Variation in readmission expenditures after high-risk surgery.

BACKGROUND: The Hospital Readmissions Reduction Program reduces payments to hospitals with excess readmissions for three common medical conditions and recently extended its readmission program to surgical patients. We sought to investigate readmission intensity as measured by readmission cost for high-risk surgeries and examine predictors of higher readmission costs. MATERIALS AND METHODS: We used the Healthcare Cost and Utilization Project's State Inpatient Database to perform a retrospective cohort study of patients undergoing major chest (aortic valve replacement, coronary artery bypass grafting, lung resection) and major abdominal (abdominal aortic aneurysm repair [open approach], cystectomy, esophagectomy, pancreatectomy) surgery in 2009 and 2010. We fit a multivariable logistic regression model with generalized estimation equations to examine patient and index admission factors associated with readmission costs. RESULTS: The 30-d readmission rate was 16% for major chest and 22% for major abdominal surgery (P < 0.001). Discharge to a skilled nursing facility was associated with higher readmission costs for both chest (odds ratio [OR]: 1.99; 95% confidence interval [CI]: 1.60-2.48) and abdominal surgeries (OR: 1.86; 95% CI: 1.24-2.78). Comorbidities, length of stay, and receipt of blood or imaging was associated with higher readmission costs for chest surgery patients. Readmission >3 wk after discharge was associated with lower costs among abdominal surgery patients. CONCLUSIONS: Readmissions after high-risk surgery are common, affecting about one in six patients. Predictors of higher readmission costs differ among major chest and abdominal surgeries. Better identifying patients susceptible to higher readmission costs may inform future interventions to either reduce the intensity of these readmissions or eliminate them altogether.

A Model to Optimize Followup Care and Reduce Hospital Readmissions after Radical Cystectomy.

PURPOSE: Radical cystectomy has one of the highest readmission rates across all surgical procedures at approximately 25%. We developed a mathematical model to optimize outpatient followup regimens for radical cystectomy. MATERIALS AND METHODS: We used delay-time analysis, a systems engineering approach, to maximize the probability of detecting patients susceptible to readmission through office visits and telephone calls. Our data source includes patients readmitted after radical cystectomy from the Healthcare Cost and Utilization Project State Inpatient Databases in 2009 and 2010 as well as from our institutional bladder cancer database from 2007 to 2011. We measured the interval from hospital discharge to the point when a patient first exhibits concerning symptoms. Our primary end point is 30-day hospital readmission. Our model optimized the timing and sequence of followup care after radical cystectomy. RESULTS: The timing of office visits and telephone calls is more important in detecting a patient at risk for readmission than the sequence of these encounters. Patients are most likely to exhibit concerning symptoms between 4 and 5 days after discharge home. An optimally scheduled office visit can detect up to 16% of potential readmissions, which can be increased to 36% with 1 office visit followed by 4 telephone calls. CONCLUSIONS: Our model improves the detection of concerning symptoms after radical cystectomy by optimizing the timing and number of outpatient encounters. By understanding how to design better outpatient followup care for patients treated with radical cystectomy we can help reduce the readmission burden for this population.

Complex ventral hernia repair using components separation with or without biologic mesh: a cost-utility analysis.

BACKGROUND: A complex ventral hernia requiring abdominal wall reconstruction presents a challenging scenario to the surgeon. The use of biologic mesh in addition to performing a components separation (CS) is controversial. Our goal was to perform the first cost-utility analysis on the use of biologic mesh in addition to performing CS when performing complex ventral hernia repair. METHODS: A comprehensive literature review was conducted to identify published complication and recurrence rates for ventral hernia repairs requiring CS with or without biologic mesh. The probabilities of the most common complications were combined with Medicare Current Procedural Terminology reimbursement codes, diagnosis related group reimbursement codes, and expert utility estimates to fit into a decision model to evaluate the cost utility of CS with and without biologic mesh in reconstructing ventral hernias. RESULTS: The decision model revealed a baseline cost increase of $775.65 and a 0.0517 increase in the quality-adjusted life-years when using biologic mesh yielding an incremental cost-utility ratio of $15,002.90/quality-adjusted life-year. One-way sensitivity analysis revealed that using biologic mesh was cost-effective using Medicare reimbursement rates but not at retail costs. The maximum price of biologic mesh to be cost-effective was $1813.53. CONCLUSIONS: The cost utility of biologic mesh when used with CS in ventral hernia repair is dependent on the financial perspective. It is cost-ineffective for hospitals and physicians paying retail costs but cost-effective for third-party payers providing Medicare reimbursement.

Participatory research in mental health care services in low- and middle-income countries: a scoping review protocol.

OBJECTIVE: The objective of this scoping review will be to identify and map the characteristics of participatory research approaches in mental health care services conducted in low- and middle-income countries (LMICs). INTRODUCTION: Developing countries have a treatment gap of 76% to 85% for mental disorders. Participatory research can help understand community perspectives, which, in turn, helps develop sustainable, contextually specific services. Although participatory research appears promising, especially in the context of LMICs, the field is heterogenous in terms of the methods used; the various stakeholders; the design, implementation, and evaluation of services; and outcome measures. INCLUSION CRITERIA: This review will include all studies on participatory research in mental health care services in LMICs. All types of participants (ie, children/adolescent/adults, gender, rural/urban, etc.) and settings will be considered. METHODS: The proposed review will follow the JBI methodology for scoping reviews. Published and unpublished studies will be searched for in MEDLINE (PubMed), Embase (Ovid), PsycINFO (EBSCOhost), CINAHL (EBSCOhost), and Google Scholar (first 10 pages). We will also search for gray literature and screen reference lists of relevant reviews. Two independent reviewers will screen the titles and abstracts of the studies, followed by full-text screening. Data will be extracted using a predefined form. The findings will be descriptively presented with supporting tables and diagrams, accompanied by a narrative summary. REVIEW REGISTRATION: Details of the review can be found in Open Science Framework https://osf.io/cn54r.

A Multi-Institutional Experience Utilizing Boari Flap in Robotic Urinary Reconstruction.

Objectives: There is presently scarce literature describing the outcomes of patients undergoing robotic ureteral reconstruction (RUR) using the Boari flap (BF) technique. Herein, we report our prospective, multi-institutional experience using BF in patients undergoing robotic urinary reconstruction. Patients and Methods: We reviewed our prospective, multicenter database for all patients undergoing RUR between September 2013 and September 2021 in which a BF was utilized. Preoperative, perioperative, and follow-up data were collected and analyzed. Major complications were defined as a Clavien-Dindo classification grade >2. Surgical failure was defined as recurrent symptoms, obstruction on imaging, or the need for additional surgical interventions. Results: We identified 50 patients who underwent RUR using a BF. Four (8%) underwent the Single Port approach. Twenty-four patients (48%) were active or former tobacco users. Thirty-four patients (68%) had previously undergone abdominal surgery, 17 (34%) had prior ureteral stricture interventions, and 9 (18%) had prior abdominopelvic radiation. The most common stricture etiology was malignancy (34.4%). The median follow-up was 15.0 months with a 90% (45/50) success rate. The five documented cases of failure occurred at a median of 1.8 months following the procedure. Conclusion: In the largest prospective, multi-institutional study of patients undergoing RUR with BF in the literature to date, we demonstrate a low rate of complications and a high rate of surgical success in three tertiary academic medical centers. All observed failures occurred within 2 months of surgical intervention.

Identifying Preoperative Predictors of Operative Time and Their Impact on Outcomes in Robot-Assisted Partial Nephrectomy.

Objective: To identify preoperative characteristics in patients with renal masses that influence operative time during robot-assisted partial nephrectomy (RAPN) and evaluate the relationship between operative time and length of stay (LOS), complication rates, and overall outcome. Materials and Methods: We queried our institutional database to identify a cohort of patients who underwent RAPN by two experienced robotic surgeons between 2012 and 2019. A multivariable regression model was developed to analyze operative time, LOS, and any grade complication within 30 days postoperatively using the bootstrap resampling technique. Results: A total of 392 patients were included. On multivariable analyses, prior abdominal surgery (p = 0.001) was associated with 22 minutes of increase in operating room time, as well as adhesive perirenal fat (22 minutes, p = 0.001). For each one unit increase in nephrometry score, there was a 4-minute increase in operating room time (p = 0.028), and for each one-cm increase in tumor size, there was an associated 12-minute increase in operating room time (p < 0.001). For each 1 year increase in age, there was an associated 0.024-day increase in LOS [odds ratio (OR) (0.013-0.035)]; in addition, for every one-cm increase in tumor size there was a 0.18-day associated increase in LOS [OR (0.070-0.28)]. Each 1-hour increase in operating room time was associated with a 0.25-day increased LOS [OR (0.092-0.41)]. Only tumor size was found to be associated with any grade complication. Conclusions: Patients with a history of abdominal surgery, larger complex tumors, and significant Gerota's fat undergoing robotic partial nephrectomy should anticipate longer operative times. Older patients with larger tumors and longer operative times can anticipate a longer LOS. Tumor size appears to be the common determinant of all three outcomes: operative time, LOS, and any grade Clavien complication.

Comparative Study of Percutaneous Tic Technique Vs Standard Percutaneous Nephrolithotomy.

OBJECTIVE: To compare the PERC-tic technique, described as placement of dual wires under fluoroscopic guidance adjacent to the stone within the obstructed calyx, to standard percutaneous nephrolithotomy (PCNL) with working wires secured down the ureter. MATERIALS AND METHODS: This is a retrospective cohort study of patients who underwent a PCNL procedure between October 2016 and November 2018. Patients undergoing the PERC-tic technique were compared to patients undergoing standard PCNL. Regression models evaluated if PERC-tic PCNL was associated with equivalent stone-free rates to standard PCNL at 90 days, need for secondary procedures, and 90-day hospital readmission. RESULTS: This study involved 126 PCNL cases of which 63 were done using the PERC-tic technique and 63 with standard PCNL. In multivariate analysis, there was no statistical difference in 90-day stone-free rate between standard PCNL and PERC-tic cohorts (P = .08). We did note a 6 times higher likelihood of needing secondary procedures for residual stones in the PERC-tic vs standard PCNL groups (71% vs 30% P <.0001). There was no statistical significance in 90-day hospital readmission rates between groups (P = .47). CONCLUSION: Our findings suggest similar stone-free rate at 90 days and higher rates of secondary procedures after PERC-tic PCNL compared to the standard approach; however, there was no difference in complications. These findings may reflect decreased visualization with the PERC-tic technique or simply be reflective of the case difficulty requiring the use of the PERC-tic technique. These findings can be used for patient counseling when considering this technique for complex stone disease.

Urothelial carcinoma in situ response to cisplatin-based neoadjuvant chemotherapy, or lack thereof: Impact on patient selection for organ preservation in muscle-invasive disease?

INTRODUCTION: Neoadjuvant cisplatin-based chemotherapy (NACT) followed by radical cystectomy improves urothelial bladder cancer survival [1]. Complete pathological response on cystectomy pathology (pT0N0) is associated with the best survival outcomes [2]. Rates of complete response have increased with improved adoption of NACT calling into question the need for radical cystectomy or perhaps use of organ preservation protocols. In patients with papillary bladder tumors, carcinoma in situ (CIS) has been shown to influence progression and develop into invasive urothelial carcinoma [3]. Furthermore, in patients with invasive urothelial carcinoma, concurrent CIS has been reported in roughly 45% to 65% of cases [4]. Thus, we sought to determine the response rate of CIS to NACT to determine if the presence of CIS should factor into excluding patients from organ preservation. METHODS: A review of our prospectively maintained bladder cancer database was performed among patients undergoing preoperative cisplatin-based chemotherapy followed by cystectomy between 2007 and 2017. Presence of CIS before and after radical cystectomy was assessed. Random bladder biopsies or transurethral resection (TUR) with enhanced imaging for CIS (Cysview) were not routinely utilized in the preoperative setting. RESULTS: One-hundred eighty-three patients were identified that underwent preoperative cisplatin chemotherapy. A total of 96 (52.4%) unique patients had documented CIS in the entire cohort. Forty-eight (50%) patients were noted to have CIS on TUR. Of these 48 patients, 26 (54.1%) were noted to have residual CIS on final pathology. An additional 48 patients were found to have CIS on final pathology that was not diagnosed on TUR, making a total of 74 (77.1%) patients with CIS refractory to NACT on cystectomy pathology. CONCLUSIONS: CIS seems to respond poorly to cisplatin-based neoadjuvant chemotherapy. If organ preservation protocols are considered, a thorough assessment for CIS with enhanced photodynamic detection cystoscopy or random bladder biopsies should be considered. Residual cisplatin-refractory disease, even if noninvasive CIS, may lead to poor outcomes. Future molecular classifiers may assist in disease signatures to help guide treatment protocols.

The Fate of Radical Cystectomy Patients after Hospital Discharge: Understanding the Black Box of the Pre-readmission Interval.

BACKGROUND: Radical cystectomy has one of the highest 30-d hospital readmission rates but circumstances leading to readmission remain poorly understood. OBJECTIVE: To examine the postdischarge period and better understand hospital readmission after radical cystectomy. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective cohort study of patients treated with radical cystectomy for bladder cancer from 2005 to 2012 using our institutional database. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We assessed patient communication with any healthcare system after hospital discharge based on timing, methods, and concern types. Logistic regression and Cox proportional-hazards analyses were used to compare postdischarge concerns among readmitted and nonreadmitted patients. We internally validated the logistic model using a bootstrap resampling technique. RESULTS AND LIMITATIONS: One-hundred patients (23%) were readmitted within 30 d of index discharge. Readmitted patients were more likely to use the emergency department with initial concerns compared with nonreadmitted patients (27% vs 1.0%, p<0.001). Patients who took longer to first communicate their concerns and who were able to tolerate their symptoms longer had lower odds of readmission. Patients who reported infection (adjusted hazard ratio: 2.8, 95% confidence interval: 1.4-5.8) and failure to thrive concerns (adjusted hazard ratio: 4.4, 95% confidence interval: 2.0-9.3) were more likely to be readmitted compared with those who communicated noninfectious wounds and/or urinary concerns. CONCLUSIONS: Radical cystectomy patients who contact the health system soon after discharge or communicated infectious or failure to thrive symptoms (fever, poor oral intake, or vomiting) are more likely to experience readmission as opposed to those that endorse pain, constipation, or ostomy issues. Better understanding of this pre-readmission interval can optimize postdischarge practices. PATIENT SUMMARY: We looked at bladder cancer patients who had surgery and the reasons why they were readmitted to hospital. We found patients who had a fever or difficulty with eating and maintaining their weight had the highest chance of being readmitted.

Treatment of ureteral anastomotic strictures with reimplantation and survival after cystectomy and urinary diversion.

OBJECTIVE: To examine whether long-term renal function and overall survival outcomes vary according to management approach for ureteral anastomotic stricture (UAS) after cystectomy and urinary diversion. METHODS: We conducted a retrospective cohort study of patients with benign UAS following cystectomy and urinary diversion using our institutional database. We compared time to stricture, renal function, rates of renal loss, and overall survival between patients undergoing ureteral reimplantation vs. those undergoing nonoperative management (nephrostomy tube or ureteral stent). A multivariable Cox proportional hazard model was used to determine whether reimplantation was independently associated with overall survival. RESULTS: We identified 87 UAS in 69 patients. Reimplantation was performed in 26 patients (37.7%), and 43 patients (62.3%) were managed nonoperatively. The interval between cystectomy and stricture diagnosis was similar in the reimplanted and nonoperative groups (3.06 vs. 4.34mo, P = 0.42). The differences between baseline and follow-up creatinine levels (+0.40 vs.+0.40mg/dl, P = 0.72) and estimated glomerular filtration rate (-25.0 vs.-18.9ml/min/1.73m2, P = 0.66) were similar between groups, as were rates of renal loss (34.6% vs. 39.5%, P = 0.68); however, mortality was significantly higher in the nonoperative group. After multivariable adjustment, overall survival remained significantly higher among UAS patients who underwent reimplantation (adjusted hazard ratio [aHR] for risk of death = 0.32, 95% CI: 0.13-0.80). CONCLUSION: Reimplantation was associated with improved overall survival but not with improved long-term renal functional outcomes compared with nonoperative management. Nonrenal complications of nonoperative UAS management may play an important role in reducing longevity.

Is Single-Stage Prosthetic Reconstruction Cost Effective? A Cost-Utility Analysis for the Use of Direct-to-Implant Breast Reconstruction Relative to Expander-Implant Reconstruction in Postmastectomy Patients.

BACKGROUND: Prosthetic breast reconstruction is most commonly performed using the two-stage (expander-implant) technique. However, with the advent of skin-sparing mastectomy and the use of acellular dermal matrices, one-stage prosthetic reconstruction has become more feasible. Prior studies have suggested that one-stage reconstruction has economic advantages relative to two-stage reconstruction despite a higher revision rate. This is the first cost-utility analysis to compare the cost and quality of life of both procedures to guide patient care. METHODS: A comprehensive literature review was conducted using the MEDLINE, EMBASE, and Cochrane databases to include studies directly comparing matched patient cohorts undergoing single-stage or staged prosthetic reconstruction. Six studies were selected examining 791 direct-to-implant reconstructions and 1142 expander-implant reconstructions. Costs were derived adopting both patient and third-party payer perspectives. Utilities were derived by surveying an expert panel. Probabilities of clinically relevant complications were combined with cost and utility estimates to fit into a decision tree analysis. RESULTS: The overall complication rate was 35 percent for single-stage reconstruction and 34 percent for expander-implant reconstruction. The authors' baseline analysis using Medicare reimbursement revealed a cost decrease of $525.25 and a clinical benefit of 0.89 quality-adjusted life-year when performing single-stage reconstructions, yielding a negative incremental cost-utility ratio. When using national billing, the incremental cost-utility further decreased, indicating that direct-to-implant breast reconstruction was the dominant strategy. Sensitivity analysis confirmed the robustness of the authors' conclusions. CONCLUSIONS: Direct-to-implant breast reconstruction is the dominant strategy when used appropriately. Surgeons are encouraged to consider single-stage reconstruction when feasible in properly selected patients.

A Cost-Utility Assessment of Mesh Selection in Clean-Contaminated Ventral Hernia Repair.

BACKGROUND: Mesh reinforcement can reduce hernia recurrence, but mesh selection is poorly understood, particularly in contaminated defects. Acellular dermal matrix has enabled single-stage ventral hernia repair in clean-contaminated wounds but can be associated with higher complications and cost compared with synthetic mesh. This study evaluated the cost-utility of synthetic mesh and acellular dermal matrix for clean-contaminated ventral hernia repairs. METHODS: A systematic review of articles comparing outcomes for synthetic and acellular dermal matrix repairs identified 14 ventral hernia repair-specific health states. Quality-adjusted life years were determined through Web-based visual analog scale survey of 300 nationally representative individuals. Overall expected cost and quality-adjusted life-years for ventral hernia repair were assessed using a Monte Carlo simulation with sensitivity analyses. RESULTS: Synthetic mesh reinforcement had an expected cost of $15,776 and quality-adjusted life-year value gained of 21.03. Biological mesh had an expected cost of $23,844 and quality-adjusted life-year value gained of 20.94. When referencing a common baseline (do nothing), acellular dermal matrix (incremental cost-effectiveness ratio, 3378 ($/quality-adjusted life years)) and synthetic mesh (incremental cost-effectiveness ratio, 2208 ($/quality-adjusted life years)) were judged cost-effective, although synthetic mesh was more strongly favored. Monte Carlo sensitivity analysis demonstrated that synthetic mesh was the preferred and most cost-effective strategy in 94 percent of simulations, supporting its overall greater cost-utility. Despite varying the willingness-to-pay threshold from $0 to $100,000 per quality-adjusted life-year, synthetic mesh remained the optimal strategy across all thresholds in sensitivity analysis. CONCLUSION: This cost-utility analysis suggests that synthetic mesh repair of clean-contaminated hernia defects is more cost-effective than acellular dermal matrix.

Reducing Wound Tension with Undermining or Imbrication-Do They Work?

BACKGROUND: For the noncolonized wound, achieving tension-free, primary wound closure is ideal. Some surgeons advocate imbrication of deeper tissues rather than undermining, posing that imbrication preserves more dermal perfusion while still reducing tension at the wound edge. We sought to determine which technique most reliably reduced wound tension while preserving dermal wound perfusion. METHODS: A total of 5 standardized, symmetrical pairs of full thickness wounds were created on Duroc swine. Wound tension was measured with a Tyrolean tensiometer before and after either method of closure, whereas a speckle contrast imager was used to assess dermal edge perfusion. Skin tension and dermal perfusion were evaluated for statistical significance via paired t tests and a multivariate analysis of variance. RESULTS: There was a significant reduction in wound tension with undermining and imbrication relative to the raw wound tension (5 and 5.9 vs 7.1 N; P < 0.05) yet no significant difference between methods of closure (P > 0.05). There was a significant reduction in dermal perfusion between unwounded skin and the imbricated wound (222 perfusion units [PU] vs 48 PU; P < 0.05) and between the unwounded skin and the undermined wound (205 vs 63 PU; P < 0.05). CONCLUSIONS: We found no significant difference in wound tension between wound undermining or imbrication and a significant decrease in dermal perfusion after imbrication and undermining although the relative decrease in perfusion was greater with imbrication. Wound undermining reduces skin tension with greater relative dermal perfusion to the skin and should be selected over wound imbrication in standard primary wound closure.

Predictors of Delayed Intervention for Patients on Active Surveillance for Small Renal Masses: Does Renal Mass Biopsy Influence Our Decision?

OBJECTIVE: To review our clinical T1a renal mass active surveillance (AS) cohort to determine whether renal mass biopsy was associated with maintenance of AS. MATERIALS AND METHODS: From our prospectively maintained database we identified patients starting AS from June 2009 to December 2011 who had at least 5 months of radiologic follow-up, unless limited by unexpected death or delayed intervention. The primary outcome was delayed intervention. Clinical, radiologic, and pathologic variables were compared. We constructed Kaplan-Meier survival curves for maintenance of AS. Cox multivariable regression analysis was performed to assess predictors of delayed intervention. RESULTS: We identified 118 patients who met criteria for inclusion with a median radiologic follow-up of 29.5 months. The delayed intervention group had greater initial mass size and faster growth rate compared to those who continued AS. Rate of renal mass biopsy was similar between the 2 groups. In the multivariable analysis, size >2 cm (hazard ratio [HR] 3.65, 95% confidence interval [CI] 1.28-10.38, P = .015), growth rate (continuous by mm/year: HR 1.26, 95% CI 1.12-1.41, P < .001), but not renal biopsy (HR 1.52, 95% CI 0.70-3.30, P = .29), were associated with increased risk of delayed intervention. Time-to-event curves also showed that size was closely associated with delayed intervention whereas renal mass biopsy was not. CONCLUSION: At our institution, growth rate and initial tumor size appear to be more influential than renal mass biopsy results in determining delayed intervention after a period of AS. Further analysis is required to determine the role of renal biopsy in the management of patients being considered for AS.

Effect of delayed resection after initial surveillance and tumor growth rate on final surgical pathology in patients with small renal masses (SRMs).

OBJECTIVE: To understand potential harms associated with delaying resection of small renal masses (SRMs) in patients ultimately treated, and whether these patients have factors associated with adverse pathology. METHODS: Patients with SRMs (≤4cm) who underwent surgical resection at our institution (2009-2015) were classified as undergoing early resection or initial surveillance with delayed resection (defined by a time from presentation to intervention of at least 6mo). Demographic and clinical variables were compared among groups. Using multivariable logistic regression, we examined the association between delayed resection and adverse pathology (Fuhrman grade 3-4, papillary type 2, sarcomatoid histology, angiomyolipoma with epithelioid features, or stage≥pT3). For patients who underwent delayed intervention, we used similar methods to examine the association between SRM growth rate and adverse pathology. RESULTS: Overall, 401 (81%) and 94 (19%) patients underwent early and delayed resection, respectively. Median time to resection was 84 days (interquartile range: 59-121) and 386 days (interquartile range: 272-702) (P<0.001). Patients undergoing delayed resection were older (62 vs. 58y, P = 0.01) and had smaller masses (2.3 vs. 2.7cm, P<0.001) at initial presentation. Utilization of partial vs. radical nephrectomy was similar regardless of resection timing (P = 0.5). Delayed resection was not associated with adverse pathology (P = 0.8); however, male sex was independently associated with adverse pathology (odds ratio: 1.7, 95% CI: 1.1-2.4, P = 0.009). In patients on surveillance, increasing annual SRM growth rate was associated with adverse pathology (odds ratio: 1.2, 95% CI: 1.03-1.3mm/y, P = 0.02). CONCLUSIONS: Delayed resection was not associated with adverse pathology. Patients on surveillance with increased SRM growth rates had a modest but significant increase in the risk of adverse pathology.

Thoracic Intercostal Nerve Blocks Reduce Opioid Consumption and Length of Stay in Patients Undergoing Implant-Based Breast Reconstruction.

BACKGROUND: Traditionally, narcotics have been used for analgesia after breast surgery. However, these agents have unpleasant side effects. Intercostal nerve blockade is an alternative technique to improve postoperative pain. In this study, the authors investigate outcomes in patients who receive thoracic intercostal nerve blocks for implant-based breast reconstruction. METHODS: A retrospective chart review was performed. The operative technique for breast reconstruction and administration of nerve blocks is detailed. Demographic factors, length of stay, and complications were recorded. The consumption of morphine, Valium, Zofran, and oxycodone was recorded. Data sets for patients receiving thoracic intercostal nerve blocks were compared against those that did not. RESULTS: One hundred thirty-two patients were included. For patients undergoing bilateral reconstruction with nerve blocks, there was a significant reduction in length of stay (1.87 days versus 2.32 days; p = 0.001), consumption of intravenous morphine (5.15 mg versus 12.68 mg; p = 0.041) and Valium (22.24 mg versus 31.13 mg; p = 0.026). For patients undergoing unilateral reconstruction with nerve blocks, there was a significant reduction in consumption of intravenous morphine (2.80 mg versus 8.17 mg; p = 0.007). For bilateral reconstruction with intercostal nerve block, cost savings equaled $2873.14 per patient. For unilateral reconstruction with intercostal nerve block, cost savings equaled $1532.34 per patient. CONCLUSION: The authors' data demonstrate a reduction in the consumption of pain medication, in the hospital length of stay, and in hospital costs for patients receiving intercostal nerve blocks at the time of pectoralis elevation for implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Cost-utility analysis of the use of prophylactic mesh augmentation compared with primary fascial suture repair in patients at high risk for incisional hernia.

BACKGROUND: Although hernia repair with mesh can be successful, prophylactic mesh augmentation (PMA) represents a potentially useful preventative technique to mitigate incisional hernia risk in select high-risk patients. The efficacy, cost-benefit, and societal value of such an intervention are not known. The aim of this study was to determine the cost-utility of using prophylactic mesh to augment fascial incisions. METHODS: A decision tree model was employed to evaluate the cost-utility of using PMA relative to primary suture closure (PSC) after elective laparotomy. The authors adopted the societal perspective for cost and utility estimates. A systematic review of the literature on PMA was performed. The costs in this study included direct hospital costs and indirect costs to society, and utilities were obtained through a survey of 300 English-speaking members of the general public evaluating 14 health state scenarios relating to ventral hernia. RESULTS: PSC without mesh demonstrated an expected average cost of $17,182 (average quality-adjusted life-year [QALY] of 21.17) compared with $15,450 (expected QALY was 21.21) for PMA. PSC was associated with an incremental cost-efficacy ratio (ICER) of -$42,444/QALY compared with PMA such that PMA was more effective and less costly. Monte Carlo sensitivity analysis was performed demonstrating more simulations resulting in ICERs for PSC above the willingness-to-pay threshold of $50,000/QALY, supporting the finding that PMA is superior. CONCLUSION: Cost-utility analysis of PSC compared to PMA for abdominal laparotomy closure demonstrates PMA to be more effective, less costly, and overall more cost-effective than PSC.

The cost effectiveness of the DIEP flap relative to the muscle-sparing TRAM flap in postmastectomy breast reconstruction.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap has gained notoriety because of its proposed benefit in decreasing donor-site morbidity but has been associated with longer operative times, higher perfusion-related complications, and increased cost relative to muscle-sparing free transverse rectus abdominis myocutaneous (TRAM) flaps. The authors performed the first cost-utility analysis examining the cost effectiveness of DIEP flaps relative to muscle-sparing free TRAM flaps in women who underwent mastectomy. METHODS: A comprehensive literature review was conducted using the MED- LINE, Embase, and Cochrane library databases to include studies directly comparing DIEP to muscle-sparing free TRAM flaps in matched patient cohorts. Eight studies were included, examining 740 DIEP flaps and 807 muscle-sparing free TRAM flaps. Costs were derived adopting both societal and third-party payer perspectives. Utilities were derived from a previous cost-utility analysis. Probabilities of clinically relevant complications were combined with cost and utility estimates to fit into a decision tree analysis. RESULTS: The overall complication rates were 24.7 percent and 21.8 percent for DIEP and muscle-sparing free TRAM flaps, respectively. The authors' baseline analysis using Medicare reimbursement revealed a cost decrease of $69.42 and a clinical benefit of 0.0035 quality-adjusted life-year when performing DIEP flap surgery relative to muscle-sparing free TRAM flap surgery, yielding an incremental cost-utility ratio of -$19,834.29. When using societal costs, the incremental cost-utility ratio increased to $87,800. CONCLUSION: DIEP flaps are cost effective relative to muscle-sparing free TRAM flaps when patients are carefully selected based on perforator anatomy and surgery is performed by experienced surgeons.

Complex ventral hernia repair using components separation with or without synthetic mesh: a cost-utility analysis.

BACKGROUND: Components separation provides a useful option among closure choices for complex ventral hernia repairs. The use of synthetic mesh in addition to performing a components separation is controversial. The authors' goal was to perform the first cost-utility analysis on the use of synthetic mesh in addition to performing components separation when performing a complex ventral hernia repair in a noncontaminated field. METHODS: A comprehensive literature review was conducted to identify published complication and recurrence rates for ventral hernia repairs (Ventral Hernia Workgroup I and II) requiring components separation with or without synthetic mesh. The probabilities of the most common complications were combined with Medicare Current Procedural Terminology reimbursement codes, Diagnosis-Related Group reimbursement codes, and expert utility estimates to fit into a decision model to evaluate the cost-effectiveness of components separation with and without synthetic mesh in reconstructing ventral hernias. RESULTS: At average retail costs, the decision model revealed a cost increase of $541.69 and a 0.0357 increase in quality-adjusted life-years when using synthetic mesh, yielding a cost-effective incremental cost-utility ratio of $15,173.39 per quality-adjusted life-year. Univariate sensitivity analysis revealed that synthetic mesh is cost-effective when it costs less than $2049.97. CONCLUSIONS: The addition of synthetic mesh when performing components separation in repairing complex ventral hernias is cost-effective when using average retail prices. Physicians and hospitals should use synthetic mesh in patients with noncontaminated wounds.