Delivery of nipple-sparing mastectomy within a single healthcare system: The impact of provider preferences.

Nipple-sparing mastectomy (NSM) offers superior esthetic outcomes without sacrificing oncologic safety for select patients requiring mastectomy. While disparities in oncologic care are well established, no study to date has investigated equitable delivery of the various mastectomy types. The objective of this study is to examine multilevel factors related to the distribution of NSM. Patients undergoing mastectomy between 2014 and 2018 across eight hospitals in a single healthcare system were retrospectively reviewed. Patients were categorized by mastectomy type-NSM or other mastectomy (OM). Patient information such as age, race, comorbidities, and median income by ZIP code was collected. Disease characteristics, such as mastectomy weight, breast cancer stage, and treatment history, were identified. Provider and system-level variables, such as specific provider, hospital of operation, and insurance status, were determined. Bivariate analysis was used to identify variables for inclusion in a backward multivariable model. A cohort of 1202 mastectomy patients was identified, with 388 receiving NSM. The average age was 55.8 years (NSM: 48.8, OM: 59.1, P < .001). 39.8% of white patients (n = 242) and 20.0% of African American patients (n = 88) received NSM (P < .001). Average mastectomy weight was 384.3 (SD 195.7) in the NSM group, compared to 839.4 (SD 521.1) in the OM group (P < .001). 41.4% (n = 359) of patients treated at academic centers, and 6.9% (n = 21) of patients treated at community centers received NSM (P < .001). In the multivariate model, the factor with the largest impact on NSM was specific provider. Odds of NSM decreased by 76%-88% for certain surgeons, while odds increased by 63 times for one surgeon. This study utilizes a large multi-institutional database to highlight disparities in NSM delivery. Expectedly, younger, relatively healthy patients, with smaller breast size were more likely to undergo NSM, in accordance with surgical guidelines. However, when all other factors were controlled, provider preferences played the most significant role in NSM delivery rates. These findings demonstrate the need for practice reexamination to ensure equitable access to NSM.

Critical evaluation of factors contributing to time to mastectomy within a single health care system.

Increased time to mastectomy (TTM) has significant implications for mortality, well-being, and satisfaction. However, certain populations are subject to disparities that increase TTM. This study examines vulnerable populations and the patient-, disease-, provider-, and system-level factors related to treatment delays. Patients undergoing mastectomy for breast cancer from 2014 to 2018 across 8 hospitals in a single health care system were retrospectively reviewed. Demographics, disease characteristics, and provider- and system-level information were collected. Time from biopsy-proven diagnosis to mastectomy was calculated. Univariate analysis identified variables for inclusion in the multivariable model. One thousand, three hundred thirty patients met inclusion. Median TTM was 55.0 days. Factors from all levels-patient, disease, provider, and systemic-were significantly related to disparities. African-American patients had 11.6% longer TTM compared to white patients (69.0 vs 56.0 days, P < .0001). TTM was 15.5% longer for low-income patients when compared to high-income patients (65.0 vs 49.0 days, P = .0014). Preoperative plastic surgery visits led to 19.3% longer TTM (P = .0012); oncologic appointments for neo-adjuvant chemotherapy led to a 231.0% increase (P < .0001). Average time from last neo-adjuvant treatment to mastectomy was 44.4 days (SD 26.5); average TTM from diagnosis for patients not receiving neo-adjuvant chemotherapy was 58.5 days (SD 13.3). Patients with Medicaid waited 14.5% longer compared to patients with commercial insurance (94.0 vs 62.0 days, P = .0005). In our review of care across a large health care system, we identified multiple levels contributing to disparities in TTM. Identification of these disparities offers valuable insight into process improvement and intervention.

Is Fear of Falling the Missing Link to Explain Racial Disparities in Fall Risk? Data from the National Health and Aging Trends Study.

OBJECTIVES: Emerging research suggests Black older adults experience a 30% decreased risk for falls compared with their White U.S. counterparts, and this is mediated neither by physical performance nor activity. Fear of falling (FOF) is a significant risk factor for falls, yet we know little about how FOF varies by race/ethnicity. The purpose of this original research brief was to investigate the relationship between race/ethnicity and FOF among older adults. METHODS: 4,981 community-dwelling Medicare beneficiaries from the National Health and Aging Trends Study (NHATS) who had not self-reported a fall in the past 12 months were analyzed. Logistic regression analyses were conducted to examine the association between race/ethnicity and fear of falling, controlling for sex, age, total annual income, and mobility assistance. RESULTS: FOF differed significantly across racial groups. Black, non-Hispanic older adults were less likely to have FOF (OR = .87, 95% CI = .71,1.07) compared with their White, non-Hispanic counterparts. In the fully adjusted model, this difference persisted and became stronger (adjusted OR = .75, 95%CI = .61, .93). CONCLUSION: The decreased risk for falls in Black older adults could be explained by lower FOF in this group. CLINICAL IMPLICATIONS: These findings should inform public health fall prevention initiatives among community-dwelling older adults.

Efficacy of Electronic Reminders in Increasing the Enhanced Recovery After Surgery Protocol Use During Major Breast Surgery: Prospective Cohort Study.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are patient-centered, evidence-based guidelines for peri-, intra-, and postoperative management of surgical candidates that aim to decrease operative complications and facilitate recovery after surgery. Anesthesia providers can use these protocols to guide decision-making and standardize aspects of their anesthetic plan in the operating room. OBJECTIVE: Research across multiple disciplines has demonstrated that clinical decision support systems have the potential to improve protocol adherence by reminding providers about departmental policies and protocols via notifications. There remains a gap in the literature about whether clinical decision support systems can improve patient outcomes by improving anesthesia providers' adherence to protocols. Our hypothesis is that the implementation of an electronic notification system to anesthesia providers the day prior to scheduled breast surgeries will increase the use of the already existing but underused ERAS protocols. METHODS: This was a single-center prospective cohort study conducted between October 2017 and August 2018 at an urban academic medical center. After obtaining approval from the institutional review board, anesthesia providers assigned to major breast surgery cases were identified. Patient data were collected pre- and postimplementation of an electronic notification system that sent the anesthesia providers an email reminder of the ERAS breast protocol the night before scheduled surgeries. Each patient's record was then reviewed to assess the frequency of adherence to the various ERAS protocol elements. RESULTS: Implementation of an electronic notification significantly improved overall protocol adherence and several preoperative markers of ERAS protocol adherence. Protocol adherence increased from 16% (n=14) to 44% (n=44; P<.001), preoperative administration of oral gabapentin (600 mg) increased from 13% (n=11) to 43% (n=43; P<.001), and oral celebrex (400 mg) use increased from 16% (n=14) to 35% (n=35; P=.006). There were no statistically significant differences in the use of scopolamine transdermal patch (P=.05), ketamine (P=.35), and oral acetaminophen (P=.31) between the groups. Secondary outcomes such as intraoperative and postoperative morphine equivalent administered, postanesthesia care unit length of stay, postoperative pain scores, and incidence of postoperative nausea and vomiting did not show statistical significance. CONCLUSIONS: This study examines whether sending automated notifications to anesthesia providers increases the use of ERAS protocols in a single academic medical center. Our analysis exhibited statistically significant increases in overall protocol adherence but failed to show significant differences in secondary outcome measures. Despite the lack of a statistically significant difference in secondary postoperative outcomes, our analysis contributes to the limited literature on the relationship between using push notifications and clinical decision support in guiding perioperative decision-making. A variety of techniques can be implemented, including technological solutions such as automated notifications to providers, to improve awareness and adherence to ERAS protocols.

Review of Autologous Fat Grafting in Postmastectomy Reconstruction Patients: Nonroutine Diagnostics and Oncologic Safety.

Autologous fat grafting (FG) is increasingly used as an adjunctive reconstruction technique to augment volume, achieve symmetry, and improve contour deformities. This study aims to characterize the oncologic and surgical safety of FG in women undergoing autologous breast reconstruction (ABR) or implant-based reconstruction (IBR). Methods: A retrospective chart review was performed for all patients undergoing FG at a multi-site single health system between 2015 to 2018. A total of 228 eligible breasts from 155 patients were identified using Current Procedural Terminology codes. Patients were divided by reconstructive technique. Bivariate analyses compared baseline characteristics and post-FG outcomes. Results: Mean age for patients undergoing ABR (129 breasts) was 52.8 years compared to 48.6 years for those undergoing IBR (99 breasts; P = 0.002). A heavier volume of fat was grafted per ABR breast (143.8mL) than per IBR breast (102.2mL; P = 0.002). Forty-seven (20.6%) breasts required FG revision, more frequently in ABR breasts (31.0%) than IBR breasts (7.1%; P < 0.001). Following FG, 17.5% of patients experienced a palpable mass, and 18.9% of breasts underwent nonroutine diagnostics or procedures, with no difference between ABR and IBR groups. Most biopsies noted benign findings such as fat necrosis (2.2%) or a benign mass (0.9%), with recurrence only noted in two patients (0.9%). Mean follow-up was 20.4 months. Conclusion: FG is a safe, surgically simple procedure more commonly performed in ABR breasts. FG use in ABR and IBR breasts is oncologically safe, with no impairment in breast surveillance and low rates of locoregional recurrence, but possibly increased incidence of nonroutine imaging and biopsies.

Are US Plastic Surgery Residents Equipped to Face the Opioid Epidemic? A National Survey.

The United States opioid epidemic is among this century's most profound threats to public health and demands that all physicians consider their role in reversing its trajectory. Previous literature demonstrated that plastic surgery trainees lack vital practices that promote opioid stewardship. However, it is not understood why this practice gap exists. This is a national survey-based study evaluating the availability and effectiveness of opioid education in US plastic surgery programs. A total of 91 residents completed the survey. Our study found that there is an unmet need for practical and comprehensive training regarding safe opioid prescribing among plastic surgery trainees. "Informal training," defined as the "learn as you go" method, was found to be more common than formal training and considerably more valuable according to trainees. Trainees cited real-world applicability of informal training and that it comes from teachers whom they know and trust as valuable attributes of this type of education. Furthermore, the severity of the opioid epidemic has not translated into improved trainee education, as there was no significant difference in knowledge on safe opioid prescribing practices between junior and senior residents. To change the course of the epidemic, plastic surgery programs need to better train younger generations who believe they are critical stakeholders. This study lays the framework for the "formalization of informal training," and the creation of practical and efficacious educational initiatives.

Perspectives of Women Who Forgo Post-mastectomy Breast Reconstruction: A Mixed Methods Analysis.

Despite a growing body of evidence suggesting improved psychosocial well-being and survival after post-mastectomy breast reconstruction (PMBR), rates remain stagnant at approximately 40%. Although PMBR access and utilization have been well reported, there is much less known from the point of view of women who decide not to undergo PMBR. This study uses a mixed methods approach to fill that gap by investigating the patient-level decisions that lead to foregoing PMBR. METHODS: A concurrent triangulation model under mixed methods research (MMR) was employed using in-depth qualitative interviews and the BREAST-Q questionnaire. Interviews were conducted until data saturation was reached and were analyzed using iterative methodologies under the grounded-theory framework. Reliability checks included inter-rater reliability using Cohen's kappa statistic (mean kappa = 0.99) and triangulation. RESULTS: Interviews with 8 patients who declined PMBR revealed (1) lack of trust in plastic surgeons; (2) reliance on self-developed support; (3) desire to resume normal life; (4) perceived lack of equivalency between reconstructed and natural breasts. Concurrent triangulation between the data revealed dissonance between the BREAST-Q scores for psychosocial well-being and reported levels of satisfaction. CONCLUSIONS: Women in this study highlighted certain deficits in the current pathway to reconstruction: lack of trust, resources, and counseling. Such feelings of suspicion and reported opposition to PMBR are at odds with low scores for satisfaction with breasts and sexual well-being. These findings can be used to guide efforts that engender confidence, provide support, empower vulnerable patient groups, and increase utilization of PMBR.

Microsurgical vascular clamp injury causing arterial stenosis and subsequent free flap necrosis: A case report.

During microanastomosis, the recipient artery must be controlled both proximally and distally, so that the donor flap artery may be anastomosed. Bulldog vascular clamps are often used; however, these clamps may fail to occlude heavily calcified vessels characteristic of diabetes and end-stage renal disease. Alternative clamps may need to be utilized, with the attendant risk of vessel injury. Herein, we present a case of free flap necrosis secondary to vascular clamp-mediated periansastomotic stenosis of a calcified free flap recipient artery. In this case, a 74-year-old diabetic male underwent anterolateral thigh free flap reconstruction for a left medial foot wound. The recipient's dorsalis pedis artery was noted to be heavily calcified intraoperatively and Bulldog clamps were unable to gain proximal and distal control, requiring the use of small-angled DeBakey vascular clamps. Ischemic flap changes were noted on postoperative day four. Subsequent angiogram demonstrated severe stenosis at the perianastomotic sites of the dorsalis pedis where the DeBakey clamps were placed for control. The arterial lesions were treated with balloon angioplasty and the patient underwent multiple debridements and placement of a split-thickness skin graft over the wound. At the six-month follow up, the wound achieved complete healing with insetting of the skin graft. In certain cases, the use of DeBakey or Satinsky clamps for arterial control in microsurgery may predispose the artery to intimal injury, causing stenosis that should be recognized early so that arteriography may be performed expeditiously. In this study, alternative methods of vascular control are described.

Use of Flap Salvage for Lower Extremity Chronic Wounds Occurs Most Often in Competitive Hospital Markets.

Wounds in the comorbid population require limb salvage to prevent amputation. Extensive health economics literature demonstrates that hospital activities are influenced by level of market concentration. The impact of competition and market concentration on limb salvage remains to be determined. METHODS: Admissions for chronic lower extremity wounds in nonrural hospitals were identified in the 2010-2011 National Inpatient Survey using ICD-9-CM diagnosis codes. The study cohort consisted of admitted patients receiving amputations, salvage without flap techniques (eg, skin grafts), or salvage with flap techniques. The all-service Herfindahl-Hirschman Index (HHI), which is a commonly used tool for market and antitrust analyses, was used to measure hospital competition. Multinomial regression analysis accounting for the complex survey design of the NIS was used to determine the relationship between the HHI and hospital adoption of limb salvage controlling for patient, hospital, and market factors. RESULTS: The study cohort represents 124,836 admissions nationally: 89,880 amputations, 26,715 salvage without flap techniques, and 8241 salvage flap techniques. Diabetics accounted for 64.1% of all study admissions. Hospitals in highly competitive markets performed more flaps for chronic lower extremity wounds than noncompetitive markets. Controlling for other factors, hospitals in highly competitive markets, relative to those in highly concentrated markets, were 2.48 percentage points more likely to perform limb salvage with flaps (P < 0.01). Other factors were less predictive. CONCLUSION: Increased hospital competition is the strongest systems-level predictor of receipt of lower extremity flaps among patients with chronic wounds. Improving access to reconstructive limb services must consider the competitive structure of hospital markets.

Telemedicine in the Wake of the COVID-19 Pandemic: Increasing Access to Surgical Care.

The COVID-19 pandemic has brought seismic shifts in healthcare delivery. The objective of this study was to examine the impact of telemedicine in the disadvantaged population. METHODS: All consecutive patients with outpatient appointments amongst 5 providers in the Plastic and Reconstructive Surgery Department between March 2, 2020, and April 10, 2020, were retrospectively reviewed. Appointment and patient characteristics collected include visit modality, reason for visit, new or established patient, history of recorded procedure, age, sex, race, insurance provider, urban/rural designation of residence, Social Vulnerability Index, and income. The primary outcome of interest was whether or not a patient missed their appointment (show versus no-show). RESULTS: During the study period, there were a total of 784 patient appointments. Before the COVID-19 pandemic, patients with a higher Social Vulnerability Index were more likely to have a no-show appointment (0.49 versus 0.39, P = 0.007). Multivariate regression modeling showed that every 0.1 increase in Social Vulnerability Index results in 1.32 greater odds of loss to follow-up (P = 0.045). These associations no longer held true after the lockdown. CONCLUSIONS: This study indicates a reduction in disparity and an increase in access following the dramatically increased use of telemedicine in the wake of the COVID-19 pandemic. Although drawbacks to telemedicine exist and remain to be addressed, the vast majority of literature points to an overwhelming benefit-both for patient experience and outcomes-of utilizing telemedicine. Future studies should focus on improving access, reducing technological barriers, and policy reform to improve the spread of telemedicine.

Conceptual Framework for a Plastic Surgery Residency Leadership Curriculum.

Leadership development remains an overlooked component in the plastic surgery residency curriculum. Through a mixed-methods assessment of physician perceptions, this study aims to establish the value and structure of a formal leadership course for trainees. METHODS: Qualitative interviews were conducted with plastic surgery residents to identify common themes concerning the current state of leadership training and goals for improvement. These themes then guided the design of a quantitative assessment, which surveyed faculty and residents regarding their perceived need for a curriculum, the domains that should be included, and the format of delivery. RESULTS: Six residents underwent interviews, which yielded the following themes: (1) surgical residents require a distinct set of leadership skills that warrants more intensive training and (2) leadership training should assume a more structured format. The survey achieved a 76% (29/38) response rate, with residents comprising 55% of respondents. Participants were neutral to slightly satisfied with current resident leadership and "learning on the job" (4.62 and 4.03 on a 7-point Likert scale, respectively). Respondents reported a moderate need for formal leadership training (2.97 on a 5-point scale). Availability was ranked as the greatest barrier to curriculum implementation. Topics considered most important included effective communication, self-awareness/emotional intelligence, and strategic thinking. Formats considered most effective included in-person lectures, small group exercises, and case studies. CONCLUSION: This study presents a conceptual framework for the implementation of a leadership curriculum for plastic surgery residents that may empower the development of stronger physician leaders.

Who, What, Where: Demographics, Severity of Presentation, and Location of Treatment Drive Delivery of Diabetic Limb Reconstructive Services within the National Inpatient Sample.

BACKGROUND: Technical advances have been made in reconstructive diabetic limb salvage modalities. It is unknown whether these techniques are widely used. This study seeks to determine the role of patient- and hospital-level characteristics that affect use. METHODS: Admissions for diabetic lower extremity complications were identified in the 2012 to 2014 National Inpatient Sample using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The study cohort consisted of admitted patients receiving amputations, limb salvage without flap techniques, or advanced limb salvage with flap techniques. Multinomial regression analysis accounting for the complex survey design of the National Inpatient Sample was used to determine the independent contributions of factors expressed as marginal effects. RESULTS: The authors' study cohort represented 155,025 admissions nationally. White non-Hispanic patients had the highest proportion of reconstruction without and with flaps, whereas black patients had the lowest. Multinomial regression models revealed that controlling for nongas gangrene and critical limb ischemia, both of which have a much greater incidence in minorities, the effect of race against receipt of reconstructive modalities was attenuated. Access to urban teaching hospitals was the strongest protective factor against amputation (9 percent reduction; p < 0.01) and predictor of receiving limb salvage without flaps (5 percent increase; p < 0.01) and with flaps (3 percent increase; p < 0.01). CONCLUSIONS: This study identified multiple patient- and hospital-level factors associated with decreased access to the gamut of reconstructive limb salvage techniques. Disparity reduction will likely require a multifaceted strategy that addresses the severity of disease presentation seen in minorities and delivery system capabilities affecting access and use of reconstructive limb salvage procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.