Neurocognitive Outcomes in Deformational Plagiocephaly: Is There an Association between Morphologic Severity and Results?

BACKGROUND: The neurodevelopmental effects of skull asymmetry and orthotic helmet therapy for deformational plagiocephaly (DP) have had limited investigation. This study assessed the long-term neurocognitive outcomes in patients with DP and their association with orthotic helmet therapy and head shape abnormality. METHODS: A total of 138 school-age children with a history of DP, 108 of whom received helmet therapy, were tested with a neurocognitive battery assessing academic achievement, intelligence quotient, and visual-motor function. Severity of presenting plagiocephaly was calculated using anthropometric and photometric measurements. Analysis of covariance was used to compare outcomes between helmeted and nonhelmeted cohorts, unilateral plagiocephaly and concomitant brachycephaly, and left-sided and right-sided plagiocephaly. The association between severity of plagiocephaly and neurocognitive outcome was assessed through a residualized change approach. RESULTS: There were no significant differences in neurocognitive outcomes between the helmeted and nonhelmeted DP cohorts or the unilateral plagiocephaly and brachycephaly cohorts. Participants with left-sided DP had significantly lower motor coordination scores than participants with right-sided DP (84.8 versus 92.7; effect size = -0.50; P = 0.03). There was a significant laterality by cephalic index interaction, with a negative association between cephalic index and reading comprehension and spelling for participants with left-sided DP. No significant associations were found between severity of presenting or posttreatment deformity and neurocognitive outcome. CONCLUSIONS: Pretreatment and posttreatment severity of plagiocephaly were not correlated with neurocognitive function at school age. Helmet therapy was not associated with better or worse long-term neurocognitive function. However, participants with left-sided DP demonstrated worse neurocognitive outcomes than participants with right-sided DP in the domains of motor coordination and some types of academic achievement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Risk Factors for Venous Thromboembolism in Children Undergoing Orthopedic Surgery.

Venous thromboembolism (VTE) is an uncommon but highly morbid and potentially preventable complication in children. This study aimed to characterize the incidence of, and risk factors for, VTE in children undergoing orthopedic surgery. A retrospective analysis was performed using the 2012 to 2017 American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database. Patient demographics, comorbidities, operative variables, and perioperative outcomes were compared between patients who did and did not develop a VTE. In total, 81,490 pediatric patients who underwent orthopedic surgery were identified. Of those, the mean±SD age was 9.7±4.8 years, and 50.1% were male. Sixty patients (0.07%) developed a postoperative VTE. On multivariate regression, demographic and surgical variables associated with a VTE were ages 16 to 18 years (P=.002; compared with ages 11 to 15 years), American Society of Anesthesiologists (ASA) classes III and V (P=.003; compared with ASA classes I and II), preoperative blood transfusion (P<.001), arthrotomy (P<.001), and femur fracture (P<.001). Postoperative adverse events occurring prior to a VTE were also assessed. Controlling for patient factors, independent risk factors for VTE included any adverse event (P<.001), major adverse events (P<.001), minor adverse events (P<.001), reoperation (P<.001), and readmission (P<.001). This study identified an incidence of VTE of 0.07% in a population of more than 80,000 children undergoing orthopedic surgery. The identification of risk factors for VTE in this patient population raises the issue of VTE prophylaxis for select high-risk subpopulations. [Orthopedics. 2022;45(1):31-37.].

Revision Total Hip and Knee Arthroplasty are Associated With Lower Hospital Consumer Assessment of Healthcare Providers and Systems Patient Satisfaction Scores Compared With Primary Arthroplasty.

INTRODUCTION: As rates of primary total joint arthroplasty continue to rise, so do rates of revision. Revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) are more frequently done at larger centers, are associated with higher morbidity, and may have different patient satisfaction outcomes. This study compares the survey results of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) between patients who underwent primary versus revision THA or TKA. METHODS: All adult patients who underwent inpatient, elective, primary, and revision THA or TKA at a single institution were selected for retrospective analysis. Patient demographics, comorbidities, functional status, surgical variables, 30-day outcomes, and HCAHPS scores were assessed. Univariate and multivariate analyses were done to determine correlations between the aforementioned variables and top-box HCAHPS survey scores for primary versus revision THA and TKA. RESULTS: Of 2,707 patients who met the inclusion criteria and had returned the HCAHPS survey, primary THA was documented in 1,075 patients (39.71%), revision THA in 75 (2.77%), primary TKA in 1,497 (55.30%), and revision TKA in 60 (2.22%). Revision THA patients were more functionally dependent, and TKA patients had higher American Society of Anesthesiologists score than their primary comparators. Revisions had longer hospital length of stay for both procedures. For THA, revision THA patients demonstrated lower total top-box rates compared withprimary THA patients (71.64% versus 75.67% top-box, P < 0.001) and lower scores on the care from doctors subsection (76.26% versus 85.34%, P < 0.001) of the HCAHPS survey. Similarly, for TKA, revision TKA patients demonstrated lower total top-box rates (76.13% versus 79.22%, P < 0.013) and lower scores on the care from doctors subsection (66.28% versus 83.65%, P < 0.001) of the HCAHPS survey. DISCUSSION: For both THA and TKA, revision procedures were associated with lower total HCAHPS scores and rated care from doctors. This suggests that HCAHPS scores may be biased by factors outside the surgeon's control, such as the complexity associated with revision procedures. LEVEL OF EVIDENCE: Level III.

Orthopaedic Foot and Ankle Surgeon Industry Compensation Reported by the Open Payments Database.

Background. The current study aims to characterize and explore trends in Open Payments Database (OPD) payments reported to orthopaedic foot and ankle (F&A) surgeons. OPD payments are classified as General, Ownership, or Research. Methods. General, Ownership, and Research payments to orthopaedic F&A surgeons were characterized by total payment sum and number of transactions. The total payment was compared by category. Payments per surgeon were also assessed. Median payments for all orthopaedic F&A surgeons and the top 5% compensated were calculated and compared across the years. Medians were compared through Mann-Whitney U tests. Results. Over the period, industry paid over $39 million through 29,442 transactions to 802 orthopaedic F&A surgeons. The majority of this payment was General (64%), followed by Ownership (34%) and Research (2%). The median annual payments per orthopaedic F&A surgeon were compared to the 2014 median ($616): 2015 ($505; P = .191), 2016 ($868; P = .088), and 2017 ($336; P = .084). Over these years, the annual number of compensated orthopaedic F&A surgeons increased from 490 to 556. Averaged over 4 years, 91% of the total orthopaedic F&A payment was made to the top 5% of orthopaedic F&A surgeons. The median payment for this group increased from $177 000 (2014) to $192 000 (2017; P = .012). Conclusion. Though median payments to the top 5% of orthopaedic F&A surgeons increased, there was no overall change in median payment over four years for all compensated orthopaedic F&A surgeons. These findings shed insight into the orthopaedic F&A surgeon-industry relationship.Levels of Evidence: III, Retrospective Study.

Risk Factors for Lymphedema After Breast Conservation Therapy and Oncoplastic Reduction.

BACKGROUND: Lymphedema is a known complication after the surgical management of breast cancer, yet the incidence is poorly defined after breast conserving therapy and oncoplastic reduction. The primary aim of this study was to define lymphedema incidence in this population. Furthermore, we sought to correlate demographic factors, surgical approach, and complementary treatment modalities with incidence. METHODS: Data were collected retrospectively on patients who underwent breast conserving therapy at our institution from 2012 to 2015 with greater than 1 year of follow-up. Patients were excluded if they underwent breast surgery before treatment, completion mastectomy, delayed breast reconstruction, or delayed breast reduction. RESULTS: Five hundred and eighty-four patients met study criteria with a 11% lymphedema rate. Patients developing lymphedema had higher preoperative body mass index (P = 0.02), larger breast mass resection volume (P < 0.01), higher rate of axillary dissection (P < 0.01), increased rate of adjuvant whole-breast radiation (P = 0.03), supraclavicular radiation (P < 0.01), axillary radiation (P < 0.01), and neoadjuvant medical therapy (P < 0.01). Multivariate analysis showed breast specimen mass, axillary radiation, and neoadjuvant medical therapy, which were associated with lymphedema (P < 0.05). There was no difference in lymphedema incidence between partial mastectomy and oncoplastic reduction cohorts with independent multivariate analyses for each showing axillary radiation and neoadjuvant medical therapy were significantly associated with lymphedema (P < 0.05), although breast specimen mass was not. CONCLUSIONS: Elevated preoperative body mass index, radiation, axillary dissection, and neoadjuvant medical therapy are associated with an increased risk of lymphedema after breast conserving surgery. Oncoplastic reconstruction is not a risk factor for lymphedema.

Pediatric Supracondylar Humerus Fracture Outcomes by Pediatric and Nonpediatric Orthopedists.

Pediatric supracondylar humerus fractures are common and often require surgical intervention by an orthopedic surgeon, who may or may not have pediatric subspecialty training. This study used a large national database to assess for potential differences in perioperative outcomes for pediatric supracondylar humerus fractures treated by pediatric and nonpediatric orthopedists. A retrospective comparative cohort analysis was performed using data from the National Surgical Quality Improvement Project-Pediatric (NSQIP-P) database 2012 to 2017. Patients 1 to 11 years old were assessed. Demographics, comorbidities, and the incidence of adverse outcomes were compared between pediatric and nonpediatric orthopedists using multivariate analysis controlling for patient characteristics. A total of 15,831 patients were included in the study. Of these, 85.2% were treated by pediatric orthopedists and 14.8% were treated by nonpediatric orthopedists. Demographics, comorbidity burden, operative time, and hospital length of stay were not significantly different between the study groups. With multivariate analysis controlling for patient factors, no differences were identified for 30-day adverse events, reoperation, or readmission whether surgery was performed by pediatric or nonpediatric orthopedists. Considering self-selection of surgeons who perform surgery for pediatric supracondylar humerus fractures, no differences in hospital or general outcome metrics were identified based on who performed these procedures. [Orthopedics. 2021;44(2):e203-e210.].

Worse overall health status negatively impacts satisfaction with breast reconstruction.

BACKGROUND: BREAST-Q is a validated measure of patient satisfaction and health-related quality of life following breast surgery. Limited evidence exists with regard to the influence of preoperative overall health status on BREAST-Q outcomes. The American Society of Anesthesiologists (ASA) physical status classification is representative of preoperative overall health and its impact on patient-reported outcomes can be assessed. METHODS: Patients who received breast reconstruction at Yale New Haven Hospital between 2013 and 2018 and completed the BREAST-Q were enrolled in the study. Associations between BREAST-Q scores within modules and between modules and ASA were analyzed. Pearson's correlation and Spearman's Rho were used to characterize correlations between patient factors and BREAST-Q scores. Significantly correlated factors were entered into a general linear model (GLM) to control for confounding variables and isolate the effect of ASA on BREAST-Q scores. RESULTS: A total of 1136 patients underwent breast reconstruction of whom 489 patients completed the BREAST-Q. Increasing ASA indicative of worsening overall health was associated with a decreased BREAST-Q score for all modules except Physical Well-being of the Abdomen (p<0.01 to p = 0.029). In a GLM controlling for relevant covariates, ASA remained a significant contributor for all modules except Physical Well-being of the Chest (p<0.01 to p = 0.021). BREAST-Q scores decreased by approximately twice as much from ASA 1 to 2 compared to ASA 2 to 3. CONCLUSION: ASA classification is an independent predictor of BREAST-Q patient-reported outcomes following breast reconstruction. Communicating the potential impact of overall health may help reduce the discrepancy in postoperative satisfaction across ASA classifications.

Risk of peri-operative complications in children receiving preoperative steroids.

BACKGROUND: Steroid use predisposes adult patients to increased perioperative complications including wound dehiscence and delayed wound healing. A similar large study investigating the perioperative impact of steroid use in pediatric patients has not been performed. METHODS: The National Surgical Quality Improvement Project Pediatric Database was queried from 2012-2017 to identify patients who received steroid preoperatively. Patient demographics, comorbidities, surgical variables, and outcomes were compared between cohorts. Patients were propensity score matched and thirty-day adverse events were compared. RESULTS: Of 425,251 pediatric surgery patients, 9716 (2.3%) received preoperative steroids. Pediatric patients treated with steroids were older and had more comorbidities. After propensity score matching, the steroid population had a significantly higher rate of adverse events, including prolonged hospital stay (15.3% vs. 9.1%, p < 0.001), seizure (0.9% vs. 0.4%, p < 0.001), readmission (14.4% vs. 9.2%, p < 0.001), and death (2.2% vs. 1.1%, p < 0.001). CONCLUSION: Preoperative steroid use is independently associated with increased 30-day postoperative adverse events among pediatric patients. Given the significant impact of steroid use on surgical outcomes, the risks and benefits of steroid treatment in children receiving surgery should be carefully evaluated.

Patients' and Physicians' Knowledge of Radiation Exposure Related to Spine Surgery.

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: Examine patients' and physicians' estimates of radiation exposure related to spine surgery. SUMMARY OF BACKGROUND DATA: Patients are commonly exposed to radiation when undergoing spine surgery. Previous studies suggest that patients and physicians have limited knowledge about radiation exposure in the outpatient setting. This has not been assessed for intraoperative imaging. METHODS: A questionnaire was developed to assess awareness/knowledge of radiation exposure in outpatient and intraoperative spine care settings. Patients and surgeons estimated chest radiograph (CXR) equivalent radiation from: cervical and lumbar radiographs (anterior-posterior [AP] and lateral), computed tomography (CT), magnetic resonance imaging (MRI), intraoperative fluoroscopy, and intraoperative CT (O-arm). Results were compared to literature-reported radiation doses. RESULTS: Overall, 100 patients and 26 providers completed the survey. Only 31% of patients were informed about outpatient radiation exposure, and only 23% of those who had undergone spine surgery had been informed about intraoperative radiation exposure. For lumbar radiographs, patients and surgeons underestimated CXR-equivalent radiation exposures: AP by five-fold (P < 0.0001) and seven-fold (P < 0.0001), respectively, and lateral by three-fold (P < 0.0001) and four-fold (P = 0.0002), respectively. For cervical CT imaging, patients and surgeons underestimated radiation exposure by 18-fold (P < 0.0001) and two-fold (P = 0.0339), respectively. For lumbar CT imaging, patients and surgeons underestimated radiation exposure by 31-fold (P < 0.0001) and three-fold (P = 0.0001), respectively. For intraoperative specific cervical and lumbar imaging, patients underestimated radiation exposure for O-arm by 11-fold (P < 0.0001) and 22-fold (P = 0.0002), respectively. Surgeons underestimated radiation exposure of lumbar O-arm by three-fold (P = 0.0227). CONCLUSION: This study evaluated patient and physician knowledge of radiation exposure related to spine procedures. Underestimation of radiation exposure in the outpatient setting was consistent with prior study findings. The significant underestimation of intraoperative cross-sectional imaging (O-arm) is notable and needs attention in the era of increased use of such technology for imaging, navigation, and robotic spine surgery. LEVEL OF EVIDENCE: 4.

Industry Payments to Orthopedic Spine Surgeons Reported by the Open Payments Database: 2014-2017.

STUDY DESIGN: This was a retrospective study of publicly available data. OBJECTIVE: The objective of this study was to characterize and assess trends in Open Payments Database (OPD) industry payments reported to orthopedic spine surgeons from 2014 to 2017. SUMMARY OF BACKGROUND DATA: There have been a lack of studies characterizing OPD industry payments to orthopedic spine surgeons over the 4 full years of data available. MATERIALS AND METHODS: General industry payments made to orthopedic spine surgeons from 2014 to 2017 were characterized by year with analysis of: number of compensated surgeons, median payment per surgeon, top strata of compensated surgeons, and subtype (ie, food/beverage). Research and Ownership Payments were characterized by median payment per surgeon. Mann-Whitney U tests were used to compare payments. RESULTS: For General Payments, the number of compensated orthopedic spine surgeons increased from 1539 in 2014 to 1673 in 2017. Later year median General Payments per surgeon were compared with the 2014 median ($1051): 2015 ($1070: P=0.375), 2016 ($1263: P=0.012), and 2017 ($978: P=0.561). In 2014, the top 10% of compensated orthopedic spine surgeons received 89% of the total General compensation to orthopedic spine surgeons, top 5% received 79%, and the top 1% received 55%. The median General Payment for these 3 top strata remained similar over the 4 years evaluated (P>0.05). For subtype analyses, the median aggregate General Payment for "education" increased (P=0.002) across the years. Finally, it was determined that the median payment per surgeon for Research and Ownership Payment categories remained stable across the time period (P>0.05). CONCLUSIONS: Many expected industry payments to surgeons to decrease under public scrutiny of the OPD, but the present study showed no net change in median payment (General, Research, and Ownership) over the years studied. In the age of greater transparency, these findings shed insight into the orthopedic spine surgeon-industry relationship. LEVEL OF EVIDENCE: Level III.

Impact of socioeconomic status on psychological functioning in survivorship following breast cancer and reconstruction.

Socioeconomic status (SES) remains an important population health risk factor and impacts a patient's experience of care during breast cancer. This study explored the relationship between SES and quality of life and satisfaction in survivorship following breast cancer and reconstruction. All patients underwent breast reconstruction at a single academic center from 2013 to 2017. Patients completed the five quality of life and satisfaction domains of the BREAST-Q, a validated patient-reported outcome measure. Estimated home value using a web-based real estate website was used to approximate a patient's socioeconomic status. Correlations were evaluated using Pearson's correlation methods, where appropriate, as well as analysis of covariance. Data were stratified for comparison utilizing t tests and linear regression models. Significance was defined as P ≤ .05. Four hundred patients underwent 711 breast reconstructions during the study time period. Satisfaction with the breast (P = .038) and psychosocial well-being (P = .012) had significant positive correlations with increasing socioeconomic status. When stratifying patients' socioeconomic status into thirds, the upper third had significantly higher psychosocial well-being (P = .001), satisfaction with breasts (P = .010), and physical well-being of the chest (P = .001) than the lower third. Significance persisted even after controlling for cancer stage, treatment, complications, and baseline comorbidities. Higher socioeconomic status is associated with greater satisfaction with breast reconstruction and psychosocial well-being following breast cancer treatment. Providing added social, psychological, and emotional support networks may be beneficial long after the initial cancer treatment and reconstruction are complete. Patients of lower socioeconomic status may benefit from additional resources.

Pediatric thyroidectomies: A surgical subspecialty comparison.

OBJECTIVE: This study aims to establish the typical population, safety, and outcomes of pediatric thyroidectomies, specifically identifying surgical complication rates. Furthermore, the study compares management and complication differences between the two specialties that most often manage these patients - Pediatric General Surgery and Otolaryngology. METHODS: National Surgical Quality Improvement Program - Pediatrics (NSQIP-P) data between the years of 2012 and 2016 was reviewed and analyzed for patient characteristics, perioperative course and outcomes. Sub-group analysis was used to compare groups based on surgeon sub-specialty: Otolaryngology or Pediatric General Surgery. RESULTS: The study identified 516 cases pediatric patients operated on by Pediatric Otolaryngology (229; 44.4%) and Pediatric General Surgery (287; 55.6%). Overall, rates of surgical and medical adverse events were low (1.2% and 0.7%, respectively). Upon univariate analysis, there were no differences between specialties in surgical adverse events (p = 1.000), medical adverse events (p = 0.196), reoperation (p = 0.505), or readmission (p = 0.262). Indication for surgery differed between specialties, with benign neoplasm more common in the Pediatric Otolaryngology group (48.9% vs. 35.2%), and thyrotoxicosis more common in the Pediatric General Surgery group (43.9% vs. 23.1%) (p < 0.001). Compared to cases done by Otolaryngology, Pediatric General Surgery was independently associated with a shorter operative time (B: -31.583 min [95% CI: -42.802 to -20.364]; p < 0.001). CONCLUSION: Thyroidectomy in the pediatric population is a safe procedure with no differences in adverse outcomes noted when comparing Pediatric General Surgeons to Pediatric Otolaryngologists. Pediatric General Surgeons were observed to have a significantly shorter operative time.

High, As Well As Low, Preoperative Platelet Counts Correlate With Adverse Outcomes After Elective Posterior Lumbar Surgery.

STUDY DESIGN: Retrospective cohort study of prospectively collected data. OBJECTIVE: Assess correlation between preoperative platelet counts and postoperative adverse events after elective posterior lumbar surgery procedures. SUMMARY OF BACKGROUND DATA: Preoperative low platelet counts have been correlated with adverse outcomes after posterior lumbar surgery. Nonetheless, the effect of varying platelet counts has not been studied in detail for a large patient population, especially on the high end of the platelet spectrum. METHODS: Patients who underwent elective posterior lumbar surgery were identified in the 2011 to 2016 National Surgical Quality Improvement Program database. Preoperative platelet counts were considered relative to 30-day perioperative adverse outcomes. Patients were classified into platelet categories based on determining upper and lower bounds on when the adverse outcomes crossed a relative risk of 1.5. Univariate and multivariate analyses compared 30-day postoperative complications, readmissions, operative time, and hospital length of stay between those with low, normal, and high platelet counts. RESULTS: In total, 137,709 posterior lumbar surgery patients were identified. Using the relative risk threshold of 1.5 for the occurrence of any adverse event, patients were divided into abnormally low (≤140,000/mL) and abnormally high (≥447,000/mL) platelet cohorts. The abnormally low and high platelet groups were associated with higher rates of any, major, minor adverse events, transfusion, and longer hospital length of stay. Furthermore, the abnormally low platelet counts were associated with a higher risk of readmissions. CONCLUSION: The data-based cut-offs for abnormally high and low platelet counts closely mirrored those found in literature. Based on these definitions, abnormally high and low preoperative platelet counts were associated with adverse outcomes after elective posterior lumbar surgery. These findings facilitate risk stratification and suggest targeted consideration for patients with high, as well as low, preoperative platelet counts. LEVEL OF EVIDENCE: 3.

Venous thromboembolism in children undergoing surgery: incidence, risk factors and related adverse events.

Background: Although less common in adults, venous thromboembolism (VTE) in children is a highly morbid, preventable adverse event. While VTE has been well studied among pediatric hospitalized and trauma patients, limited work has been done to examine postoperative VTE in children undergoing surgery. Methods: Using data from National Surgical Quality Improvement Project Pediatric database (NSQIP-P) from 2012 to 2016, a retrospective cohort analysis was performed to determine the incidence of, and risk factors for, VTE in children undergoing surgery. Additionally, the relationships between VTE and other postoperative adverse outcomes were evaluated. Results: Of 361 384 pediatric surgical patients, 378 (0.10%) were identified as experiencing postoperative VTE. After controlling for patient and surgical factors, we found that American Society of Anesthesiologists (ASA) class of II or greater, aged 16-18 years, non-elective surgery, general surgery (compared with several other surgical specialties), cardiothoracic surgery (compared with general surgery) and longer operative time were significantly associated with VTE in pediatric patients (p<0.001 for each comparison). Furthermore, a majority of adverse events were found to be associated with increased risk of subsequent VTE (p<0.001). Conclusion: In a large pediatric surgical population, an incidence of postoperative VTE of 0.10% was observed. Defined patient and surgical factors, and perioperative adverse events were found to be associated with such VTE events.

Cleft lip repair: are outcomes between unilateral and bilateral clefts comparable?

This study sought to compare patient demographics, operative course, and peri-operative outcomes between unilateral and bilateral cleft patients. Primary cleft lip repairs were isolated from the National Surgical Quality Improvement Program Pediatric Database (NSQIP-P). Unilateral and bilateral cases of primary cleft lip were identified by ICD codes. Demographics, comorbidities, and post-operative outcomes were compared between cohorts. Patients were propensity matched to control for differences before repeating the analysis. About 4550 cleft lip repairs were evaluated over the 5-year period. Of the cases where the cleft type was identifiable, 75.5% were unilateral clefts and 24.5% were bilateral clefts. The bilateral cleft population had significantly more comorbidities including higher rates of ventilator dependence (1.0% versus 0.4%, p = 0.02), asthma (1.6% versus 0.7%, p = 0.011), tracheostomy (1.6% versus 0.5%, p < 0.001), gastrointestinal disease (16.9% versus 12.7%, p < 0.001), previous cardiac surgery (3.6% versus 2.2%, p = 0.015), developmental delay (9.9% versus 4.6%, p < 0.001), structural central nervous system abnormalities (5.0% versus 2.5%, p < 0.001), and nutritional support (8.0% versus 3.2%, p < 0.001). Following propensity matching, there were no significant differences in complications, readmissions, or reoperations between the cohorts. Patients with bilateral cleft lip have significantly more comorbidities than unilateral cleft lip patients. However, peri-operative outcomes are comparable between the groups.

Patient-related Factors and Perioperative Outcomes Are Associated with Self-Reported Hospital Rating after Spine Surgery.

BACKGROUND: Since 2013, the Centers for Medicare & Medicaid Services has tied a portion of hospitals' annual reimbursement to patients' responses to the Hospital Consumer Assessment and Healthcare Providers and Systems (HCAHPS) survey, which is given to a random sample of inpatients after discharge. The most general question in the HCAHPS survey asks patients to rate their overall hospital experience on a scale of 0 to 10, with a score of 9 or 10 considered high, or "top-box." Previous work has suggested that HCAHPS responses, which are meant to be an objective measure of the quality of care delivered, may vary based on numerous patient factors. However, few studies to date have identified factors associated with HCAHPS scores among patients undergoing spine surgery, and those that have are largely restricted to surgery of the lumbar spine. Consequently, patient and perioperative factors associated with HCAHPS scores among patients receiving surgery across the spine have not been well elucidated. QUESTIONS/PURPOSES: Among patients undergoing spine surgery, we asked if a "top-box" rating on the overall hospital experience question on the HCAHPS survey was associated with (1) patient-related factors present before admission; (2) surgical variables related to the procedure; and/or (3) 30-day perioperative outcomes. METHODS: Among 5517 patients undergoing spine surgery at a single academic institution from 2013 to 2017 and who were sent an HCAHPS survey, 27% (1480) returned the survey and answered the question related to overall hospital experience. A retrospective, comparative analysis was performed comparing patients who rated their overall hospital experience as "top-box" with those who did not. Patient demographics, comorbidities, surgical variables, and perioperative outcomes were compared between the groups. A multivariate logistic regression analysis was performed to determine patient demographics, comorbidities, and surgical variables associated with a top-box hospital rating. Additional multivariate logistic regression analyses controlling for these variables were performed to determine the association of any adverse event, major adverse events (such as myocardial infarction, pulmonary embolism), and minor adverse events (such as urinary tract infection, pneumonia); reoperation; readmission; and prolonged hospitalization with a top-box hospital rating. RESULTS: After controlling for potential confounding variables (including patient demographics), comorbidities that differed in incidence between patients who rated the hospital top-box and those who did not, and variables related to surgery, the patient factors associated with a top-box hospital rating were older age (compared with age ≤ 40 years; odds ratio 2.2, [95% confidence interval 1.4 to 3.4]; p = 0.001 for 41 to 60 years; OR 2.5 [95% CI 1.6 to 3.9]; p < 0.001 for 61 to 80 years; OR 2.1 [95% CI 1.1 to 4.1]; p = 0.036 for > 80 years), and being a man (OR 1.3 [95% CI 1.0 to 1.7]; p = 0.028). Further, a non-top-box hospital rating was associated with American Society of Anesthesiologists Class II (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.024), Class III (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.020), or Class IV (OR 0.2 [95% CI 0.1 to 0.5]; p = 0.003). The only surgical factor positively associated with a top-box hospital rating was cervical surgery (compared with lumbar surgery; OR 1.4 [95% CI 1.1 to 1.9]; p = 0.016), while nonelective surgery (OR 0.5 [95% CI 0.3 to 0.8]; p = 0.004) was associated with a non-top-box hospital rating. Controlling for the same set of variables, a non-top-box rating was associated with the occurrence of any adverse event (OR 0.5 [95% CI 0.3 to 0.7]; p < 0.001), readmission (OR 0.5 [95% CI 0.3 to 0.9]; p = 0.023), and prolonged hospital stay (OR, 0.6 [95% CI 0.4 to 0.8]; p = 0.004). CONCLUSIONS: Identifying patient factors present before surgery that are independently associated with HCAHPS scores underscores the survey's limited utility in accurately measuring the quality of care delivered to patients undergoing spine surgery. HCAHPS responses in the spine surgery population should be interpreted with caution and should consider the factors identified here. Given differing findings in the literature regarding the effect of adverse events on HCAHPS scores, future work should aim to further characterize this relationship. LEVEL OF EVIDENCE: Level III, therapeutic study.

Impact of Insurance Payer on Type of Breast Reconstruction Performed.

BACKGROUND: The impact of insurance and socioeconomic status on breast reconstruction modalities when access to care is controlled is unknown. METHODS: Records for patients who underwent breast reconstruction at an academic medical center between 2013 and 2017 were reviewed and analyzed using chi-square analysis and logistic regression. RESULTS: One thousand six hundred eighty-three breast reconstructions were analyzed. The commercially insured were more likely to undergo microvascular autologous breast reconstruction (44.4 percent versus 31.3 percent; p < 0.001), with an odds ratio of 2.22, whereas patients with Medicare and Medicaid were significantly more likely to receive tissue expander/implant breast reconstruction, with an odds ratio of 1.42 (41.7 percent versus 47.7 percent; p = 0.013). Comparing all patients with microvascular reconstruction, the commercially insured were more likely to receive a perforator flap (79.7 percent versus 55.3 percent versus 43.9 percent), with an odds ratio of 4.23 (p < 0.001). When stratifying patients by median household income, those in the highest income quartile were most likely to receive a perforator flap (82.1 percent) (p < 0.001), whereas those in the lowest income quartile were most likely to receive a muscle-sparing transverse rectus abdominis myocutaneous flap (36.4 percent) (p < 0.001). CONCLUSIONS: Patients at the same academic medical center had significantly different breast reconstruction modalities when stratified by insurance and household income. Despite similar access to care, differences in insurance types may favor higher rates of perforator flap breast reconstruction among the commercially insured. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Breast reconstruction patterns and outcomes in academic and community practices within a single institution.

Breast reconstruction is a common procedure that is performed in both community and academic settings. At Yale-New Haven Hospital (YNHH), both academic (AP) and community-based (CP) plastic surgeons perform breast reconstructions. We aim to compare practice patterns in breast reconstruction between two practice environments within a single institution. A retrospective chart review of all breast reconstructions at YNHH between 2013 and 2018 was performed. Data collected included demographics, preoperative history, and postoperative outcomes. Results were further subdivided by practice setting. A total of 1045 patients (1683 breasts) underwent breast reconstruction during the study period. About 52.8% were performed by AP while 47.2% were performed by CP. CP had higher rates of autologous reconstruction (P < .001) and nipple-sparing mastectomy (P < .0001). Age and BMI were similar between the cohorts. However, patients cared for by AP had 2.6% increased prevalence of diabetes (P = .064), 5.5% greater prevalence of psychiatric diagnoses (P = .004), and 7.1% higher open abdominal surgery rates (P < .001). Outcomes were similar between the groups except for higher infection rates (P = .027) and explant rates (P = .003) in the CP cohort. When evaluating insurance status, the AP cohort had 30.5% fewer patients with commercial insurance, 16.7% more patients with Medicaid and 6.1% more patients with Medicare (P < .001). Within our institution, academic and community-based plastic surgeons perform breast reconstruction with overall similar complication rates. Patients treated by AP have a higher rate of preoperative medical and psychiatric comorbidities. Patients treated by CP have higher rates of infection and implant explant. AP plastic surgeons care for a significantly higher rate of Medicare and Medicaid patients with proportionally fewer patients with commercial insurance.

Veau III and Veau IV Cleft Palate: Do Peri-Operative Complications Differ?

OBJECTIVE: The Veau classification represents the most commonly used system for characterizing cleft palate severity. Conflicting evidence exists as to how increasing Veau classification affects outcomes. This study compared perioperative outcomes between Veau III and IV cleft palate repairs. METHODS: The National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was used to identify cleft palate repairs between 2012 and 2016 using CPT codes. Patients with alveolar bone grafts were excluded. Veau III (unilateral) and Veau IV (bilateral) cleft palate repairs were identified using International Classification of Disease code 9 and 10 (ICD-9 and -10 codes. Patient demographics, comorbidities, and adverse events were compared between the cohorts. RESULTS: A total of 5026 patients underwent cleft palate repair between 2012 and 2016. Of the 2114 patients with identifiable Veau classification, 1302 had Veau III cleft palates and 812 had Veau IV cleft palates.The Veau IV cleft palate patient population was older (377.8 versus 354.1 days, P < 0.001) and had significantly more comorbidities including a higher incidence of chronic lung disease (P = 0.014), airway abnormalities (P = 0.001), developmental delay (P = 0.018), structural central nervous system deformities (P < 0.001), and nutritional support (P < 0.001). Veau IV cleft palate repairs also had longer operative times (153.2 versus 140.2 minutes, P < 0.001). Despite significant differences in comorbidities and perioperative factors, there were no differences in 30-day complications, readmissions, or reoperation rates between Veau III and IV cleft palate repairs. CONCLUSIONS: Patients undergoing Veau IV cleft palate repair have a significantly greater number of comorbidities than Veau III cleft palate repairs. Despite differences in patient populations, 30-day surgical outcomes are comparable between the cohorts.