Assessing the Benefits and Downsides of Physician Review Websites to Plastic Surgeons: A Cost-Benefit Analysis.

BACKGROUND: Patients often evaluate the reputations of plastic surgeons based on their performances on physician review websites. This article aims to compare rating methodologies and conduct a cost-benefit analysis of physician review websites to further understand how plastic surgeons and their patients can utilize review websites to inform their practice and care. METHODS: A review of online literature, blogs, and 17 of the most common physician review websites was conducted to identify information on review website methodology, cost, and benefits most pertinent to plastic surgeons and their patients. RESULTS: Physician review websites utilize various combinations of physician-related and unrelated criteria to evaluate plastic surgeons. Across 17 reviewed platforms, most (71%) utilize star ratings to rate physicians, 18% require an appointment to conduct a review, and 35% feature search engine optimization. Many websites (53%) allow physicians to pay for benefits or extension packages, with benefits offered including advertising, search engine optimization, competitor blocking, social media marketing, consultant services, and data analytics. Competitor blocking was provided by the most number of websites who offered additional services for pay (78%). CONCLUSIONS: Appointments are not required to post physician reviews on many review websites, and many websites allow physicians to purchase packages to enhance their search engine optimization or consumer reach. Accordingly, plastic surgeons' reputations on review websites may be influenced by factors extraneous to actual patient care. Patients and physicians should be cognizant that physician review websites may not be reflective of factors related to quality of patient care.

Complications, Costs, and Healthcare Resource Utilization After Staged, Delayed, and Immediate Free-Flap Breast Reconstruction: A Longitudinal, Claims-Based Analysis.

BACKGROUND: There is a lack of consensus detailing the optimal approach to free-flap breast reconstruction when considering immediate, delayed, or staged techniques. This study compared costs, complications, and healthcare resource utilization (HCRU) across staged, delayed, and immediate free-flap breast reconstruction. PATIENTS AND METHODS: Retrospective study using MarketScan databases to identify women who underwent mastectomies and free-flap reconstructions between 2014 and 2018. Complications, costs, and HCRU [readmission, reoperation, emergency department (ED) visits] occurring 90 days after mastectomy and 90 days after free flap were compared across immediate, delayed, and staged reconstruction. RESULTS: Of 3310 women identified, 69.8% underwent immediate, 11.7% underwent delayed, and 18.5% underwent staged free-flap reconstruction. Staged reconstruction was associated with the highest rate (57.8% staged, 42.3% delayed, 32.0% immediate; p < 0.001) and adjusted relative risk [67% higher than immediate (95% CI: 49-87%; p < 0.001)] of surgical complications. Staged displayed the highest HCRU (staged 47.9%, delayed, 38.4%, immediate 25.2%; p < 0.001), with 16.5%, 30.7%, and 26.5% of staged patients experiencing readmission, reoperation, or ED visit, respectively. The adjusted probability of HCRU was 206% higher (95% CI: 156-266%; p < 0.001) for staged compared with immediate. Staged had the highest mean total cost (staged $106,443, delayed $80,667, immediate $76,756; p < 0.001) with regression demonstrating the adjusted mean cost for staged is 31% higher (95% CI: 23-39%; p < 0.001) when compared with immediate. CONCLUSIONS: Staged free-flap reconstruction is associated with increased complications, costs, and HCRU, while immediate demonstrated the lowest. The potential esthetic benefits of a staged approach should be balanced with the increased risk for adverse events after surgery.

An Assessment of Patient Satisfaction and Decisional Regret in Patients Undergoing Staged Free-Flap Breast Reconstruction.

BACKGROUND: In the setting of radiation therapy or significant medical comorbidities, free-flap breast reconstruction may be intentionally delayed or staged with tissue expander placement ("delayed-immediate" approach). The effect of a staged approach on patient satisfaction and decisional regret remains unclear. METHODS: All patients undergoing free-flap breast reconstruction (n = 334) between 2014 and 2019 were identified. Complication rates, patient satisfaction using the BREAST-Q, and decisional regret using the Decision Regret Scale were compared between patients undergoing immediate, delayed, and staged approaches. RESULTS: Overall, 100 patients completed the BREAST-Q and Decision Regret Scale. BREAST-Q scores for psychosocial well-being (P = 0.19), sexual well-being (P = 0.26), satisfaction with breast (P = 0.28), physical well-being (chest, P = 0.49), and physical well-being (abdomen, P = 0.42) did not significantly vary between patients undergoing delayed, staged, or immediate reconstruction. Overall, patients experienced low regret after reconstruction (mean score, 11.5 ± 17.1), and there was no significant difference in regret scores by reconstruction timing (P = 0.09). Compared with normative BREAST-Q data, unlike immediate and delayed approaches, staged reconstruction was associated with lower sexual well-being (P = 0.006). Furthermore, a significantly higher infection rate was seen among staged patients (immediate 0%, delayed 5%, staged 20%, P = 0.01). CONCLUSIONS: Staged free-flap breast reconstruction confers similar long-term satisfaction and decisional regret as immediate and delayed reconstruction but may be associated with worsened sexual well-being, when compared with normative data, and an increased risk of surgical site infection. When counseling patients regarding the timing of reconstruction, it is important to weigh these risks in the context of equivalent long-term satisfaction and decisional regret between immediate, delayed, and staged approaches.

An Assessment of Bleeding Complications Necessitating Blood Transfusion across Inpatient Plastic Surgery Procedures: A Nationwide Analysis Using the National Surgical Quality Improvement Program Database.

BACKGROUND: This study described the prevalence of bleeding complications necessitating blood transfusion across plastic surgery procedures and identified those procedures that may be associated with higher rates of bleeding. METHODS: The authors retrospectively identified patients who suffered from postoperative bleeding complications from 2010 to 2015 using the National Surgical Quality Improvement Program database. This is defined by the National Surgical Quality Improvement Program as the need for transfusion of at least one unit of packed or whole red blood cells. Patient characteristics were described using summary statistics, and National Surgical Quality Improvement Program and univariate analysis of patient characteristics and bleeding complications was performed. RESULTS: Overall, 1955 of 95,687 patients experienced bleeding complications. Patients with bleeding complications were more likely to be diagnosed with hypertension, have a longer total operative time, and have a previously diagnosed bleeding disorder. The most common primary plastic surgery procedure associated with bleeding complications was breast reconstruction with a free flap, and breast reconstruction with a pedicled transverse rectus abdominis musculocutaneous flap had the highest rate of bleeding. A return to the operating room was required in 539 patients (27.6 percent) who suffered a postoperative bleeding complication. Patients with a preexisting bleeding disorder [n = 1407 (1.5 percent)] were more likely to be diabetic, have a lower preoperative hematocrit, and have a longer operative time. In addition, these patients were more likely to suffer from other nonbleeding complications (1.29 percent versus 0.35 percent; p < 0.01). CONCLUSIONS: Complex procedures (i.e., free flap breast reconstruction) have a higher prevalence of bleeding requiring a transfusion. Furthermore, patients undergoing combined procedures-specifically, breast oncologic and reconstructive cases-may be at a higher risk for experiencing bleeding-related complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Prevalence and Cost Analysis of Chronic Pain After Hernia Repair: A Potential Alternative Approach With Neurostimulation.

OBJECTIVES: Chronic pain (CP) affects a significant number of patients following hernia repair, ranging from 11 to 54% in the literature. The aim of this study was to assess the prevalence, overall costs, and health care utilization associated with CP after hernia repair. MATERIALS AND METHODS: A retrospective longitudinal study was performed using the Truven MarketScan® data base to identify patients who develop chronic neuropathic posthernia repair pain from 2001 to 2012. Patients were grouped into CP and No Chronic Pain (No CP) cohorts. Patients were excluded if they 1) were under 18 years of age; 2) had a previous pain diagnosis; 3) had CP diagnosed <90 days after the index hernia repair; 4) had less than one year of follow-up; or 5) had less than one-year baseline record before hernia repair. Patients were grouped into the CP cohort if their CP diagnosis was made within the two years following index hernia repair. Total, outpatient, and pain prescription costs were collected in the period of five years prehernia to nine years posthernia repair. A longitudinal multivariate analysis was used to model the effects of chronic neuropathic posthernia repair pain on total inpatient/outpatient and pain prescription costs. RESULTS: We identified 76,173 patients who underwent hernia repair and met inclusion criteria (CP: n = 14,919, No CP: n = 61,254). There was a trend for increased total inpatient/outpatient and pain prescription costs one-year posthernia repair, when compared to baseline costs for both cohorts. In both cohorts, total inpatient/outpatient costs remained elevated from baseline through nine years posthernia repair, with the CP cohort experiencing significantly higher cumulative median costs (CP: $51,334, No CP: $37,388). The CP diagnosis year was associated with a 1.75-fold increase (p < 0.001) in total inpatient/outpatient costs and a 2.26-fold increase (p < 0.001) in pain prescription costs versus all other years. In the longitudinal analysis, the CP cohort had a 1.14-fold increase (p < 0.001) in total inpatient/outpatient costs and 2.00-fold increase (p < 0.001) in pain prescription costs. CONCLUSIONS: Our study demonstrates the prevalence of CP after hernia surgery to be nearly 20%, with significantly increased costs and healthcare resource utilization. While current treatment paradigms are effective for many, there remains a large number of patients that could benefit from an overall approach that includes nonopioid treatments, such as potentially incorporating neurostimulation, for CP that presents posthernia repair.

Independent Associations With 30- and 90-Day Unplanned Readmissions After Elective Lumbar Spine Surgery: A National Trend Analysis of 144 123 Patients.

BACKGROUND: Unplanned hospital readmissions contribute significantly to soaring national healthcare expenditures. To alleviate this burden, Centers for Medicare and Medicaid Services implemented initiatives to penalize hospitals for unplanned 30-d hospital readmissions. There is a paucity of data identifying patient risk factors independently associated with 30- and 90-d readmissions. OBJECTIVE: To investigate similarities in patient risk factors associated with 30- and 90-d unplanned readmissions following elective lumbar spine surgery. METHODS: The National Readmission Database (NRD) was queried to identify patients undergoing elective lumbar spine surgery between 2013 and 2014. Patients were grouped by no readmission (Non-R), unplanned readmission within 30 days (30-R), and unplanned readmission within 31 to 90 days (90-R). Multivariate analysis determined factors associated with 30- and 90-d readmissions. RESULTS: We identified 144 123 patients with 10 592 (7.3%) patients experiencing an unplanned readmission (30-R: n = 7228 [5.0%]; 90-R: n = 3364 [2.3%]; Non-R: n = 133 531). The most common inpatient complication observed in those patients readmitted was dural tear (30-R: 7.7%, 90-R: 4.6%, Non-R: 4.3%). The most prevalent 30- and 90-d complication seen among the readmitted cohort was infection (30-R: 18.5%, 90-R: 7.4%). In multivariate regression analysis, age, insurance status, chronic obstructive pulmonary disorder (COPD), depression, hypertension, diabetes, deficiency anemia, and obesity were independently associated with 30-d readmission; however, age and obesity were not independently associated with 90-d readmission. CONCLUSION: Our study demonstrated national unplanned readmission rates after elective spinal surgery to be 7.3%. With age, insurance status, COPD, depression, hypertension, diabetes, deficiency anemia, obesity, and depression all independently associated with unplanned hospital readmission. Future solutions that focus on reducing preventable readmissions may improve patient outcomes and reduce healthcare costs.

Check the Record: Remote CT Scans for Breast Flap Perforator Mapping.

BACKGROUND: Perforator mapping with computed tomography angiography (CTA) prior to autologous breast reconstruction reduces donor-site morbidity and operative time, but is costly. The aim of this study was to evaluate whether pre-existing CT scans could be used for dominant perforator identification before autologous reconstruction. METHODS: We identified all female patients who underwent mastectomy with immediate or delayed breast reconstruction with abdominal free flaps at a single institution between 2006 and 2016. Medical records were reviewed to identify patients with pre-existing CT scans of the abdomen/pelvis. CT images were reviewed by the senior surgeon and ranked on a 1 to 3 scale to indicate utility for preoperative planning. An analysis was performed to assess financial savings and radiation avoidance associated with the use of pre-existing scans. RESULTS: Of 301 identified patients, 44.9% (n = 135) had an available pre-existing CT. A dominant perforator was identified on 92.6% of scans. A higher proportion of dominant perforators was identified using positron emission tomography (PET)/CT scans compared with CT scans with intravenous (IV) contrast and noncontrast CTs (p < 0.0001). Compared with PET/CTs and CTs with IV contrast, the average utility score for noncontrast CTs was lower (p = 0.0001). Dominant perforators were clearly identified in patients who had both a remote CT scan and a preoperative CTA. Perforator mapping using remote CT scans yielded a projected radiation reduction of 13.2 mGy per patient and yielded a projected annual U.S. health care savings of $28,459,638. CONCLUSION: Our study suggests that pre-existing CT scans represent a viable and economical alternative for perforator mapping before abdominal-based free flap breast reconstruction.

Review of Neurosurgery Medical Professional Liability Claims in the United States.

BACKGROUND: Due to disparaging costs and rates of malpractice claims in neurosurgery, there has been significant interest in identifying high-risk specialties, types of malpractice claims, and characteristics of claim-prone physicians. OBJECTIVE: To characterize the malpractice claims against neurosurgeons. METHODS: This was a comprehensive analysis of all malpractice liability claims involving a neurosurgeon as the primary defendant, conducted using the Physician Insurers Association of America Data Sharing Project from January 1, 2003 and December 31, 2012. RESULTS: From 2003 to 2012, 2131 closed malpractice claims were filed against a neurosurgeon. The total amount of indemnity paid collective between 1998 to 2002, 2003 to 2007, and 2008 to 2012 was $109 614 935, $140 031 875, and $122 577 230, respectively. Of all the neurosurgery claims, the most prevalent chief medical factor was improper performance (42.1%, $124 943 933), presenting medical condition was intervertebral disc disorder (20.6%, $54 223 206), and operative procedure performed involved the spinal cord and/or spinal canal (21.0%, $62 614 995). Eighty-five (22.91%) of the total neurosurgery claims resulted in patient death, resulting in $32 067 759 paid. Improper performance of the actual procedure was the most prevalent and highest total paid cause for patient death ($9 584 519). CONCLUSION: From 2003 to 2012, we found that neurosurgery malpractice claims rank among one of the most costly and prevalent, with the average indemnities paid annually and the overall economic burden increasing. Diagnoses and procedures involving the spine, along with improper performance, were the most prevalent malpractice claims against neurosurgeons. Continued medical malpractice reform is essential to correct the overall health care cost burdens, and ultimately improve patient safety.

Prevalence and Cost Analysis of Complex Regional Pain Syndrome (CRPS): A Role for Neuromodulation.

OBJECTIVE: The diagnosis and treatment of complex regional pain syndrome (CRPS) is challenging and there is a paucity of data describing its overall cost burden and quantifying its impact on the US healthcare system. The aim of this study was to assess the prevalence and healthcare utilization costs associated with CRPS. MATERIALS AND METHODS: A retrospective longitudinal study was performed using the Truven MarketScan® database to identify patients with a new indexed diagnosis of CRPS (Type I, II, or both) from 2001 to 2012. We collected total, outpatient, and pain prescription costs three years prior to CRPS diagnosis (baseline), at year of CRPS diagnosis, and eight-year post-CRPS diagnosis. A longitudinal multivariate analysis was used to model the estimated total and pain prescription cost ratios comparing patients diagnosed before and after CRPS. RESULTS: We included 35,316 patients with a newly indexed diagnosis of CRPS (Type I: n = 18,703, Type II: n = 14,599, Unspecified: n = 2014). Baseline characteristics were similar between the CRPS cohorts. Compared to two- and three-year baseline costs, one-year prior to diagnosis for all CRPS patients yielded the highest interquartile median [IQR] costs: total costs $7904[$3469, $16,084]; outpatient costs $6706[$3119, $12,715]; and pain prescription costs $1862[$147, $7649]. At the year of CRPS diagnosis, the median [IQR] costs were significantly higher than baseline costs: total costs $8508[$3943, $16,666]; outpatient costs $7251[$3527, $13,568]; and pain prescription costs $2077[$140, $8856]. Over the eight-year period after CRPS diagnosis, costs between all the years were similar, ranging from the highest (one-year) to lowest (seven-years), $4845 to $3888. The median total cumulative cost 8-years after CRPS diagnosis was $43,026 and $12,037 for pain prescription costs. [Correction added on 06 November 2017 after first online publication: the preceding sentence has been updated to demonstrate the median cumulative cost in replacement of the additive cumulative mean costs.]. During the CRPS diagnosis period, patients are expected to have a total cost 2.17-fold and prescription cost 2.56-fold of their baseline cost annually. CONCLUSIONS: Our study demonstrates that there is a significant increase in cost and healthcare resource utilization one-year prior to and around the time of CRPS diagnosis. Furthermore, there is an increased annual cost post-diagnosis compared to baseline costs prior to CRPS diagnosis.