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J Reconstr Microsurg
DOI: 10.1055/a-2460-4821
Original Article

Unplanned 180-day Readmissions and Health Care Utilization after Immediate Breast Reconstruction for Breast Cancer

Arturo J. Rios-Diaz   *
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
,
Theodore E. Habarth-Morales   *
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
2   Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
,
Emily L. Isch
3   Division of Plastic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
,
Chris Amro
4   Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
,
Harrison D. Davis
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
5   Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
,
Robyn B. Broach
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
,
Matthew Jenkins
3   Division of Plastic Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
,
John P. Fischer
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
,
Joseph M. Serletti
1   Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract

Background To assess the burden of postdischarge health care utilization given by readmissions beyond 30 days following immediate breast reconstruction (IBR) nationwide.

Methods Women with breast cancer who underwent mastectomy and concurrent IBR (autologous and implant-based) were identified within the 2010 to 2019 Nationwide Readmission Database. Cox proportional hazards and generalized linear regression controlling for patient- and hospital-level confounders were used to determine factors associated with 180-day unplanned readmissions and incremental hospital costs, respectively.

Results Within 180 days, 10.7% of 100,942 women were readmitted following IBR. Readmissions tended to be publicly insured (30.8 vs. 21.7%, p < 0.001) and multimorbid (Elixhauser Comorbidity Index > 2 31.6 vs. 19.6%, p < 0.001) compared with nonreadmitted patients. There were no differences in readmission rates among types of IBR (tissue expander 11.2%, implant 10.7%, autologous 10.8%; p > 0.69). Of all readmissions, 40% occurred within 30 days and 21.7% in a different hospital and 40% required a major procedure in the operating room. Infection was the leading cause of readmissions (29.8%). In risk-adjusted analyses, patients with carcinoma in situ, publicly insured, low socioeconomic status, and higher comorbidity burden were associated with increased readmissions (all p < 0.05). Readmissions resulted in additional $8,971.78 (95% confidence interval: $8,537.72–9,405.84, p < 0.001) in hospital costs, which accounted for 15% of the total cost of IBR nationwide.

Conclusion The majority of inpatient health care utilization given by readmissions following mastectomy and IBR occurs beyond the 30-day benchmark. There is evidence of fragmentation of care as a quarter of readmissions occur in a different hospital and over one-third require major procedures. Mitigating postoperative infectious complications could result in the highest reduction of readmissions.

Keywords

breast cancer - mastectomy - immediate breast reconstruction - unplanned readmission - costs - epidemiology - health care utilization - nationwide

Authors' Contributions

Conception and design of the study: A.J.R.D., T.E.H.M., R.B.B., M.J., J.M.S., J.P.F.; data acquisition: A.J.R.D., T.E.H.M., M.J., R.B.B.; data analysis: A.J.R.D., T.E.H.M.; data interpretation: A.J.R.D., T.E.H.M., R.B.B., E.L.I., M.J., J.M.S., J.P.F.; drafting of the article: A.J.R.D., T.E.H.M., C.A., E.L.I., H.D.D.; critical revisions of the manuscript: A.J.R.D., T.E.H.M., CA, E.L.I., H.D.D., M.J., R.B.B., J.M.S., J.P.F.


* Authors contributed equally.


Supplementary Material



Publication History

Received: 18 July 2024

Accepted: 17 October 2024

Accepted Manuscript online:
04 November 2024

Article published online:
23 December 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Fontanarosa PB, McNutt RA. Revisiting hospital readmissions. JAMA 2013; 309 (04) 398-400
    CrossrefPubMedSearch in Google Scholar
  • 2 Cemal Y, Albornoz CR, Disa JJ. et al. A paradigm shift in U.S. breast reconstruction: part 2. The influence of changing mastectomy patterns on reconstructive rate and method. Plast Reconstr Surg 2013; 131 (03) 320e-326e
    CrossrefPubMedSearch in Google Scholar
  • 3 Yang RL, Newman AS, Lin IC. et al. Trends in immediate breast reconstruction across insurance groups after enactment of breast cancer legislation. Cancer 2013; 119 (13) 2462-2468
    CrossrefPubMedSearch in Google Scholar
  • 4 Siddiqui A, Ueno C, Agarwal J. et al. Evidence-based performance measures for autologous breast reconstruction: An American Society of Plastic Surgeons quality Performance Measure Set. Plast Reconstr Surg 2020; 145 (02) 284e-294e
    CrossrefPubMedSearch in Google Scholar
  • 5 Manahan MA, Wooden WA, Becker SM. et al. Evidence-based performance measures: quality metrics for the care of patients undergoing breast reconstruction. Plast Reconstr Surg 2017; 140 (06) 775e-781e
    CrossrefPubMedSearch in Google Scholar
  • 6 Mlodinow AS, Ver Halen JP, Lim S, Nguyen KT, Gaido JA, Kim JYS. Predictors of readmission after breast reconstruction: a multi-institutional analysis of 5012 patients. Ann Plast Surg 2013; 71 (04) 335-341
    CrossrefPubMedSearch in Google Scholar
  • 7 Collier W, Scheefer Van Boerum M, Kim J, Kwok AC. Are 30-day outcomes enough? Late infectious readmissions following prosthetic-based breast reconstruction. Plast Reconstr Surg 2019; 144 (03) 360e-368e
    CrossrefPubMedSearch in Google Scholar
  • 8 Sawyer JD, Franke J, Scaife S, Sommer NZ, Neumeister MW. Autologous breast reconstruction is associated with lower 90-day readmission rates. Plast Reconstr Surg Glob Open 2022; 10 (02) e4112
    CrossrefPubMedSearch in Google Scholar
  • 9 Fischer JP, Nelson JA, Cleveland E. et al. Breast reconstruction modality outcome study: a comparison of expander/implants and free flaps in select patients. Plast Reconstr Surg 2013; 131 (05) 928-934
    CrossrefPubMedSearch in Google Scholar
  • 10 Berry T, Brooks S, Sydow N. et al. Complication rates of radiation on tissue expander and autologous tissue breast reconstruction. Ann Surg Oncol 2010; 17 (Suppl. 03) 202-210
    CrossrefPubMedSearch in Google Scholar
  • 11 Phillips BT, Halvorson EG. Antibiotic prophylaxis following implant-based breast reconstruction: what is the evidence?. Plast Reconstr Surg 2016; 138 (04) 751-757
    CrossrefPubMedSearch in Google Scholar
  • 12 Olsen MA, Nickel KB, Fox IK. Surveillance and prevention of surgical site infections in breast oncologic surgery with immediate reconstruction. Curr Treat Options Infect Dis 2017; 9 (02) 155-172
    CrossrefPubMedSearch in Google Scholar
  • 13 Gahm J, Ljung Konstantinidou A, Lagergren J. et al. Effectiveness of single vs multiple doses of prophylactic intravenous antibiotics in implant-based breast reconstruction: a randomized clinical trial. JAMA Netw Open 2022; 5 (09) e2231583
    CrossrefPubMedSearch in Google Scholar
  • 14 Martin MS, Kebede S, Saad OA, Baker NF, Losken A. Impact of socioeconomic status on breast reconstruction outcomes. Ann Plast Surg 2022; 88 (5, Suppl 5): S481-S484
    CrossrefPubMedSearch in Google Scholar
  • 15 Wexelman B, Schwartz JA, Lee D, Estabrook A, Ma AMT. Socioeconomic and geographic differences in immediate reconstruction after mastectomy in the United States. Breast J 2014; 20 (04) 339-346
    CrossrefPubMedSearch in Google Scholar
  • 16 Stankowski TJ, Schumacher JR, Hanlon BM. et al. Barriers to breast reconstruction for socioeconomically disadvantaged women. Breast Cancer Res Treat 2022; 195 (03) 413-419
    CrossrefPubMedSearch in Google Scholar
  • 17 Butler PD, Morris MP, Momoh AO. Persistent disparities in postmastectomy breast reconstruction and strategies for mitigation. Ann Surg Oncol 2021; 28 (11) 6099-6108
    CrossrefPubMedSearch in Google Scholar
  • 18 James TA, Kasumova G, Alapati A, Mamtani A. Unplanned readmissions following breast cancer surgery. Am J Surg 2019; 218 (05) 988-992
    CrossrefPubMedSearch in Google Scholar
  • 19 Sharma K, Grant D, Parikh R, Myckatyn T. Race and breast cancer reconstruction: is there a health care disparity?. Plast Reconstr Surg 2016; 138 (02) 354-361
    CrossrefPubMedSearch in Google Scholar
  • 20 Nkana ZH, Wood KL, Karczewski AM. et al. Evaluation of racial disparities in postoperative outcomes following breast reconstruction at a single institution in Wisconsin. WMJ 2021; 120 (S1): S42-S47
    PubMedSearch in Google Scholar
  • 21 Butler PD, Nelson JA, Fischer JP. et al. African-American women have equivalent outcomes following autologous free flap breast reconstruction despite greater preoperative risk factors. Am J Surg 2015; 209 (04) 589-596
    CrossrefPubMedSearch in Google Scholar
  • 22 Norton EC, Dowd BE. Log odds and the interpretation of logit models. Health Serv Res 2018; 53 (02) 859-878
    CrossrefPubMedSearch in Google Scholar
  • 23 Fischer JP, Fox JP, Nelson JA, Kovach SJ, Serletti JM. A Longitudinal assessment of outcomes and healthcare resource utilization after immediate breast reconstruction-comparing implant- and autologous-based breast reconstruction. Ann Surg 2015; 262 (04) 692-699
    CrossrefPubMedSearch in Google Scholar
  • 24 Zogg CK, Pawlik TM, Haider AH. Three common methodological issues in studies of surgical readmission rates: the trouble with readmissions. JAMA Surg 2018; 153 (12) 1074-1076
    CrossrefPubMedSearch in Google Scholar
  • 25 Anderson PA, Savage JW, Vaccaro AR. et al. Prevention of surgical site infection in spine surgery. Neurosurgery 2017; 80 (3S): S114-S123
    CrossrefPubMedSearch in Google Scholar
  • 26 Nelson JA, Nelson P, Tchou J, Serletti JM, Wu LC. The ethnic divide in breast reconstruction: a review of the current literature and directions for future research. Cancer Treat Rev 2012; 38 (05) 362-367
    CrossrefPubMedSearch in Google Scholar
  • 27 Kruper L, Xu X, Henderson K, Bernstein L. Disparities in reconstruction rates after mastectomy for ductal carcinoma in situ (DCIS): patterns of care and factors associated with the use of breast reconstruction for DCIS compared with invasive cancer. Ann Surg Oncol 2011; 18 (11) 3210-3219
    CrossrefPubMedSearch in Google Scholar
  • 28 Connors SK, Goodman MS, Myckatyn T, Margenthaler J, Gehlert S. Racial disparities in breast reconstruction at a comprehensive cancer center. J Racial Ethn Health Disparities 2022; 9 (06) 2323-2333
    CrossrefPubMedSearch in Google Scholar
  • 29 Albornoz CR, Cordeiro PG, Hishon L. et al. A nationwide analysis of the relationship between hospital volume and outcome for autologous breast reconstruction. Plast Reconstr Surg 2013; 132 (02) 192e-200e
    CrossrefPubMedSearch in Google Scholar
  • 30 Gooiker GA, van Gijn W, Post PN, van de Velde CJH, Tollenaar RAEM, Wouters MWJM. A systematic review and meta-analysis of the volume-outcome relationship in the surgical treatment of breast cancer. Are breast cancer patients better of with a high volume provider?. Eur J Surg Oncol 2010; 36 (Suppl. 01) S27-S35
    CrossrefPubMedSearch in Google Scholar