J Reconstr Microsurg 2020; 36(06): 450-457
DOI: 10.1055/s-0040-1702175
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

A Nationwide Analysis of Early and Late Readmissions following Free Tissue Transfer for Breast Reconstruction

David Alejandro Magno-Padron
1   Department of Plastic Surgery, University of Utah School of Medicine, Salt Lake City, Utah
,
Willem Collier
2   Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
,
Jaewhan Kim
3   Department of Family and Preventative Medicine, University of Utah School of Medicine, Salt Lake City, Utah
,
Jayant P. Agarwal
1   Department of Plastic Surgery, University of Utah School of Medicine, Salt Lake City, Utah
,
Alvin C. Kwok
1   Department of Plastic Surgery, University of Utah School of Medicine, Salt Lake City, Utah
› Author Affiliations
Further Information

Publication History

13 September 2019

05 January 2020

Publication Date:
15 March 2020 (online)

Abstract

Background Traditionally, surgical quality outcomes are assessed using a 30-day postoperative window. For breast cancer patients undergoing free tissue transfer for breast reconstruction, we sought to describe the distribution of and specific risk factors for early and late readmissions within a 0- to 90-day postoperative period.

Patients and Methods The Nationwide Readmissions Database was used to conduct a retrospective cohort study. Breast cancer patients undergoing free tissue transfer for breast reconstruction were identified using International Classification of Diseases -9 diagnosis and procedure codes. Ninety-day readmissions related to infection or wound complications were identified. Univariable and multivariable logistic regression models were used to identify patient risk factors for readmissions that occurred early (0–30 days) and late (31–90 days) after their index procedure.

Results In the weighted sample, we identified approximately 7,305 free flap breast reconstructions and a surgical wound-related readmission rate of 4.3% (n = 312): 65.4% of the readmissions occurred early while 34.6% occurred late after surgery. The mean days to readmission was 26, and 75% of all readmissions occurred within the first 36 days after surgery. Variables independently associated with readmissions during the 0- to 90-day postoperative period included: history of chronic obstructive pulmonary disease (p = 0.036), hypertension (p = 0.03), obesity (p ≤ 0.001), and history of smoking (p = 0.004). The variables independently associated with the early readmission period were the same as those identified for the 0- to 90-day postoperative period. The variables independently associated with late readmissions were different: history of depression (p = 0.001) and history of smoking (p = 0.001).

Conclusion The conventional 30-day hospital readmission rate classically used as a quality metric is overlooking a significant portion of admissions after free flap-based breast reconstruction. Different variables were found to be associated with readmission in the early versus late cohorts. Interventions targeting these variables could decrease readmissions and their associated costs.

Supplementary Material

 
  • References

  • 1 Plastic Surgery Statistics Report. Available at: https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf 2018
  • 2 Fischer JP, Nelson JA, Au A, Tuggle III CT, Serletti JM, Wu LC. Complications and morbidity following breast reconstruction--a review of 16,063 cases from the 2005-2010 NSQIP datasets. J Plast Surg Hand Surg 2014; 48 (02) 104-114
  • 3 Duraes EF, Schwarz G, Durand P. , et al. Complications following abdominal-based free flap breast reconstruction: is a 30 days complication rate representative?. Aesthetic Plast Surg 2015; 39 (05) 694-699
  • 4 Jagsi R, Momoh AO, Qi J. , et al. Impact of radiotherapy on complications and patient-reported outcomes after breast reconstruction. J Natl Cancer Inst 2018; 110 (02) 157-165
  • 5 Santosa KB, Qi J, Kim HM, Hamill JB, Wilkins EG, Pusic AL. Long-term patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg 2018; 153 (10) 891-899
  • 6 Zhong T, McCarthy C, Min S. , et al. Patient satisfaction and health-related quality of life after autologous tissue breast reconstruction: a prospective analysis of early postoperative outcomes. Cancer 2012; 118 (06) 1701-1709
  • 7 Atisha DM, Rushing CN, Samsa GP. , et al. A national snapshot of satisfaction with breast cancer procedures. Ann Surg Oncol 2015; 22 (02) 361-369 4246-9
  • 8 Chung CU, Wink JD, Nelson JA, Fischer JP, Serletti JM, Kanchwala SK. Surgical site infections after free flap breast reconstruction: an analysis of 2,899 patients from the ACS-NSQIP datasets. J Reconstr Microsurg 2015; 31 (06) 434-441
  • 9 Mlodinow AS, Ver Halen JP, Lim S, Nguyen KT, Gaido JA, Kim JY. Predictors of readmission after breast reconstruction: a multi-institutional analysis of 5012 patients. Ann Plast Surg 2013; 71 (04) 335-341
  • 10 Massenburg BB, Sanati-Mehrizy P, Ingargiola MJ, Rosa JH, Taub PJ. Flap failure and wound complications in autologous breast reconstruction: a national perspective. Aesthetic Plast Surg 2015; 39 (06) 902-909
  • 11 Xu F, Sun H, Zhang C. , et al. Comparison of surgical complication between immediate implant and autologous breast reconstruction after mastectomy: A multicenter study of 426 cases. J Surg Oncol 2018; 118 (06) 953-958
  • 12 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360 (14) 1418-1428
  • 13 Surgeons ACo. American College of Surgeons national surgical quality improvement program. Available at: https://www.facs.org/quality-programs/acs-nsqip
  • 14 Johnson C, Campwala I, Gupta S. Examining the validity of the ACS-NSQIP Risk Calculator in plastic surgery: lack of input specificity, outcome variability and imprecise risk calculations. J Investig Med 2017; 65 (03) 722-725
  • 15 O'Neill AC, Bagher S, Barandun M, Hofer SO, Zhong T. Can the American College of Surgeons NSQIP surgical risk calculator identify patients at risk of complications following microsurgical breast reconstruction?. J Plast Reconstr Aesthet Surg 2016; 69 (10) 1356-1362
  • 16 Scheefer M, Collier WH, Kim J, Kwok A. Are 30 day outcomes enough? Late infectious readmissions following prosthetic-based breast reconstruction. Plast Reconstr Surg Glob Open 2018 6. (9 Suppl): 196-197
  • 17 Introduction to the NRD, 2015. Healthcare cost and utilization project (HCUP). Available at: https://www.hcup-us.ahrq.gov/db/nation/nrd/Introduction_NRD_2010-2015.jsp 2018 . 0
  • 18 Survey: analysis of complex survey samples. J Stat Softw 2019 . Available at: https://www.jstatsoft.org/index.php/jss/article/view/v009i08/paper-5.pdf . Accessed February 15, 2020
  • 19 Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68 (06) 394-424
  • 20 Weir HK, Anderson RN, Coleman King SM. , et al. Heart disease and cancer deaths - trends and projections in the United States, 1969-2020. Prev Chronic Dis 2016; 13: E157
  • 21 services. C. f. M. a. M. Women's Health and Cancer Rights Act (WHCRA). Available at: https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/whcra_factsheet.html
  • 22 Albornoz CR, Bach PB, Mehrara BJ. , et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg 2013; 131 (01) 15-23
  • 23 McDaniel JC, Browning KK. Smoking, chronic wound healing, and implications for evidence-based practice. J Wound Ostomy Continence Nurs 2014; 41 (05) 415-423 , quiz E1–E2
  • 24 Haak T, Jungmann E, Raab C, Usadel KH. Elevated endothelin-1 levels after cigarette smoking. Metabolism 1994; 43 (03) 267-269
  • 25 Sørensen LT, Nielsen HB, Kharazmi A, Gottrup F. Effect of smoking and abstention on oxidative burst and reactivity of neutrophils and monocytes. Surgery 2004; 136 (05) 1047-1053
  • 26 Scott DA, Poston RN, Wilson RF, Coward PY, Palmer RM. The influence of vitamin C on systemic markers of endothelial and inflammatory cell activation in smokers and non-smokers. Inflamm Res 2005; 54 (03) 138-144 4
  • 27 Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg 2012; 255 (06) 1069-1079
  • 28 Wang CY, Dudzinski J, Nguyen D, Armbrecht E, Maher IA. Association of smoking and other factors with the outcome of Mohs reconstruction using flaps or grafts. JAMA Facial Plast Surg 2019; 21 (05) 407-413
  • 29 Kiecolt-Glaser JK, Marucha PT, Malarkey WB, Mercado AM, Glaser R. Slowing of wound healing by psychological stress. Lancet 1995; 346 (8984): 1194-1196
  • 30 Walburn J, Vedhara K, Hankins M, Rixon L, Weinman J. Psychological stress and wound healing in humans: a systematic review and meta-analysis. J Psychosom Res 2009; 67 (03) 253-271
  • 31 Gouin JP, Kiecolt-Glaser JK. The impact of psychological stress on wound healing: methods and mechanisms. Immunol Allergy Clin North Am 2011; 31 (01) 81-93
  • 32 Dao TK, Chu D, Springer J. , et al. Clinical depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder as risk factors for in-hospital mortality after coronary artery bypass grafting surgery. J Thorac Cardiovasc Surg 2010; 140 (03) 606-610
  • 33 Cole-King A, Harding KG. Psychological factors and delayed healing in chronic wounds. Psychosom Med 2001; 63 (02) 216-220
  • 34 Broadbent E, Petrie KJ, Alley PG, Booth RJ. Psychological stress impairs early wound repair following surgery. Psychosom Med 2003; 65 (05) 865-869
  • 35 Britteon P, Cullum N, Sutton M. Association between psychological health and wound complications after surgery. Br J Surg 2017; 104 (06) 769-776
  • 36 Ward N, Roth JS, Lester CC, Mutiso L, Lommel KM, Davenport DL. Anxiolytic medication is an independent risk factor for 30-day morbidity or mortality after surgery. Surgery 2015; 158 (02) 420-427
  • 37 Kiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R. Psychological influences on surgical recovery. Perspectives from psychoneuroimmunology. Am Psychol 1998; 53 (11) 1209-1218
  • 38 Drinane JJ, Pham TH, Schalet G, Rezak K. Depression is associated with worse outcomes among women undergoing breast reconstruction following mastectomy. J Plast Reconstr Aesthet Surg 2019; 72 (08) 1292-1298
  • 39 Chuba PJ, Stefani WA, Dul C. , et al. Radiation and depression associated with complications of tissue expander reconstruction. Breast Cancer Res Treat 2017; 164 (03) 641-647
  • 40 Brandão T, Schulz MS, Matos PM. Psychological adjustment after breast cancer: a systematic review of longitudinal studies. Psychooncology 2017; 26 (07) 917-926
  • 41 Stafford L, Judd F, Gibson P, Komiti A, Mann GB, Quinn M. Screening for depression and anxiety in women with breast and gynaecologic cancer: course and prevalence of morbidity over 12 months. Psychooncology 2013; 22 (09) 2071-2078
  • 42 Thompson LMA, Bobonis Babilonia M. Distinguishing depressive symptoms from similar cancer-related somatic symptoms: implications for assessment and management of major depression after breast cancer. South Med J 2017; 110 (10) 667-672
  • 43 Stanton AL, Wiley JF, Krull JL, Crespi CM, Weihs KL. Cancer-related coping processes as predictors of depressive symptoms, trajectories, and episodes. J Consult Clin Psychol 2018; 86 (10) 820-830
  • 44 Blanco C, Markowitz JC, Hellerstein DJ. , et al. A randomized trial of interpersonal psychotherapy, problem solving therapy, and supportive therapy for major depressive disorder in women with breast cancer. Breast Cancer Res Treat 2019; 173 (02) 353-364
  • 45 Holoyda KA, Simpson AM, Ye X, Agarwal JP, Kwok AC. Immediate bilateral breast reconstruction using abdominally based flaps: an analysis of the nationwide inpatient sample database. J Reconstr Microsurg 2019; 35 (08) 594-601
  • 46 Kwok AC, Simpson AM, Ye X, Tatro E, Agarwal JP. Immediate unilateral breast reconstruction using abdominally based flaps: analysis of 3,310 cases. J Reconstr Microsurg 2019; 35 (01) 74-82
  • 47 Kwok AC, Edwards K, Donato DP. , et al. Operative time and flap failure in unilateral and bilateral free flap breast reconstruction. J Reconstr Microsurg 2018; 34 (06) 428-435
  • 48 Olsen MA, Nickel KB, Fox IK, Margenthaler JA, Wallace AE, Fraser VJ. Comparison of wound complications after immediate, delayed, and secondary breast reconstruction procedures. JAMA Surg 2017; 152 (09) e172338
  • 49 Sullivan SR, Fletcher DR, Isom CD, Isik FF. True incidence of all complications following immediate and delayed breast reconstruction. Plast Reconstr Surg 2008; 122 (01) 19-28
  • 50 Miller RB, Reece G, Kroll SS. , et al. Microvascular breast reconstruction in the diabetic patient. Plast Reconstr Surg 2007; 119 (01) 38-45 , discussion 46–48
  • 51 Dao TK, Youssef NA, Armsworth M, Wear E, Papathopoulos KN, Gopaldas R. Randomized controlled trial of brief cognitive behavioral intervention for depression and anxiety symptoms preoperatively in patients undergoing coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2011; 142 (03) e109-e115