The Validity of Hospital Discharge Data for Autologous Breast Reconstruction Research:

Quality of Surgical Outcomes Reporting in Plastic Surgery: A 15-Year Analysis of Complication Data

BACKGROUND

Postoperative complication data are integral to assessing patient outcomes and identifying areas for improving quality in surgical care. Accurate appraisal of surgical techniques requires consistency and reliability in complication data reporting. The purpose of this study was to analyze the quality of complication reporting in plastic surgery.

METHODS

The authors critically reviewed the literature from January 1, 2000, to December 31, 2014, to identify articles reporting surgical outcomes after three index procedures: autologous breast reconstruction, prosthetic breast reconstruction, and reduction mammaplasty. Studies were extracted from the journals Plastic and Reconstructive Surgery and Annals of Plastic Surgery. Two authors independently analyzed data using a modification of established criteria for complication reporting that incorporates 10 critical elements.

RESULTS

Two hundred ninety-six articles reporting outcomes for 299,819 procedures in 249,942 patients were analyzed. Of the 10 reporting criteria, no articles met all criteria, fewer than 1 percent met nine, 16 percent met seven to eight, 43 percent met five to six, 35 percent met three to four, and 6 percent met one to two (mean, five criteria met). Commonly underreported criteria included complication definitions (37 percent of articles reported), aesthetic or patient-reported outcome (28 percent), and complication severity (16 percent). Only 46 studies (16 percent) reported complication severity, with 15 different definitions of what constituted a "major" complication. Risk factors for complications were absent in 37 percent of articles.

CONCLUSIONS

Inconsistency in reporting complications in the plastic surgery literature confounds the comparison of surgical outcomes. The use of standard guidelines to accurately, efficiently, and reproducibly report complication data is essential for quality assurance and improvement.

Association between unilateral or bilateral mastectomy and breast cancer death in patients with unilateral ductal carcinoma

Background

Utilization of bilateral mastectomy for unilateral breast cancer is increasing despite cost and surgical risks with conflicting reports of survival benefit. Current studies evaluating death after bilateral mastectomy have included patients treated both with breast conservation therapy and unilateral mastectomy. In this study, we directly compared breast cancer–specific death of patients who underwent bilateral or unilateral mastectomy for unilateral breast cancer using a matched cohort analysis.

Methods

This was an observational study of women diagnosed with unilateral breast cancer from 1998 through 2002, using the Surveillance, Epidemiology, and End Results (SEER) database. A 4-to-1 matched cohort of patients was selected including 14,075 patients. Mortality of the groups was compared using Cox proportional hazards models for cause-specific death.

Results

A total of 41,510 patients diagnosed with unilateral breast cancer were included. Unilateral mastectomy was performed in 93% of patients, while bilateral mastectomy was performed in the remaining 7% of patients. When 4-to-1 matching was performed, 11,260 unilateral mastectomy and 2,815 bilateral mastectomy patients were included. Patients with bilateral mastectomy did not have a significantly lower hazard of breast cancer–specific death when compared with patients with unilateral mastectomy (hazard ratio: 0.92 vs 1.00, p=0.11).

Conclusion

Bilateral mastectomy did not provide a clinically or statistically significant breast cancer–specific mortality benefit over unilateral mastectomy based on a matched cohort analysis of a nationwide population database. These findings should be interpreted in the context of patient preference and alternative benefits of bilateral mastectomy.

Validation of ICD-9-CM Diagnosis Codes for Surgical Site Infection and Noninfectious Wound Complications After Mastectomy

BACKGROUND Few studies have validated ICD-9-CM diagnosis codes for surgical site infection (SSI), and none have validated coding for noninfectious wound complications after mastectomy. OBJECTIVES To determine the accuracy of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes in health insurer claims data to identify SSI and noninfectious wound complications, including hematoma, seroma, fat and tissue necrosis, and dehiscence, after mastectomy. METHODS We reviewed medical records for 275 randomly selected women who were coded in the claims data for mastectomy with or without immediate breast reconstruction and had an ICD-9-CM diagnosis code for a wound complication within 180 days after surgery. We calculated the positive predictive value (PPV) to evaluate the accuracy of diagnosis codes in identifying specific wound complications and the PPV to determine the accuracy of coding for the breast surgical procedure. RESULTS The PPV for SSI was 57.5%, or 68.9% if cellulitis-alone was considered an SSI, while the PPV for cellulitis was 82.2%. The PPVs of individual noninfectious wound complications ranged from 47.8% for fat necrosis to 94.9% for seroma and 96.6% for hematoma. The PPVs for mastectomy, implant, and autologous flap reconstruction were uniformly high (97.5%-99.2%). CONCLUSIONS Our results suggest that claims data can be used to compare rates of infectious and noninfectious wound complications after mastectomy across facilities, even though PPVs vary by specific type of postoperative complication. The accuracy of coding was highest for cellulitis, hematoma, and seroma, and a composite group of noninfectious complications (fat necrosis, tissue necrosis, or dehiscence). Infect Control Hosp Epidemiol 2017;38:334-339.

Management of cardiovascular disease in aging persons with haemophilia

With the aging of the haemophilia population, age related comorbidities become more and more a medical issue. Managing haemophilia patients with cardiovascular disease is a difficult task for many haemophilia-treating physicians. Over the years, insights on prevalence, risk factors and management of cardiovascular disease in haemophilia have improved substantially. It is now recognised that many risk factors, such as hypertension and overweight, occur quite frequently in patients with haemophilia. Several new insights in anticoagulation management of atrial fibrillation and coronary ischaemia in haemophilia have been suggested. This review provides an general overview of the current knowledge of these topics in literature.

ICD-9 diagnosis codes have poor sensitivity for identification of preexisting comorbidities in traumatic fracture patients: A study of the National Trauma Data Bank

BACKGROUND

The use of large national databases for clinical research has increased recently in the field of trauma care as they allow study of rare events without the logistical difficulties of a prospective study. However, many of these databases use administrative billing codes, such as International Classification of Disease-9th Rev. (ICD-9) codes, to identify preexisting patient comorbidities. While the accuracy of these billing codes for research purposes has previously been called into question, this has not been studied in a trauma population.

METHODS

All patients with proximal tibia fractures in the 2011 and 2012 American College of Surgeons' National Trauma Data Bank were reviewed. Rates of 12 individual comorbidities in this population were computed using both ICD-9 diagnosis codes and also National Trauma Data Bank chart-abstracted variables. The sensitivity was computed for ICD-9 coding of each comorbidity taking chart-abstracted data elements as criterion standard. With the use of multivariate logistic regression, controlling for age and Injury Severity Score (ISS), the odds ratio for mortality was computed for each comorbidity, using both ICD-9 diagnoses and chart-abstracted diagnoses.

RESULTS

A total of 32,441 patients with proximal tibia fractures were identified. The sensitivities of ICD-9 billing codes for the comorbidities analyzed ranged from 18.8% for previous myocardial infarction to 2.4% for alcoholism. In individual multivariate analyses of each comorbidity, there was a change in the statistical significance of the odds ratio for mortality for 6 of 12 comorbidities analyzed.

CONCLUSION

Researchers and those evaluating research in the field of trauma should carefully consider the accuracy of data elements in future studies, especially ICD-9-coded comorbidity diagnoses.

Automating Quality Metrics in the Era of Electronic Medical Records: Digital Signatures for Ventilator Bundle Compliance

Ventilator-associated events (VAEs) are associated with increased risk of poor outcomes, including death. Bundle practices including thromboembolism prophylaxis, stress ulcer prophylaxis, oral care, and daily sedation breaks and spontaneous breathing trials aim to reduce rates of VAEs and are endorsed as quality metrics in the intensive care units. We sought to create electronic search algorithms (digital signatures) to evaluate compliance with ventilator bundle components as the first step in a larger project evaluating the ventilator bundle effect on VAE. We developed digital signatures of bundle compliance using a retrospective cohort of 542 ICU patients from 2010 for derivation and validation and testing of signature accuracy from a cohort of random 100 patients from 2012. Accuracy was evaluated against manual chart review. Overall, digital signatures performed well, with median sensitivity of 100% (range, 94.4%–100%) and median specificity of 100% (range, 100%–99.8%). Automated ascertainment from electronic medical records accurately assesses ventilator bundle compliance and can be used for quality reporting and research in VAE.