Malpractice Cases in Breast Surgery: An Assessment of Litigation Involving Surgeons.

INTRODUCTION: Improving patient safety and quality are priorities in health care. The study of malpractice cases provides an opportunity to identify areas for quality improvement. While the issues surrounding malpractice cases in breast cancer are often multifactorial, there are few studies providing insight into malpractice cases specifically related to common breast cancer surgical procedures. We sought to characterize the factors in liability cases involving breast cancer surgery. METHODS: Closed cases from 2008 to 2019 involving a breast cancer diagnosis, a primary responsible service of general surgery, surgical oncology, or plastic surgery, and a breast cancer procedure were reviewed using data from the Controlled Risk Insurance Company (CRICO) Strategies Comparative Benchmarking System database, a national repository of professional liability data. RESULTS: A total of 174 malpractice cases were reviewed, of which 41 cases were closed with payment. Plastic surgeons were most commonly named (64%, 111/174), followed by general surgeons (30%, 53/174), and surgical oncologists (6%, 10/174). The most common allegation was error in surgical treatment (87%, 152/174), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infections represented the top five injury descriptions. On average, indemnity payments were larger for high clinical severity cases. Technical skills, followed by clinical judgment, were the most commonly named contributing factors. The average payment per case was $130,422. CONCLUSION: Malpractice cases predominantly involve technical complications related to plastic surgery procedures. Better understanding of the malpractice environment involving surgical procedures performed for breast cancer may provide practical insight to guide initiatives aimed at improving patient outcomes.

Evaluating the role of sentinel lymph node biopsy in patients with DCIS treated with breast conserving surgery.

INTRODUCTION: The role of sentinel lymph node biopsy (SLNB) for patients with ductal carcinoma in-situ (DCIS) is limited given the rarity of nodal metastasis in non-invasive disease. Although SLNB is typically a safe procedure, there are potential complications and associated costs. The purpose of this study is to assess national surgical practice patterns and clinical outcomes with respect to the use of SLNB for DCIS in patients undergoing breast conserving surgery (BCS). METHODS: Case-level data from the National Cancer Data Base (NCDB) was assessed to identify adult patients ≥ 18 with DCIS, who underwent BCS and SLNB. Patient demographics and hospital characteristics were grouped for analytic purposes. A multivariate analysis was performed for patient and hospital characteristics. RESULTS: We identified 15,422 patients with DCIS undergoing BCS in 2015, of which 2,698 (18%) underwent SLNB. A multivariate analysis demonstrated a significant association between greater frequency of SLNB in patients age range of 60-69, receipt of care at a community facility, and higher nuclear grade DCIS. Positive sentinel nodes metastasis was identified in 0.9% patients undergoing BCS and SLNB for DCIS. CONCLUSION: The role of SLNB in patients with DCIS undergoing BCS is limited and does not routinely provide meaningful information or benefit to clinical management. Despite this, nearly one in five patients undergoing BCS for DCIS had lymph node sampling performed. Given the potential increased morbidity and financial implications, this finding represents an opportunity for further education and improvement in patient selection for SLNB.

Development and Implications of an Evidence-based and Public Health-relevant Definition of Complicated Appendicitis in Children.

OBJECTIVE: To characterize the influence of intraoperative findings on complications and resource utilization as a means to establish an evidence-based and public health-relevant definition for complicated appendicitis. SUMMARY OF BACKGROUND DATA: Consensus is lacking surrounding the definition of complicated appendicitis in children. Establishment of a consensus definition may have implications for standardizing the reporting of clinical research data and for refining reimbursement guidelines. METHODS: This was a retrospective cohort study of patients ages 3 to 18 years who underwent appendectomy from January 1, 2013 to December 31, 2014 across 22 children's hospitals (n = 5002). Intraoperative findings and clinical data from the National Surgical Quality Improvement Program-Pediatric Appendectomy Pilot Database were merged with cost data from the Pediatric Health Information System Database. Multivariable regression was used to examine the influence of 4 intraoperative findings [visible hole (VH), diffuse fibrinopurulent exudate (DFE) extending outside the right lower quadrant (RLQ)/pelvis, abscess, and extra-luminal fecalith] on complication rates and resource utilization after controlling for patient and hospital-level characteristics. RESULTS: At least 1 of the 4 intraoperative findings was reported in 26.6% (1333/5002) of all cases. Following adjustment, each of the 4 findings was independently associated with higher rates of adverse events compared with cases where the findings were absent (VH: OR 5.57 [95% CI 3.48-8.93], DFE: OR 4.65[95% CI 2.91-7.42], abscess: OR 8.96[95% CI 5.33-15.08], P < 0.0001, fecalith: OR 5.01[95% CI 2.02-12.43], P = 0.001), and higher rates of revisits (VH: OR 2.02 [95% CI 1.34-3.04], P = 0.001, DFE: OR 1.59[95% CI 1.07-2.37], P = 0.02, abscess: OR 2.04[95% CI 1.2-3.49], P = 0.01, fecalith: OR 2.31[95% CI 1.06-5.02], P = 0.04). Each of the 4 findings was also independently associated with increased resource utilization, including longer cumulative length of stay (VH: Rate ratio [RR] 3.15[95% CI 2.86-3.46], DFE: RR 3.06 [95% CI 2.83-3.13], abscess: RR 3.94 [95% CI 3.55-4.37], fecalith: RR 2.35 [95% CI 1.87-2.96], P =  < 0.0001) and higher cumulative hospital cost (VH: RR 1.97[95% CI 1.64-2.37], P < 0.0001, DFE: RR 1.8[95% CI 1.55-2.08], P =  < 0.0001, abscess: RR 2.02[95% CI 1.61-2.53], P < 0.0001, fecalith: RR 1.49[95% CI 0.98-2.28], P = 0.06) compared with cases where the findings were absent. CONCLUSION AND RELEVANCE: The presence of a visible hole, diffuse fibrinopurulent exudate, intra-abdominal abscess, and extraluminal fecalith were independently associated with markedly worse outcomes and higher cost in children with appendicitis. The results of this study provide an evidence-based and public health-relevant framework for defining complicated appendicitis in children.

Leveraging the Incidence, Burden, and Fiscal Implications of Unplanned Hospital Revisits for the Prioritization of Prevention Efforts in Pediatric Surgery.

OBJECTIVE: To characterize procedure-level burden of revisit-associated resource utilization in pediatric surgery with the goal of establishing a prioritization framework for prevention efforts. SUMMARY OF BACKGROUND DATA: Unplanned hospital revisits are costly to the health care system and associated with lost productivity on behalf of patients and their families. Limited objective data exist to guide the prioritization of prevention efforts within pediatric surgery. METHODS: Using the Pediatric Health Information System (PHIS) database, 30-day unplanned revisits for the 30 most commonly performed pediatric surgical procedures were reviewed from 47 children's hospitals between January 1, 2012 and March 31, 2015. The relative contribution of each procedure to the cumulative burden of revisit-associated length of stay and cost from all procedures was calculated as an estimate of public health relevance if prevention efforts were successfully applied (higher relative contribution = greater potential public health relevance). RESULTS: 159,675 index encounters were analyzed with an aggregate 30-day revisit rate of 10.8%. Four procedures contributed more than half of the revisit-associated length of stay burden from all procedures, with the highest relative contributions attributable to complicated appendicitis (18.4%), gastrostomy (13.4%), uncomplicated appendicitis (13.0%), and fundoplication (9.4%). Four procedures contributed more than half of the revisit-associated cost burden from all procedures, with the highest relative contributions attributable to complicated appendicitis (18.8%), gastrostomy (14.6%), fundoplication (10.4%), and uncomplicated appendicitis (10.2%). CONCLUSIONS AND RELEVANCE: A small number of procedures account for a disproportionate burden of revisit-associated resource utilization in pediatric surgery. Gastrostomy, fundoplication, and appendectomy should be considered high-priority targets for prevention efforts within pediatric surgery.

Development and Implementation of a Surgical Quality Improvement Pathway for Pediatric Intussusception Patients.

Children with intussusception can be admitted or discharged from the emergency department (ED) following enema reduction, but little is known about best practices for surgical follow-up and the need for a return to care. METHODS: We developed a standardized clinical assessment and management plan (SCAMP) for ileocolic intussusception to enable the discharge from the ED of successfully reduced patients meeting certain criteria with 2 planned follow-up phone calls by surgical personnel after discharge. Outcomes included incidence of complications in discharged patients, bacteremia, the success of follow-up phone calls, rates of recurrent intussusception, and return to care. RESULTS: Of the 118 patient encounters treated through the SCAMP in 2 pilot studies from February 2013 to December 2017, 76% met discharge criteria, of whom 88% underwent outpatient management. There were no instances of bowel perforation, necrosis, or death in the discharged group. No patients developed bacteremia despite withholding antibiotics for the indication of intussusception. Sixty-two percent and 59% of patients received 24-hour follow-up phone calls, and 28% and 55% of patients received second follow-up phone calls in pilots 1 and 2, respectively. Of those successfully discharged, 74% did not return to care, 19% returned for recurrent intussusception, and 7% returned for unrelated symptoms. Nearly all patients who returned to care did so through the ED and not the clinic. CONCLUSIONS: Implementation of the SCAMP demonstrated that patients meeting certain criteria could be safely discharged from the ED, avoid antibiotics, and safely undergo phone-based follow-up for concerns of recurrent intussusception.

Extended Versus Narrow-spectrum Antibiotics in the Management of Uncomplicated Appendicitis in Children: A Propensity-matched Comparative Effectiveness Study.

OBJECTIVE: The aim of this study was to compare the effectiveness of extended versus narrow spectrum antibiotics in preventing surgical site infections (SSIs) and hospital revisits in children with uncomplicated appendicitis. SUMMARY OF BACKGROUND DATA: There is a paucity of high-quality evidence in the pediatric literature comparing the effectiveness of extended versus narrow-spectrum antibiotics in the prevention of SSIs associated with uncomplicated appendicitis. METHODS: Clinical data from the ACS NSQIP-Pediatric Appendectomy Pilot Project were merged with antibiotic utilization data from the Pediatric Health Information System database for patients undergoing appendectomy for uncomplicated appendicitis at 17 hospitals from January 1, 2013 to June 30, 2015. Patients who received piperacillin/tazobactam (extended spectrum) were compared with those who received either cefoxitin or ceftriaxone with metronidazole (narrow spectrum) after propensity matching on demographic and severity characteristics. Study outcomes were 30-day SSI and hospital revisit rates. RESULTS: Of the 1389 patients included, 39.1% received piperacillin/tazobactam (range by hospital: 0% to 100%), and the remainder received narrow-spectrum agents. No differences in demographics or severity characteristics were found between groups following matching. In the matched analysis, the rates of SSI were similar between groups [extended spectrum: 2.4% vs narrow spectrum 1.8% (odds ratio, OR: 1.05, 95% confidence interval, 95% CI 0.34-3.26)], as was the rate of revisits [extended spectrum: 7.9% vs narrow spectrum 5.1% (OR: 1.46, 95% CI 0.75-2.87)]. CONCLUSIONS: Use of extended-spectrum antibiotics was not associated with lower rates of SSI or hospital revisits when compared with narrow-spectrum antibiotics in children with uncomplicated appendicitis. Our results challenge the routine use of extended-spectrum antibiotics observed at many hospitals, particularly given the increasing incidence of antibiotic-resistant organisms.

Influence of Time to Appendectomy and Operative Duration on Hospital Cost in Children with Uncomplicated Appendicitis.

BACKGROUND: The goal of this study was to examine the influence of time to appendectomy (TTA) and operative duration (OD) on hospital cost as surrogate measures of perioperative efficiency. STUDY DESIGN: We conducted a retrospective cohort analysis of 2,116 children undergoing appendectomy for uncomplicated appendicitis at 16 children's hospitals from January 2013 to December 2014. Time to appendectomy (emergency department presentation to incision) and OD were obtained from the NSQIP Pediatric Appendectomy Pilot Database and merged with cost data from the Pediatric Health Information System Database. Multivariate regression was used to examine the influence of TTA and OD (categorized by quartiles of hospital-level means) on hospital cost, adjusting for patient and hospital-level characteristics. RESULTS: Median TTA and OD across all patients was 7.3 hours (interquartile range 4.4 to 12.4 hours) and 36 minutes (interquartile range 26 to 49 minutes), respectively. The longest quartile of OD was associated with 38% higher total cost ($2,512/case; rate ratio [RR] 1.38; 95% CI 1.27 to 1.5; p < 0.001) and 27% higher operating room-associated cost ($960/case; RR 1.27; 95% CI 1.22 to 1.34; p < 0.001) compared with the shortest quartile. The longest quartile of TTA was associated with 23% higher total cost ($1,589/case; RR 1.23; 95% CI 1.14 to 1.32; p < 0.001) and 53% higher room-associated cost ($906/case; RR 1.53; 95% CI 1.35 to 1.74; p < 0.001) compared with the shortest quartile. The influence of TTA and OD were independent but potentiating effects, with median cost for hospitals in both the longest quartiles of TTA and OD being 79% higher than those in the shortest quartiles. CONCLUSIONS: Longer TTA and OD were independently associated with increased hospital cost, with OD being the most significant driver of cost variation across hospitals. Identification of best practices from high-efficiency hospitals might provide a high-yield strategy for improving value in appendicitis care.

Utilizing trauma admissions as an opportunity to identify developmental and behavioral concerns.

BACKGROUND: Developmental and behavioral problems are often underdiagnosed in the pediatric population, and are risk factors for injury from trauma. Early intervention for these concerns yields improved outcomes. No prior research has screened for these difficulties during pediatric trauma admissions. METHODS: The current study utilized "The Survey of Wellbeing of Young Children" (SWYC) to assess for possible areas of concern by parent report. Concerns were compared to the presence of screening documented in their pediatrician's last well-child visit note. RESULTS: Of the 27 participants, 59.3% had developmental, behavioral, parental, or familial concerns. Overall, 46.2% of pediatricians had formally screened for concerns at the child's last well child visit, resulting in 25.9% being identified with new concerns found on the SWYC. CONCLUSIONS: Pediatric trauma admissions provide an important opportunity to screen for behavioral and developmental concerns in a population that is at risk for these concerns and that could greatly benefit from having problems identified.

Time to Appendectomy and Risk of Complicated Appendicitis and Adverse Outcomes in Children.

Importance: Management of appendicitis as an urgent rather than emergency procedure has become an increasingly common practice in children. Controversy remains as to whether this practice is associated with increased risk of complicated appendicitis and adverse events. Objective: To examine the association between time to appendectomy (TTA) and risk of complicated appendicitis and postoperative complications. Design, Setting, and Participants: In this retrospective cohort study using the Pediatric National Surgical Quality Improvement Program appendectomy pilot database, 2429 children younger than 18 years who underwent appendectomy within 24 hours of presentation at 23 children's hospitals from January 1, 2013, through December 31, 2014, were studied. Exposures: The main exposure was TTA, defined as the time from emergency department presentation to appendectomy. Patients were further categorized into early and late TTA groups based on whether their TTA was shorter or longer than their hospital's median TTA. Exposures were defined in this manner to compare rates of complicated appendicitis within a time frame sensitive to each hospital's existing infrastructure and diagnostic practices. Main Outcomes and Measures: The primary outcome was complicated appendicitis documented at operation. The association between treatment delay and complicated appendicitis was examined across all hospitals by using TTA as a continuous variable and at the level of individual hospitals by using TTA as a categorical variable comparing outcomes between late and early TTA groups. Secondary outcomes included length of stay (LOS) and postoperative complications (incisional and organ space infections, percutaneous drainage procedures, unplanned reoperation, and hospital revisits). Results: Of the 6767 patients who met the inclusion criteria, 2429 were included in the analysis (median age, 10 years; interquartile range, 8-13 years; 1467 [60.4%] male). Median hospital TTA was 7.4 hours (range, 5.0-19.2 hours), and 574 patients (23.6%) were diagnosed with complicated appendicitis (range, 5.2%-51.1% across hospitals). In multivariable analyses, increasing TTA was not associated with risk of complicated appendicitis (odds ratio per 1-hour increase in TTA, 0.99; 95% CI, 0.97-1.02). The odds ratios of complicated appendicitis for late vs early TTA across hospitals ranged from 0.39 to 9.63, and only 1 of the 23 hospitals had a statistically significant increase in their late TTA group (odds ratio, 9.63; 95% CI, 1.08-86.17; P = .03). Increasing TTA was associated with longer LOS (increase in mean LOS for each additional hour of TTA, 0.06 days; 95% CI, 0.03-0.08 days; P < .001) but was not associated with increased risk of any of the other secondary outcomes. Conclusions and Relevance: Delay of appendectomy within 24 hours of presentation was not associated with increased risk of complicated appendicitis or adverse outcomes. These results support the premise that appendectomy can be safely performed as an urgent rather than emergency procedure.