Prevalence and Cost of Routine Preoperative Care for Low-Risk Cataract Surgery a Decade after Choosing Wisely.

PURPOSE: Examine the frequency and cost of procedural clearance tests and examinations in preparation for low-risk cataract surgery among members of a commercial healthcare organization in the United States. Determine what characteristics most strongly predict receipt of preoperative care and the probability that preoperative care impacts postsurgical adverse events. DESIGN: Retrospective healthcare claims analysis and medical records review from a large, blended-health organization headquartered in Western Pennsylvania. PARTICIPANTS: Members aged ≥ 65 years who were continuously enrolled 6 months before and after undergoing cataract surgery from 2018 to 2021 and had approved surgery claims. METHODS: Preoperative exams or tests occurring in the 30 days before surgery were identified via procedural and diagnosis codes on claims of eligible members (e.g., Current Procedural Terminology codes for blood panels and preprocedural International Classification of Diseases, 10th Revision, Clinical Modification codes). Prevalence and cost were directly estimated from claims; variables predictive of preoperative care receipt and adverse events were tested using mixed effects modeling. MAIN OUTCOME MEASURES: Total costs, prevalence, and strength of association as indicated by odds ratios. RESULTS: Up to 42% of members undergoing cataract surgery had a physician office visit for surgical clearance, and up to 23% of members had testing performed in isolation or along with clearance visits. The combined costs for the preoperative visits and tests were $4.3 million (approximately $107-$114 per impacted member). There was little difference in member characteristics between those receiving and not receiving preoperative testing or exams. Mixed effects models showed that the most impactful determinants of preoperative care were the surgical facility and member's care teams; for preoperative testing, facilities were a stronger predictor than care teams. Adverse events were rare and unassociated with receipt of preoperative testing, exams, or a combination of the two. CONCLUSIONS: Rates of routine preoperative testing before cataract surgery appear similar to those prior to the implementation of the Choosing Wisely campaign, which was meant to reduce this use. Additionally, preoperative evaluations, many likely unnecessary, were common. Further attention to and reconsideration of current policies and practice for preoperative care may be warranted, especially at the facility level. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Bone Health Screening Prior to Medicare Eligibility-Osteoporosis Screening and Fracture Prevention After Distal Radius Fractures in Patients Aged 50-59.

PURPOSE: Current guidelines recommend bone mineral density (BMD) testing after fragility fractures in patients aged 50 years or older. This study aimed to assess BMD testing and subsequent fragility fractures after low-energy distal radius fractures (DRFs) among patients aged 50-59 years. METHODS: We used the 2010-2020 MarketScan dataset to identify patients with initial DRFs with ages ranging between 50 and 59 years. We assessed the 1-year BMD testing rate and 3-year non-DRF fragility fracture rate. We created Kaplan-Meier plots to depict fragility fracture-free probabilities over time and used log-rank tests to compare the Kaplan-Meier curves. RESULTS: Among 78,389 patients aged 50-59 years with DRFs, 24,589 patients met our inclusion criteria, and most patients were women (N = 17,580, 71.5%). The BMD testing rate within 1 year after the initial DRF was 12.7% (95% CI, 12.3% to 13.2%). In addition, 1-year BMD testing rates for the age groups of 50-54 and 55-59 years were 10.4% (95% CI, 9.9% to 11.0%) and 14.9% (95% CI, 14.2% to 15.6%), respectively. Only 1.8% (95% CI, 1.5% to 2.1%) of men, compared with 17.1% (95% CI, 16.5% to 17.7%) of women, underwent BMD testing within 1 year after the initial fracture. The overall 3-year fragility fracture rate was 6.0% (95% CI, 5.6% to 6.3%). The subsequent fragility fracture rate was lower for those with any BMD testing (4.4%; 95% CI, 3.7% to 5.2%), compared with those without BMD testing (6.2%; 95% CI, 5.9% to 6.6%; P < .05). CONCLUSIONS: We report a low BMD testing rate for patients aged between 50 and 59 years after initial isolated DRFs, especially for men and patients aged between 50 and 54 years. Patients who received BMD testing had a lower rate of subsequent fracture within 3 years. We recommend that providers follow published guidelines and initiate an osteoporosis work-up for patients with low-energy DRFs to ensure early diagnosis. This provides an opportunity to initiate treatment that may prevent subsequent fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis II.

Is the Centralization of Complex Surgical Procedures an Unintended Spillover Effect of Global Capitation? - Insights from the Maryland Global Budget Revenue Program.

OBJECTIVE: To determine if global budget revenue (GBR) models incent the centralization of complex surgical care. SUMMARY BACKGROUND: In 2014, Maryland initiated a statewide GBR model. While prior research has shown improvements in cost and outcomes for surgical care post-GBR implementation, the mechanism remains unclear. METHODS: Utilizing state inpatient databases, we compared the proportion of adults undergoing elective complex surgeries (gastrectomy, pneumonectomy/lobectomy, proctectomies, and hip/knee revision) at high-concentration hospitals (HCHs) in Maryland and control states. Annual concentration, per procedure, was defined as hospital volume divided by state volume. HCHs were defined as hospitals with a concentration at least at the 75 th percentile in 2010. We estimated the difference-in-differences (DiD) of the probability of patients undergoing surgery at HCHs before and after GBR implementation. FINDINGS: Our sample included 122,882 surgeries. Following GBR implementation, all procedures were increasingly performed at HCHs in Maryland. States satisfied the parallel trends assumption for the centralization of gastrectomy and pneumonectomy/lobectomy. Post-GBR, patients were more likely to undergo gastrectomy (DiD: 5.5 p.p., 95% CI [2.2, 8.8]) and pneumonectomy/lobectomy (DiD: 12.4 p.p., 95% CI [10.0, 14.8]) at an HCH in Maryland compared with control states. For our hip/knee revision analyses, we assumed persistent counterfactuals and noted a positive DiD post-GBR implementation (DiD: 4.8 p.p., 95% CI [1.3, 8.2]). No conclusion could be drawn for proctectomy due to different pre-GBR trends. CONCLUSIONS: GBR implementation is associated with increased centralization for certain complex surgeries. Future research is needed to explore the impact of centralization on patient experience and access.

The impact of a statewide payment reform on transcatheter aortic valve replacement (TAVR) utilization and readmissions.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is an increasingly used but relatively expensive procedure with substantial associated readmission rates. It is unknown how cost-constrictive payment reform measures, such as Maryland's All Payer Model, impact TAVR utilization given its relative expense. This study investigated the impact of Maryland's All Payer Model on TAVR utilization and readmissions among Maryland Medicare beneficiaries. METHODS: This was a quasi-experimental investigation of Maryland Medicare patients undergoing TAVR between 2012 and 2018. New Jersey data were used for comparison. Longitudinal interrupted time series analyses were used to study TAVR utilization and difference-in-differences analyses were used to investigate post-TAVR readmissions. RESULTS: During the first year of payment reform (2014), TAVR utilization among Maryland Medicare beneficiaries dropped by 8% (95% confidence interval [CI]: -9.2% to -7.1%; p < 0.001), with no concomitant change in TAVR utilization in New Jersey (0.2%, 95% CI: 0%-1%, p = 0.09). Longitudinally, however, the All Payer Model did not impact TAVR utilization in Maryland compared to New Jersey. Difference-in-differences analyses demonstrated that implementation of the All Payer Model was not associated with significantly greater declines in 30-day post-TAVR readmissions in Maryland versus New Jersey (-2.1%; 95% CI: -5.2% to 0.9%; p =0.1). CONCLUSIONS: Maryland's All Payer Model resulted in an immediate decline in TAVR utilization, likely a result of hospitals adjusting to global budgeting. However, beyond this transition period, this cost-constrictive reform measure did not limit Maryland TAVR utilization. In addition, the All Payer Model did not reduce post-TAVR 30-day readmissions. These findings may help inform expansion of globally budgeted healthcare payment structures.

Predictors and Consequences of Intraoperative Anastomotic Failure in DIEP Flaps.

BACKGROUND: Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on postoperative patient outcomes and surgical costs. METHODS: A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and postoperative outcomes were collected. Data were analyzed using Student's t-tests, Chi-square analysis, and multivariate logistic regression. RESULTS: Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (odds ratio [OR] 1.02, 95% confidence Interval [CI] 1.00-1.03, p <0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01-6.34, p <0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02-0.60, p <0.05). Intraoperative anastomotic failure increased the odds of postoperative hematoma (OR 8.85, CI 1.35-59.1, p <0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, p <0.05), longer hospital stays (2.2 days longer, p <0.05), and higher total operating room cost ($28,529.50 vs. $37,272.80, p <0.05). CONCLUSION: Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of postoperative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success.

The Global Macroeconomic Burden of Breast Cancer: Implications for Oncologic Surgery.

OBJECTIVE: In this study, we quantified the global macroeconomic burden of breast cancer to underscore the critical importance of improving access to oncologic surgical care internationally. SUMMARY BACKGROUND DATA: Breast cancer mortality in many low and middle-income countries (LMICs) is dramatically higher than in high-income countries. Prior to identifying solutions, however, it is important to first define the burden of disease. METHODS: Data from the Institute of Health Metrics and Evaluation (2005-2015) were used to assess epidemiologic trends for 194, middle, and low-income countries. Economic burden defined by Welfare Loss (WL) was calculated by measuring disability-adjusted-life-years lost to breast cancer alongside the dollar equivalent of a value of statistical life year and as a function of each country's gross domestic product (GDP). RESULTS: Annual mortality rates among breast cancer patients were significantly greater in LMICs in South Asia (3.06 per 100 women) and Sub-Saharan Africa (2.76 per 100 women), compared with high-income countries like the United States (1.69 per 100 women). From 2005-2015, mortality in South Asia increased by 8.20% and decreased by 6.45% in Sub-Saharan Africa; mortality rates in 2015 were observed as 27.9 per 100,000 in South Asia and 18.61 per 100,000 in Sub-Saharan Africa. Countries in South Asia demonstrated the greatest rise in WL due to breast cancer, from 0.05% to 0.08% of GDP. CONCLUSIONS: The burden of disease and economic impact of breast cancer is intensifying in LMICs. Global efforts to improve access to surgical care for women with breast cancer could reduce mortality and mitigate the social and financial impact of this disease in LMICs.

Exploring provider- and practice-level drivers of cost-consciousness in breast cancer reconstruction-secondary analysis of a survey of the American Society of Plastic Surgeons.

BACKGROUND: The role of physicians in dampening health care costs is a renewed focus of policy-makers. We examined provider- and practice-level factors affecting four domains of cost-consciousness among plastic surgeons performing breast reconstruction. METHODS: Secondary analysis was performed on the survey responses of 329 surgeons who routinely performed breast reconstruction. Using a 5-point Likert scale, we queried four domains of cost-consciousness: out-of-pocket cost awareness, cost discussions, cognizance of patients' financial burden, and attitudes regarding cost discussions. Multivariable linear regression was performed to identify provider- and practice-level factors affecting these domains according to composite scores. RESULTS: Overall cost-consciousness scores (CS) were moderate and ranged from 2.14 to 4.30. There were no significant differences across practice settings. Male gender (p = 0.048), Hispanic ethnicity (p = 0.021), and increasing clinical experience (p = 0.015) were associated with higher out-of-pocket cost awareness. Increasing surgeon experience was also associated with having cost discussions (p = 0.039). No provider- or practice-level factors were associated with cognizance of patients' financial burden. Salaried physicians displayed a more positive attitude toward out-of-pocket cost discussions (p = 0.049). On pairwise testing, the out-of-pocket cost awareness was significantly different between Hispanic surgeons and white surgeons (4.30 vs. 3.55), and between surgeons with more than 20 years' experience and with less than 5 years' experience (3.87 vs. 3.37). CONCLUSIONS: Surgeon gender, ethnicity, and experience and practice compensation type inform various domains of cost-consciousness in breast reconstruction. Structural and behavioral interventions could possibly increase physicians' cost-consciousness.

The Impact of Policy Reform on Utilization of Popular Reconstructive Procedures.

OBJECTIVES: Medicaid beneficiaries systematically face challenges in accessing healthcare, especially with regard to specialty services like reconstructive surgery. This study evaluated the impact of 2 healthcare reform policies, Medicaid expansion and global hospital budgeting, on utilization of reconstructive surgery by Medicaid patients. METHODS: Utilization of reconstructive surgery by Medicaid patients in New Jersey (Medicaid expansion/no global budget), Maryland (Medicaid expansion/with global budgets), and Florida (no Medicaid expansion/no global budget) between 2012 and 2016 was compared using quasi-experimental, interrupted time-series modeling. Subgroup analyses by procedure type and urgency were also undertaken. RESULTS: During the study period, the likelihood of Medicaid patients using reconstructive surgery significantly increased in expansion states (Maryland: 0.3% [95% confidence interval = 0.17% to 0.42%] increase per quarter, P < 0.001; New Jersey: 0.4% [0.31% to 0.52%] increase per quarter, P = 0.004) when compared with Florida (nonexpansion state). Global budgeting did not significantly impact overall utilization of reconstructive procedures by Medicaid beneficiaries. Upon subgroup analyses, there was a greater increase in utilization of elective procedures than emergent procedures by Medicaid beneficiaries after Medicaid expansion (elective: 0.9% [0.8% to 1.3%] increase per quarter, P = 0.04; emergent/urgent: 0.2% [0.1% to 0.4%] increase per quarter, P = 0.02). In addition, Medicaid expansion had the greatest absolute effect on breast reconstruction (1.0% [95% confidence interval = 0.7% to 1.3%] increase per quarter) compared with other procedure types. CONCLUSIONS: Medicaid expansion increased access to reconstructive surgery for Medicaid beneficiaries, especially for elective procedures. Encouragingly, although cost-constrictive, global hospital budgeting did not limit longitudinal utilization of reconstructive surgery by Medicaid patients, who are traditionally at higher risk for complications/readmissions.

Tissue Expander-Based Breast Reconstruction in the Prepectoral Versus Subpectoral Plane: An Analysis of Short-Term Outcomes.

BACKGROUND: Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. We hypothesize that prepectoral patients benefit from lower short-term complications and shorter periods to second-stage reconstruction compared with individuals receiving reconstruction in the subpectoral plane. METHODS: An institutional review board-approved retrospective review of all adult postmastectomy patients receiving tissue expanders (TEs) was completed for a 21-month period (n = 286). RESULTS: A total of 286 patients underwent mastectomy followed by TE placement, with 59.1% receiving prepectoral TEs and 40.9% receiving subpectoral TEs. Participants receiving prepectoral TEs required fewer clinic visits before definitive reconstruction (6.4 vs 8.8, P <0.01) and underwent definitive reconstruction 71.6 days earlier than individuals with subpectoral TE placement (170.8 vs 242.4 days, P < 0.01). Anesthesia time was significantly less for prepectoral TE placement, whether bilateral (68.0 less minutes, P < 0.01) or unilateral (20.7 minutes less, P < 0.01). Operating room charges were higher in the prepectoral subgroup ($31,276.8 vs $22,231.8, P < 0.01). Partial necrosis rates were higher in the prepectoral group (21.7% vs 10.9%, P < 0.01). CONCLUSIONS: Patients undergoing breast reconstruction using prepectoral TE-based reconstruction benefit from less anesthesia time, fewer postoprative clinic visits, and shorter time to definitive reconstruction, at the compromise of higher operating room charges.

Treatment of Facial Fractures at Safety-Net Hospitals: A National Analysis of Inpatient Burden and Cost.

PURPOSE: Safety-net hospitals (SNHs) are vital in the care of trauma populations, but little is known about the burden of facial trauma presenting to SNHs. The authors sought to characterize the presentation and treatment of facial fractures across SNHs and determine the association between SNH care and healthcare utilization in patients undergoing fracture repair. METHODS: Adult patients presenting with a facial fracture as their primary admitting diagnosis from the year 2012 to 2015 were identified in the National Inpatient Sample. The "safety-net burden" of each hospital was defined based on the proportion of Medicaid and self-pay discharges. Patient factors analyzed were sex, race, age, income level, insurance status, fracture location, and comorbidities. Hospital factors analyzed were safety-net burden, teaching status, geographic region, bed size, and ownership status. The main outcomes were length of stay (LOS), hospital costs, time to repair, and postoperative complications. RESULTS: Of 78,730 patients, 27,080 (34.4%) were treated at SNHs and 24,844 (31.6%) were treated at non-SNHs. Compared to non-SNHs, patients treated at SNHs were more likely to undergo operative repair at SNHs (65.8% versus 53.9%, P < 0.001). Overall mean LOS was comparable between non-SNH and SNH (3.43 versus 3.38 days, P = 0.611), as was mean hospital cost ($15,487 versus $15,169, P = 0.434). On multivariate linear regression, safety-net status was not a predictor of increased LOS, cost, or complications. However, safety-net status was significantly associated with lower odds of undergoing repair within 48 hours of admission (odds ratio 0.783, 95% confidence interval = 0.680-0.900, P = 0.001). CONCLUSIONS: Safety-net hospitals are able to treat facial trauma patients with greater injury burden and lower socioeconomic resources without increased healthcare utilization. Healthcare reform must address the financial challenges that endanger these institutions to ensure timely treatment of all patients.

Classification of breast tissue expander infections: Back to the basics.

BACKGROUND: Infections following tissue expander (TE) placement are frequent complications in breast reconstruction. While breast surgery is a clean case, implant-based breast reconstruction has rates of infection up to 31%, decidedly higher than the typical 1% to 2% rate of surgical site infections (SSI). Few authors use the Center for Disease Control's (CDC) SSI definition for TE infections. We highlight how adoption of a consistent definition of TE infection may change how infections are researched, categorized, and ultimately managed. METHODS: Two researchers with definitional discrepancies of infection performed an independent analysis of all postmastectomy patients receiving TEs (n = 175) in 2017. RESULTS: Researcher One, using a clinical definition, delineated an infection rate of 19.4%. Antibiotics alone successfully treated 50% of cases. Researcher Two found an infection rate of 13.7% using CDC criteria. These infections were further delineated by a SSI rate of 6.3% and a TE infection rate post port access of 7.4%. Only 45.5% SSI's and 15.4% of TE infections were salvaged with antibiotics alone. CONCLUSIONS: Rigorous adoption of CDC criteria for infection characterization in published research will help standardize the definition of infection and allow surgeons to create evidence-based infection prevention regimens.

The Effects of Medicaid Expansion on Triage and Regional Transfer After Upper-Extremity Trauma.

PURPOSE: Underinsured hand trauma patients are more likely to be transferred to quaternary care centers, which burdens these patients and centers. By increasing insurance coverage, care for less severe upper-extremity injuries may be available closer to patients' homes. We evaluated whether the 2014 expansion of Medicaid in Maryland under the Affordable Care Act decreased the number of uninsured upper-extremity trauma patients and the volume of unnecessary emergency trauma visits at our hand center. METHODS: We identified all upper-extremity trauma patients between 2010 and 2017 at our hand trauma referral center. Injury severity was classified based on the need for subspecialty care. Bivariate relations between insurance status and demographic covariates, including injury type and distance, both before and after Medicaid expansion were evaluated. We used patient-level and multinomial logistic regression models to evaluate changes in payer and transfer appropriateness. RESULTS: We studied 12,009 acute upper-extremity trauma patients. With Medicaid expansion, the percentage of trauma patients with Medicaid coverage increased from 15% to 24%, with a decrease in uninsured from 31% to 24%. After Medicaid expansion, non-transfer patient appropriateness decreased and appropriateness of transfers remained consistent across all payers. The average distance patients traveled for care remained similar before and after expansion. CONCLUSIONS: Medicaid expansion significantly decreased the proportion of uninsured upper-extremity trauma patients. We identified no significant changes in the distances these patients traveled for specialized care. In addition, the appropriateness of transferred patients did not change significantly after expansion, whereas appropriateness of nontransferred patients actually declined after Medicaid expansion. CLINICAL RELEVANCE: This study indicates no notable change in adherence to transfer guidelines after expansion, and a possible increase in use of emergency services by newly insured patients.

The Crisis of Deficiency in Emergency Coverage for Hand and Facial Trauma: Exploring the Discrepancy Between Availability of Elective and Emergency Surgical Coverage.

INTRODUCTION: Injuries are one of the most common reasons for emergency department visits, with approximately 40.2 million injury-related visits occurring in 2011. Facial, hand, and wrist injuries make up a large portion of these visits. Despite the high demand for specialists to attend to these injury-related emergency department visits, recent studies have suggested a discrepancy between elective surgical coverage and trauma care in general. The goal of this study was to determine if there was a difference between access to elective surgical procedures in comparison with on-call emergency care for facial and hand/wrist conditions in New York State. METHODS: Hospitals throughout New York State, excluding New York City, were selected from the Department of Health Web site, hospitals.nyhealth.gov. A phone survey was administered between May 2012 and October 2013, to quantify the availability of elective and emergent procedures for facial and hand/wrist conditions. We compared the availability of emergency facial and hand/wrist surgical care based on hospital characteristics such as bed size and access to a surgical intensive care unit. RESULTS: We selected 113 hospitals, and 52 hospitals participated for a response rate of 46%. A total of 88% of hospitals offered elective hand procedures, but only 27% had consistent coverage for emergency hand trauma. Furthermore, only 29 % of hospitals had a facial specialist consistently available whereas the availability for elective facial procedures was 79%. CONCLUSION: Our study results show a discrepancy between the availability of surgeons for elective procedures and on-call emergency care for facial and hand/wrist condition.

Evidence-Based Practice in the Surgical Treatment of Thumb Carpometacarpal Joint Arthritis.

PURPOSE: Thumb carpometacarpal (CMC) arthritis contributes considerably to functional disability in the aging adult United States (US) population. Owing to the increasing growth in this segment of our population, its burden on health care resources will increase in the future. Variations exist in the degree of complexity and cost among different surgical treatments. We examined the national trends of the surgical treatment of thumb CMC arthritis and hypothesized that current practice patterns are not supported by evidence favoring the simpler trapeziectomy-only procedure. METHODS: Using a random 5%, nationally representative, sample of Medicare fee-for-service beneficiaries diagnosed with thumb CMC arthritis between 2001 and 2010, we used a multinomial logistic regression model to assess the association between patients' characteristics and the surgical treatment. Furthermore, we used surgeons' unique identifiers to examine how their practice preferences have changed over time. RESULTS: Our findings demonstrated an increasing trend in the utilization of trapeziectomy with ligament reconstruction and tendon interposition (LRTI) from 84% in 2001 to 90% in 2010. Ninety-five percent of surgeons performed only 1 type of surgical procedure, and among those, 93% of surgeons performed only trapeziectomy with LRTI. Compared with 2001, the odds of a patient undergoing thumb CMC arthrodesis or prosthetic arthroplasty slightly increased between 2007 and 2010. CONCLUSIONS: The majority of hand surgeons in the US use trapeziectomy with LRTI as the surgical treatment of choice for thumb CMC arthritis. Although clinical trials from the United Kingdom support the use of the less complex trapeziectomy-only procedure, US surgeons are still reticent to change their practice, which favors LRTI. National comparative studies are still needed to examine the effectiveness of various surgical options for the treatment of thumb CMC joint arthritis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Health-Related Quality of Life and the Desire for Revision Surgery Among Children With Cleft Lip and Palate.

PURPOSE: Children with cleft lip with or without palate (CLCP) require multiple reconstructive procedures, however, little is known about their desire for surgical revision. The purpose of this study was to examine the relationship between health-related quality of life (HRQOL) and the desire for revision. METHODS: The authors surveyed children with CLCP (n = 71) and their caregivers regarding general and cleft-specific HRQOL and the desire for revision surgery. The authors used logistic regression models to evaluate the relationship between HRQOL and the desire for revision stratified by age, and determined the level of agreement between caregivers and children. RESULTS: In this cohort, 54.9% of children desired revision, primarily of the nose (n = 23), lip (n = 20), and dentoalveolar structures (n = 19). Children 11 years or older were more likely to desire revision than younger children (OR 3.39, 95% CI [1.19, 9.67], P <0.05). Children who reported poorer HRQOL with respect to appearance (OR 2.31, 95% CI [1.25-4.29], P = 0.008), social development (OR 0.91, 95% CI [0.84-0.99], P = 0.02), and communication (OR 0.94, 95% CI [0.89-0.99], P = 0.02) were significantly more likely to desire revision than children who reported more positive HRQOL. Caregivers' and children's desires for revision were only modestly correlated (r = 0.41). CONCLUSIONS: Children with CLCP who report poorer HRQOL are more likely to desire revision than children with higher HRQOL; these differences are further magnified among older children. Given the modest correlation between patient and caregiver goals for revision, it is important to evaluate both perspectives when considering revision surgery.

Morphomic analysis as an aid for preoperative risk stratification in patients undergoing major head and neck cancer surgery.

BACKGROUND: Patients undergoing major head and neck cancer surgery (MHNCS) may develop significant postoperative complications. To minimize the risk of complications, clinicians often assess multiple measures of preoperative health in terms of medical comorbidities. One emerging method to decrease surgical complications is preoperative assessment of patient frailty measured by specific tissue characteristics. We hypothesize that morphomic characteristics of the temporalis region serve as predictive markers for the development of complications after MHNCS. METHODS: We performed a retrospective review of 69 patients with available computed tomography (CT) imaging who underwent MHNCS from 2006-2012. To measure temporalis region characteristics, we used morphomic analysis of available preoperative CT scans to map out the region. All available CT scans had been performed as part of the patient's routine work-up and were not ordered for morphomic analysis. We describe the correlation among temporalis fat pad volume (TFPV), mean zygomatic arch thickness, and incidence of postoperative complications. RESULTS: We noted significant difference in the zygomatic bone thickness and TFPV between patients who had medical complications, surgical complications, or total major complications and those who did not. Furthermore, by use of binary logistic regression, our data suggest decreased TFPV and zygomatic arch thickness are stronger predictors of developing postoperative complications than previously studies preoperative characteristics. CONCLUSIONS: We describe morphomic analysis of the temporalis region in patients undergoing MHNCS to identify patients at risk for complications. Regional anatomic morphology may serve as a marker to objectively determine a patient's overall health. Use of the temporalis region is appropriate in patients undergoing MHNCS because of the availability of preoperative scans as part of routine work up for head and/or neck cancer.

Surgical Treatment of Cubital Tunnel Syndrome: Trends and the Influence of Patient and Surgeon Characteristics.

PURPOSE: To examine trends in and determinants of the use of different procedures for treatment of cubital tunnel syndrome. METHODS: We performed a retrospective cross-sectional analysis of the Healthcare Cost and Utilization Project Florida State Ambulatory Surgery Database for 2005 to 2012. We selected all patients who underwent in situ decompression, transposition, or other surgical treatments for cubital tunnel syndrome. We tested trends in the use of these techniques and performed a multivariable analysis to examine associations among patient characteristics, surgeon case volume, and the use of different techniques. RESULTS: Of the 26,164 patients who underwent surgery for cubital tunnel syndrome, 80% underwent in situ decompression, 16% underwent transposition, and 4% underwent other surgical treatment. Over the study period, there was a statistically significant increase in the use of in situ release and a decrease in the use of transposition. Women and patients treated by surgeons with a higher cubital tunnel surgery case volume underwent in situ release with a statistically higher incidence than other techniques. CONCLUSIONS: In Florida, surgeon practice reflected the widespread adoption of in situ release as the primary treatment for cubital tunnel syndrome, and its relative incidence increased during the study period. Patient demographics and surgeon-level factors influenced procedure selection. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Association between hospital case volume and the use of bronchoscopy and esophagoscopy during head and neck cancer diagnostic evaluation.

BACKGROUND: There are no clinical guidelines on best practices for the use of bronchoscopy and esophagoscopy in diagnosing head and neck cancer. This retrospective cohort study examined variation in the use of bronchoscopy and esophagoscopy across hospitals in Michigan. METHODS: A total of 17,828 patients were identified with head and neck cancer in the 2006 to 2010 Michigan State Ambulatory Surgery Databases. A hierarchical, mixed-effect logistic regression was used to examine whether a hospital's risk-adjusted rate of concurrent bronchoscopy or esophagoscopy was associated with its case volume (< 100, 100-999, or ≥ 1000 cases per hospital) for those undergoing diagnostic laryngoscopy. RESULTS: Of 9218 patients undergoing diagnostic laryngoscopy, 1191 (12.9%) received concurrent bronchoscopy and 1675 (18.2%) underwent concurrent esophagoscopy. The median hospital rate of bronchoscopy was 2.7% (range, 0%-61.1%), and low-volume (odds ratio [OR] = 27.1; 95% confidence interval [CI] = 1.9, 390.7) and medium-volume (OR = 28.1; 95% CI = 2.0, 399.0) hospitals were more likely to perform concurrent bronchoscopy compared to high-volume hospitals. The median hospital rate of esophagoscopy was 5.1% (range, 0%-47.1%), and low-volume (OR = 9.8; 95% CI = 1.5, 63.7) and medium-volume (OR = 8.5; 95% CI = 1.3, 55.0) hospitals were significantly more likely to perform concurrent esophagoscopy relative to high-volume hospitals. CONCLUSIONS: Patients with head and neck cancer who are undergoing diagnostic laryngoscopy are much more likely to undergo concurrent bronchoscopy and esophagoscopy at low- and medium-volume hospitals than at high-volume hospitals. Whether this represents overuse of concurrent procedures or appropriate care that leads to earlier diagnosis and better outcomes merits further investigation.

A systematic review of complications of implant-based breast reconstruction with prereconstruction and postreconstruction radiotherapy.

PURPOSE: To conduct a systematic review of the literature to assess outcomes data on complications associated with implant-based breast reconstruction performed before or after chest wall radiation to assist in guiding the decision-making process for reconstruction of the irradiated breast. METHODS: Studies from a PubMed search that met predetermined inclusion criteria were identified and included. Complications of interest were low- and high-grade capsular contractures, minor and major complications, reconstruction failure rates, and reconstruction completion rates. Pooled complication rates were calculated. RESULTS: A total of 26 articles were included in the study after screening 1,006 publications, with 14 studies presenting data on prereconstruction radiation and 23 studies presenting data on postreconstruction radiation. Complication rates evaluated in patients exposed to radiation before or after implant reconstruction were not significantly different. Reconstruction failure rates were similar at 19 and 20 % for pre- and postreconstruction radiation patients, respectively. Completion rates were similar at 83 and 80 % for pre- and postreconstruction radiation patients, respectively. CONCLUSIONS: Review of the current literature suggests similar overall success and failure rates with radiotherapy provided both before and after reconstruction. Failure rates in both groups of patients are clinically significant when considering implant reconstruction in the setting of radiation.