Brittany L. Vieira

Risk Factors for Unscheduled 30-day Readmission after Benign Hysterectomy

Objectives Readmission rates after hysterectomy have been reported, but specific risk factors for readmission have not been fully delineated. We aimed to determine risk factors for and implications of 30-day unscheduled readmission after benign hysterectomy using data from the American College of Surgeons National Surgical Quality Improvement Program. Methods We identified benign hysterectomy procedures recorded at all participating National Surgical Quality Improvement Program institutions between 2011 and 2012. Outcomes of interest were 30-day unscheduled readmission rates, variables associated with readmission, and complication and mortality rates associated with readmission. Bivariate analyses were performed using Pearson &khgr;2 and independent t tests for categorical and continuous variables, respectively. Multivariable regression analysis was performed to identify factors independently associated with readmission. Results In total, 21,228 hysterectomies were identified during the study period. Thirty-day readmission rates were 3.8% for abdominal hysterectomy, 2.7% for laparoscopic hysterectomy, 2.9% for laparoscopic-assisted vaginal hysterectomy, and 3.0% for vaginal hysterectomy. Readmission was associated with increased perioperative complications (49.2% vs 6.1%, P < 0.001), return to the operating room (26.3% vs 0.6%, P < 0.001), and mortality (0.3% vs 0.01%, P < 0.001). The most common complications in patients requiring readmission were surgical site infections (28.4%), sepsis (12.8%), urinary tract infection (9.7%), and blood transfusion (6.7%). Variables that were independently associated with 30-day readmission after multivariable regression analysis included younger age (odds ratio [OR] 0.98/year, P < 0.001), smoking (OR 1.28, P = 0.01), diabetes mellitus (OR 1.47, P = 0.008), dyspnea (OR 1.48, P = 0.04), bleeding disorders (OR 1.82, P = 0.04), American Society of Anesthesiologists class ≥3 (OR 1.32, P = 0.009), prior surgery within 30 days (OR 3.60, P = 0.04), longer operative time (OR 1.20 per hour of operative time, P < 0.001), inpatient status (OR 1.36, P = 0.001), and longer length of hospital stay (OR 1.04/day, P < 0.001). Conclusions Using a large national database, we identified several patient-related and procedural risk factors for unscheduled 30-day readmission after hysterectomy. Readmission was associated with significantly higher rates of complications, a return to the operating room, and a 30-fold increase in mortality. Our findings reinforce the importance of patient selection and optimization of comorbidities before hysterectomy. Future research should aim to further delineate differential risks of readmission by surgical route as well as modifiable risk factors for readmission.

Combining Abdominal and Cosmetic Breast Surgery Does Not Increase Short-term Complication Rates: A Comparison of Each Individual Procedure and Pretreatment Risk Stratification Tool

BACKGROUND Combined abdominal and breast surgery presents a convenient and relatively cost-effective approach for accomplishing both procedures. OBJECTIVES This study is the largest to date assessing the safety of combined procedures, and it aims to develop a simple pretreatment risk stratification method for patients who desire a combined procedure. METHODS All women undergoing abdominoplasty, panniculectomy, augmentation mammaplasty, and/or mastopexy in the TOPS database were identified. Demographics and outcomes for combined procedures were compared to individual procedures using χ(2) and Students t-tests. Multiple logistic regression provided adjusted odds ratios for the effect of a combined procedure on 30-day complications. Among combined procedures, a logistic regression model determined point values for pretreatment risk factors including diabetes (1 point), age over 53 (1), obesity (2), and 3+ ASA status (3), creating a 7-point pretreatment risk stratification tool. RESULTS A total of 58,756 cases met inclusion criteria. Complication rates among combined procedures (9.40%) were greater than those of aesthetic breast surgery (2.66%; P < .001) but did not significantly differ from abdominal procedures (9.75%; P = .530). Nearly 77% of combined cases were classified as low-risk (0 points total) with a 9.78% complication rates. Medium-risk patients (1 to 3 points) had a 16.63% complication rate, and high-risk (4 to 7 points) 38.46%. CONCLUSIONS Combining abdominal and breast procedures is safe in the majority of patients and does not increase 30-day complications rates. The risk stratification tool can continue to ensure favorable outcomes for patients who may desire a combined surgery. LEVEL OF EVIDENCE 4 Risk.

A Multi-institutional Analysis of Insurance Status as a Predictor of Morbidity Following Breast Reconstruction

Background: Although recent literature suggests that patients with Medicaid and Medicare are more likely than those with private insurance to experience complications following a variety of procedures, there has been limited evaluation of insurance-based disparities in reconstructive surgery outcomes. Using a large, multi-institutional database, we sought to evaluate the potential impact of insurance status on complications following breast reconstruction. Methods: We identified all breast reconstructive cases in the 2008 to 2011 Tracking Operations and Outcomes for Plastic Surgeons clinical registry. Propensity scores were calculated for each case, and insurance cohorts were matched with regard to demographic and clinical characteristics. Outcomes of interest included 15 medical and 13 surgical complications. Results: Propensity-score matching yielded 493 matched patients for evaluation of Medicaid and 670 matched patients for evaluation of Medicare. Overall complication rates did not significantly differ between patients with Medicaid or Medicare and those with private insurance (P = 0.167 and P = 0.861, respectively). Risk-adjusted multivariate regressions corroborated this finding, demonstrating that Medicaid and Medicare insurance status does not independently predict surgical site infection, seroma, hematoma, explantation, or wound dehiscence (all P > 0.05). Medicaid insurance status significantly predicted flap failure (odds ratio = 3.315, P = 0.027). Conclusions: This study is the first to investigate the differential effects of payer status on outcomes following breast reconstruction. Our results suggest that Medicaid and Medicare insurance status does not independently predict increased overall complication rates following breast reconstruction. This finding underscores the commitment of the plastic surgery community to providing consistent care for patients, irrespective of insurance status.

Rates and Predictors of Readmission Following Body Contouring Procedures: An Analysis of 5100 Patients From The National Surgical Quality Improvement Program Database

Background Hospital readmissions can be a major contributor to increased healthcare costs and are a salient current topic in healthcare. There is a paucity of large, prospective studies that evaluate rates and risk factors of readmission within the aesthetic subset of plastic surgery. Objectives The authors propose to determine the rates of unplanned readmission following body contouring procedures and to analyze the predictors associated with it. Methods The 2011 and 2012 National Surgical Quality Improvement Program Database was queried for body contouring procedures using the appropriate Current Procedural Terminology codes. The rate of unplanned readmission, preoperative risk factors, comorbidities, and medical and surgical postoperative complications data were analyzed using multivariate regression models to determine predictors of readmission after these procedures. Results We identified 5100 patients who underwent body contouring procedures, of which 142 (2.8%) experienced an unplanned readmission. Forty-eight per cent of readmitted patients experienced at least one surgical complication, and 23.9% experienced at least one medical complication. Multivariate regression analyses identified several independent predictors of unplanned readmission: increasing age (odds ratio [OR] 1.018 per year, P = 0.039), bleeding disorders (OR 3.674, P = 0.039), increased operative time (each additional hour conferring a 20% increased risk), surgical complications (OR 19.179, P < 0.001), and medical complications (OR 10.240, P < 0.001). Conclusions The unplanned readmission rate for body contouring procedures is low overall (2.8%). We identified age, bleeding disorders, operative duration, and postoperative complication as independent risk factors for unplanned readmission. These data can help guide preoperative risk stratification and future interventions in high-risk patient populations. Level of Evidence 2.

Abstract 61: Intraoperative Nerve Blocks for Tissue Expander Breast Reconstruction: Results of a Prospective, Double-Blind, Randomized, Placebo-controlled Trial

METHODS: A prospective, randomized, double-blinded, placebo–controlled, clinical trial was conducted in which patients undergoing immediate tissue expander/implant based breast reconstruction were randomized to either: 1) intraoperative intercostal and pectoral nerve blocks with 0.25 % bupivacaine with 1:200,000 epinephrine and 4 mg dexamethasone or 2) sham nerve blocks with normal saline. The surgeon, patient and researchers collecting postoperative data were blind to group allocation. Quality of recovery (QoR 40), pain score, and opioid use in the postoperative period were compared between groups using the Mann-Whitney’s U test. Fisher’s exact test was used between categorical variables.

Abstract 5. Is There A Limit? A Risk Assessment Model of Liposuction and Lipoaspirate Volume on Morbidity Following Abdominoplasty

Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA, Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY, USA, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Illinois, Chicago IL, USA.

Operative Time Longer Than 240 Minutes is Predictive of 30-Day Complications After Vaginal Hysterectomy [43].

INTRODUCTION: The relationship between operative time and morbidity is incompletely understood in gynecology. We aimed to evaluate the effect of operative time on 30-day complication rates after vaginal hysterectomy. METHODS: Patients undergoing vaginal hysterectomy for benign indications from 2005 to 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Clinical characteristics and complications were compared for patients with operative time shorter and longer than 240 minutes. Multivariable analysis was performed to determine the independent effect of operative time on complications. RESULTS: A total of 10,311 vaginal hysterectomies were identified. Complications increased significantly as surgical duration increased, with an inflection point at 240 minutes. Characteristics associated with operative time longer than 240 minutes included older age, nonsmoking status, hypertension, chronic obstructive pulmonary disease, higher ASA (American Society of Anesthesiologists) level, higher relative value units average, inpatient status, general anesthesia, and resident physician involvement. Operative time longer than 240 minutes was associated with increased rates of overall complications (15.7% compared with 6.7%, P<.001), medical complications (13.5% compared with 5.6%, P<.001), urinary tract infection (UTI; 8.9% compared with 3.5%, P<.001), blood transfusion (4.3% compared with 1.5%, P<.001), and reoperation (2.9% compared with 1.2%, P=.02), although mortality rates were similar (0% compared with 0.4%, P=.74). After multivariable analysis, longer operative time independently predicted overall complications, medical complications, UTI, and reoperation. CONCLUSION: We demonstrated that operative time longer than 4 hours during vaginal hysterectomy is predictive of 30-day overall complications, medical complications, UTI, and reoperation. Future research should aim to identify modifiable contributors to prolonged operative time.