Justin P. Fox

A Longitudinal Assessment of Outcomes and Healthcare Resource Utilization After Immediate Breast Reconstruction-Comparing Implant- and Autologous-based Breast Reconstruction.

OBJECTIVES Immediate breast reconstruction (IBR) after mastectomy for cancer has increased in recent years, yet long-term, modality-specific comparative data are lacking. We performed this study to compare short- and long-term outcomes after expander, autologous (AT), and direct-to-implant (DI) breast reconstruction. METHODS Using four state-level inpatient and ambulatory surgery databases, we conducted a retrospective cohort study of adult women who underwent mastectomy with immediate breast reconstruction from 2008 to 2009. Our primary outcomes were complications within 90 days of surgery, rate of secondary breast surgery within 3 years, and cumulative healthcare charges. RESULTS The final cohort included 15,154 women who underwent mastectomy with tissue expander (TE: 70.5%), autologous (AT: 18.1%), or direct to implant (DI: 11.3%) reconstruction. Ninety-day complications were lowest after expander and highest after AT breast reconstruction (TE = 6.5% [reference] vs AT = 13.1% [2.09, 1.82-2.41] vs DI = 6.6% [1.03, 0.84-1.27], P < 0.001). However, adjusted rates of secondary breast procedures were most frequent after expander (2021/1000 discharges) and least frequent after AT (949.0/1000 discharges) reconstruction (P < 0.001). Specifically, unplanned revisions were highest among the tissue expander cohort (TE = 59.2% vs AT = 34.4% vs DI = 45.9%, P < 0.001). The cumulative, adjusted healthcare charges for secondary breast procedures differed slightly across groups (TE = 

Complicated breast cancer–related lymphedema: evaluating health care resource utilization and associated costs of management

63,806 vs AT = 

Geographic Variation in Access to Plastic Surgeons.

66,882 vs DI = 

Influence of race, insurance status, and geographic access to plastic surgeons on immediate breast reconstruction rates

64,145, P < 0.001). CONCLUSIONS Complications and secondary breast procedures, including unplanned revisions, after breast reconstruction are common and vary by reconstructive modality. The frequency of these secondary procedures adds substantial healthcare charges to the care of the breast reconstruction patient.

The Relationship Between Geographic Access to Plastic Surgeons and Immediate Breast Reconstruction Rates Among Women Undergoing Mastectomy for Cancer.

BACKGROUND Lymphedema can become a disabling condition necessitating inpatient care. This study aimed to estimate complicated lymphedema incidence after breast cancer surgery and calculate associated hospital resource utilization. METHODS We identified adult women undergoing lumpectomy and/or mastectomy with axillary lymph node surgery between 2006 and 2012 using 5-state inpatient databases. Patients were grouped according to the development of complicated lymphedema. The primary outcomes were all-cause hospitalizations and health care charges within 2 years of surgery. Multivariate regression models were used to compare outcomes. RESULTS Of 56,075 women included, 2.3% had at least 1 hospital admission for complicated lymphedema within 2 years of surgery. Despite confounder adjustment, women with complicated lymphedema experienced 5 fold more all-cause (incidence rate ratio = 5.02, 95% confidence interval: 4.76 to 5.29) admissions compared with women without lymphedema. This resulted in substantially higher health care charges (

Trends in open abdominal surgery in the United States—Observations from 9,950,759 discharges using the 2009–2013 National Inpatient Sample (NIS) datasets

58,088 vs

Incisional hernia in the United States: trends in hospital encounters and corresponding healthcare charges

31,819 per patient, P < .001). Although axillary dissection and certain comorbidities were associated with complicated lymphedema, breast reconstruction appeared unrelated. CONCLUSIONS Complicated lymphedema develops in a quantifiable number of patients. The health care burden of lymphedema underscored here mandates further investigation into targeted, anticipatory management strategies for breast cancer-related lymphedema.

A Risk Model and Cost Analysis of Incisional Hernia After Elective, Abdominal Surgery Based Upon 12,373 Cases

Introduction: While recent studies project a national shortage of plastic surgeons, there may currently exist areas within the United States with few plastic surgeons. We conducted this study to describe the current geographic distribution of the plastic surgery workforce across the United States. Methods: Using the 2013 to 2014 Area Health Resource File, we estimated the number of plastic surgeons at the health service area (HSA) level in 2010 and 2012. The density of plastic surgeons was calculated as a ratio per 100,000 population. The HSAs were grouped by plastic surgeon density, and population characteristics were compared across subgroups. Characteristics of HSAs with increases and decreases in plastic surgeon density were also compared. Results: The final sample included 949 HSAs with a total population of 313,989,954 people. As of 2012, there were an estimated 7600 plastic surgeons, resulting in a national ratio of 2.42 plastic surgeons/100,000 population. However, over 25million people lived in 468HSAs (49.3%)without a plastic surgeon, whereas 106 million people lived in 82 HSAs (8.6%) with 3.0 or more/100,000 population. Plastic surgeons were more likely to be distributed in HSAs where a higher percentage of the population was younger than 65 years, female, and residing in urban areas. Between 2010 and 2012, 11 HSAs without a plastic surgeon increased density, whereas 15 HSAs lost all plastic surgeons. Conclusions: Plastic surgeons are asymmetrically distributed across the United States leaving over 25 million people without geographic access to the specialty. This distribution tends to adversely impact older and rural populations.

Development of a Clinically Actionable Incisional Hernia Risk Model after Colectomy Using the Healthcare Cost and Utilization Project

BACKGROUND This study evaluates the rates of immediate breast reconstruction (IBR) among racial and insurance status subgroups, in the setting of a changing plastic surgeon workforce. METHODS Using state level inpatient and ambulatory surgery data, we identified discharges for adult women who underwent mastectomy for breast cancer. This information was supplemented with plastic surgeon workforce data and aggregated to the health service area-level (HSA). Hierarchical linear models were used to risk standardized IBR rates for 8 race-payer subgroups. RESULTS The final cohort included 65,246 women treated across 67 HSAs. The plastic surgeon density per 100,000 population directly related to the IBR rate. While all subgroups saw a modest increase in IBR rates, Caucasian women with private insurance realized the largest absolute increase (46%) while African-American and Asian women with public insurance saw the smallest increase (6%). CONCLUSION Significant disparities persist in the provision of IBR according to the form of insurance a patient possesses. Of heightened concern is the novel finding that even within privately insured patients, women of color have significantly lower IBR rates compared to Caucasian women.

Concurrent panniculectomy in the obese ventral hernia patient: Assessment of short-term complications, hernia recurrence, and healthcare utilization

INTRODUCTION: Breast reconstruction is an important component of breast cancer treatment. Despite healthcare policy requiring payers to cover and referring physicians to discuss such procedures, reconstruction rates remain low, particularly among minority populations1. We conducted this study to determine if geographic access to a plastic surgeon contributes to the likelihood of receiving breast reconstruction; the type of reconstruction received; or when reconstruction is performed. Additionally, we explored the relationship between plastic surgeon distribution and healthcare disparities in breast reconstruction.