breast reconstruction has increased in recent years and is associated with higher débridement rates. These rates may indicate changing trends for clinicians when deciding whether to débride tissue during breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Drivers of Hospital Costs in the Self-Pay Facelift (Rhytidectomy) Patient: Analysis of Hospital Resource Utilization in 1890 Patients.

INTRODUCTION: Rhytidectomy is one of the most commonly performed cosmetic procedures by plastic surgeons. Increasing attention to the development of a high-value, low-cost healthcare system is a priority in the USA. This study aims to analyze specific patient and hospital factors affecting the cost of this procedure. METHODS: We conducted a retrospective cohort study of self-pay patients over the age of 18 who underwent rhytidectomy using the Healthcare Utilization Cost Project National Inpatient Sample database between 2013 and 2014. Mean marginal cost increases patient characteristics, and outcomes were studied. Generalized linear modeling with gamma regression and a log-link function were performed along with estimated marginal means to provide cost estimates. RESULTS: A total of 1890 self-pay patients underwent rhytidectomy. Median cost was $11,767 with an interquartile range of $8907 [$6976-$15,883]. The largest marginal cost increases were associated with postoperative hematoma ($12,651; CI $8181-$17,120), West coast region ($7539; 95% CI $6412-$8666), and combined rhinoplasty ($7824; 95% CI $3808-$11,840). The two risk factors associated with the generation of highest marginal inpatient costs were smoking ($4147; 95% CI $2804-$5490) and diabetes mellitus ($5622; 95% CI $3233-8011). High-volume hospitals had a decreased cost of - $1331 (95% CI - $2032 to - $631). CONCLUSION: Cost variation for inpatient rhytidectomy procedures is dependent on preoperative risk factors (diabetes and smoking), postoperative complications (hematoma), and regional trends (West region). Rhytidectomy surgery is highly centralized and increasing hospital volume significantly decreases costs. Clinicians and hospitals can use this information to discuss the drivers of cost in patients undergoing rhytidectomy. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The financial impact and drivers of hospital charges in contralateral prophylactic mastectomy and reconstruction: a Nationwide Inpatient Sample hospital analysis.

PURPOSE: Rates of contralateral prophylactic mastectomy (CPM) have increased over the last decade; it is important for surgeons and hospital systems to understand the economic drivers of increased costs in these patients. This study aims to identify factors affecting charges in those undergoing CPM and reconstruction. METHODS: Analysis of the Healthcare Cost and Utilization Project National Inpatient Sample was undertaken (2009-2012), identifying women aged ≥18 with unilateral breast cancer undergoing unilateral mastectomy with CPM and immediate breast reconstruction (IBR) (CPM group), in addition to unilateral mastectomy and IBR alone (UM group). Generalized linear modeling with gamma regression and a log-link function provided mean marginal hospital charge (MMHC) estimates associated with the presence or absence of patient, hospital and operative characteristics, postoperative complications, and length of stay (LOS). RESULTS: Overall, 70,695 women underwent mastectomy and reconstruction for unilateral breast cancer; 36,691 (51.9%) in the CPM group, incurring additional MMHCs of $20,775 compared to those in the UM group (p < 0.001). In the CPM group, MMHCs were reduced in those aged >60 years (p < 0.001), while African American or Hispanic origin increased MMHCs (p < 0.001). Diabetes, depression, and obesity increased MMHCs (p < 0.001). MMHCs increased with larger (p < 0.001) hospitals, Western location (p < 0.001), greater household income (p < 0.001), complications (p < 0.001), and increasing LOS (p < 0.001). MMHCs decreased in urban teaching hospitals and Midwest or Southern regions (p < 0.001). CONCLUSION: There are many patient and hospital factors affecting charges; this study provides surgeons and hospital systems with transparent, quantitative charge data in patients undergoing contralateral prophylactic mastectomy and immediate breast reconstruction.