Microvascular Breast Reconstruction in the Era of Value-Based Care: Use of a Cosurgeon Is Associated with Reduced Costs, Improved Outcomes, and Added Value.

BACKGROUND: Reducing complications while controlling costs is a central tenet of value-based health care. Bilateral microvascular breast reconstruction is a long operation with a relatively high complication rate. Using a two-surgeon team has been shown to improve safety in bilateral microvascular breast reconstruction; however, its impact on cost and efficiency has not been robustly studied. The authors hypothesized that a cosurgeon for bilateral microvascular breast reconstruction is safe, effective, and associated with reduced costs. METHODS: The authors retrospectively reviewed all patients who underwent bilateral microvascular breast reconstruction with either a single surgeon or surgeon/cosurgeon team over an 18-month period. Charges were converted to costs using the authors' institutional cost-to-charge ratio. Surgeon opportunity costs were estimated using time-driven activity-based costing. Propensity scoring controlled for baseline characteristics between the two groups. A locally weighted logistic regression model analyzed the cosurgeon's impact on outcomes and costs. RESULTS: The authors included 150 bilateral microvascular breast reconstructions (60 single-surgeon and 90 surgeon/cosurgeon reconstructions) with a median follow-up of 15 months. After matching, the presence of a cosurgeon was associated with a significantly reduced mean operative duration (change in operative duration, -107 minutes; p < 0.001) and cost (change in total cost, -$1101.50; p < 0.001), which was even more pronounced when surgeon/cosurgeon teams worked together frequently (change in operative duration, -132 minutes; change in total cost, -$1389; p = 0.007). The weighted logistic regression models identified that a cosurgeon was protective against breast-site complications and trended toward reduced overall and major complication rates. CONCLUSION: The practice of using a of cosurgeon appears to be associated with reduced costs and improved outcomes, thereby potentially adding value to bilateral microvascular breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Relationship Between Financial Toxicity and Surgical Treatment for Early-Stage Breast Cancer: A Propensity Score-Matched Comparison of Breast-Conserving Therapy and Mastectomy.

BACKGROUND: Financial toxicity (FT) can lead to decreased quality of life and poor treatment outcomes. However, there is limited published data on the extent to which the various surgical treatment approaches for early-stage breast cancer are determinants for FT. STUDY DESIGN: We performed a single-institution cross-sectional survey of adult female patients with stage 0 to II breast cancer undergoing unilateral breast-conserving therapy or unilateral mastectomy. FT was measured using the Comprehensive Score for Financial Toxicity (COST) survey. Propensity matching was performed to optimize comparability of study groups. A multivariate regression model was used to identify factors associated with worsening FT as a robustness check. Our secondary end point was prevalence of coping strategies associated with cost of cancer care. RESULTS: Among 294 patients who met inclusion criteria, 203 underwent breast-conserving therapy and 91 received mastectomy. We generated 72 total matched pairs and noted no differences in demographic and socioeconomic characteristics. Of these, 55 pairs had complete COST information, which was comparable on adjusted analysis (26.6 vs 24.7; p = 0.481). High annual income (ß = 4.83; p < 0.001) and supplemental insurance (ß = 5.37; p < 0.001) were significantly associated with higher COST scores, while change in employment status (ß = -4.81; p < 0.001) correlated significantly with lower COST scores. No significant differences were observed in coping strategies. CONCLUSIONS: Choice of BCT or mastectomy was not associated with a differential risk for FT in early-stage cancer. Decisions on ablative approach should be made based on patient preferences and disease-specific criteria. Transparent counseling on FT for high-risk populations promotes patient-centricity.

Interview Scores Correlate with Fellow Microsurgical Skill and Performance.

BACKGROUND: The interview process for surgical trainees aims to select those individuals who will perform best during training and have the greatest potential as future surgeons. The objective of this study was to evaluate the relationship between criteria assessed at interview, technical skills, and performance, for the first time, to optimize the selection process for a Microsurgery fellowship. METHODS: Twenty microsurgery fellows in three consecutive annual cohorts at a single academic center were prospectively evaluated. At interview, subjects were scored for multiple standardized domains. At the start and at end of the fellowship, microsurgical technical skill was assessed both in the laboratory and operating room (OR) using a validated assessment tool. At the end of the fellowship, there was a final evaluation of performance. RESULTS: At the start, microsurgical skill significantly correlated with almost all domains evaluated at interview, most closely with prior plastic surgery training experience. At the end of the fellowship, skill level improved in all trainees, with the greatest improvement made by the lowest ranked and skilled trainees. The highest ranked trainees, however, made the greatest improvement in speed. CONCLUSIONS: The results of this study, for the first time, validate the current interview process to correctly select the highest performing and most skilled candidates and support the effectiveness of a 1-year microsurgical fellowship in improving microsurgical skill in all trainees, irrespective of their initial ability. The importance of valuing the relative quality of prior training and experience at selection is also highlighted.

Factors Correlating With Microsurgical Performance: A Clinical and Experimental Study.

BACKGROUND: Microsurgery is one the most complex surgical skills to master. The factors correlating with microsurgical performance, however, are poorly understood. Understanding these factors will aid in the training and assessment of microsurgeons. METHODS: A total of 29 microsurgery fellows enrolled in a dedicated 1-year microsurgery fellowship were included in the study. For the clinical evaluations, microsurgical anastomosis performance was evaluated during multiple procedures in the operating room at the start, midpoint, and end of the fellowship by all departmental faculty using a validated microsurgical assessment tool. For the laboratory evaluations, blinded video recordings of each fellow performing an arterial femoral anastomosis in a live rat model at the start and end of the fellowship were evaluated using 3 validated microsurgical global ratings scale tools. Correlations between performance and the factors assessed by the tools were evaluated. RESULTS: In the clinical study there were a total of 474 anastomosis evaluations; clinical performance correlated best with speed, instrument handling, and motion. In the laboratory study 58 evaluations were conducted, and performance tracked most closely with instrument handling, flow of operation, and operative steps, as well as correlating significantly inversely with time taken. The most common errors committed were unequal stitch bites, wrong grasp/damage tissue, and loose knot. CONCLUSIONS: Speed, both subjective and objective, instrument handling, operative flow, and motion, were relevant to performance of a microsurgical anastomosis. A prospective trial is now necessary to determine whether these factors should be considered in definitions of competency in microsurgery training pathways.