1
|
Kwasnicki RM, Irukulla M, Che Bakri NA, Whiteman E, Gardiner M, Dunne J, Henry FP, Gokani V, Hunter JE, Williams G, Wood SH. Identifying variation in the cost of abdominally based breast reconstruction in the UK. J Plast Reconstr Aesthet Surg 2024; 88:466-472. [PMID: 38096767 DOI: 10.1016/j.bjps.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 01/02/2024]
Abstract
AIMS To understand variation in the cost of autologous breast reconstruction in the UK, including identifying key areas of cost variability, differences between and within units and the impact of enhanced recovery protocols (ERAS). METHODS A micro-costing study was designed based on the responses to a national survey of clinical preferences completed by the majority of plastic surgeons and anaesthetists involved in the UK. Detailed costs were estimated from macro elements such as ward and theatre running costs, down to that of surgical meshes, anaesthetic drugs and flap monitoring devices. RESULTS The largest variation in cost arose from postoperative location and length of stay, preoperative imaging and flap monitoring strategies. Plastic surgeon costs varied from £1282 to £3141, whereas anaesthetic costs were between £32 and £151 (not including salary). Estimated cost variation within units was up to £893 per case. Units with ERAS had significantly lower total costs than those without (p < 0.05). CONCLUSION This study reveals significant cost variation in breast reconstruction in the UK based on clinician preferences. Many areas of practice driving this variation lack strong evidence of any clinical advantage. The total cost of a deep inferior epigastric perforator in the majority, if not all units, likely surpasses the national tariff for reimbursement, particularly when considering additional resource demand for immediate and bilateral breast reconstruction, as well as future symmetrisation procedures. Whilst units should look to streamline costs through ERAS, there should also be a realistic tariff that promotes excellent care.
Collapse
Affiliation(s)
- Richard M Kwasnicki
- Department of Plastic and Reconstructive Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK; Department of Surgery and Cancer, Imperial College London, London, UK.
| | - Meghna Irukulla
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Elena Whiteman
- Department of Plastic Surgery, Chelsea and Westminster Hospital, London, UK
| | - Matthew Gardiner
- Department of Plastic Surgery, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Frimley, UK
| | - Jonathan Dunne
- Department of Plastic and Reconstructive Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Francis P Henry
- Department of Plastic and Reconstructive Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Vimal Gokani
- Department of Plastic and Reconstructive Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Judith E Hunter
- Department of Plastic and Reconstructive Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Georgina Williams
- Department of Plastic and Reconstructive Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Simon H Wood
- Department of Plastic and Reconstructive Surgery, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| |
Collapse
|
2
|
Araya S, Hackley M, Amadio GM, Deng M, Moss C, Reinhardt E, Walchak A, Tecce MG, Patel SA. Survey of Surgeon-reported Postoperative Protocols for Deep Inferior Epigastric Perforator Flap in Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5402. [PMID: 38025610 PMCID: PMC10653572 DOI: 10.1097/gox.0000000000005402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/20/2023] [Indexed: 12/01/2023]
Abstract
Background The use of deep inferior epigastric perforator (DIEP) flaps is a well-established breast reconstruction technique. Methods A 29-question survey was e-mailed to 3186 active American Society of Plastic Surgeons members, aiming to describe postoperative monitoring practice patterns among surgeons performing DIEP flaps. Results From 255 responses (8%), 79% performing DIEP surgery were analyzed. Among them, 34.8% practiced for more than 20 years, 34.3% for 10-20 years, and 30.9% for less than 10 years. Initial 24-hour post-DIEP monitoring: intensive care unit (39%) and floor (36%). Flap monitoring: external Doppler (71%), tissue oximetry (41%), and implantable Doppler (32%). Postoperative analgesia: acetaminophen (74%), non-steroidal anti-inflammatory drugs (69%), neuromodulators (52%), and opioids (4.4%) were administered on a scheduled basis. On postoperative day 1, 61% halt intravenous fluids, 67% allow ambulation, 70% remove Foley catheter, and 71% start diet. Most surgeons discharged patients from the hospital on postoperative day 3+. Regardless of experience, patients were commonly discharged on day 3. Half of the surgeons are in academic/nonacademic settings and discharge on/after day 3. Conclusions This study reveals significant heterogeneity among the practice patterns of DIEP surgeons. In light of these findings, it is recommended that a task force be convened to establish standardized monitoring protocols for DIEP flaps. Such protocols have the potential to reduce both the length of hospital stays and overall care costs all while ensuring optimal pain management and vigilant flap monitoring.
Collapse
Affiliation(s)
- Sthefano Araya
- From the Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, Pa
| | - Madison Hackley
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pa
| | - Grace M. Amadio
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pa
| | - Mengying Deng
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, Pa
| | - Civanni Moss
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pa
| | | | - Adam Walchak
- From the Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, Pa
| | - Michael G. Tecce
- From the Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, Pa
| | - Sameer A. Patel
- From the Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, Pa
| |
Collapse
|
3
|
Yusuf CT, Lopez CD, Colakoglu S, Cooney CM, Cooney DS. The impact of COVID-19 pandemic on free tissue transfer outcomes: A NSQIP analysis. J Plast Reconstr Aesthet Surg 2023; 86:183-191. [PMID: 37729775 PMCID: PMC10300056 DOI: 10.1016/j.bjps.2023.06.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/12/2023] [Accepted: 06/22/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND The COVID-19 pandemic significantly impacted hospital resources and patient care, although its effect on free tissue transfer procedures is poorly understood. We conducted the current study to investigate the potential impact of COVID-19 and its accompanying system shut-downs on the surgical outcomes of patients undergoing free flap procedures. METHODS Patients undergoing free tissue transfer procedures were identified from the National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2020. We used 2016-2019 as baseline (pre-pandemic) data to compare with 2020 (peri-pandemic). We divided the patients into the following 3 groups: all patients undergoing free tissue transfer, breast reconstruction free tissue transfer, and non-breast free tissue transfer cases. Outcomes of interest included patient morbidity/mortality, time to surgery, time to takeback, and length of hospital stay. We used Pearson's chi-square and Fisher's exact tests to assess categorical variables. Wilcoxon's ranked sign tests and ANOVA tests were used for non-parametric and parametric continuous variables, respectively. Significance was set at alpha < 0.05. RESULTS When comparing peri-pandemic to pre-pandemic rates, patient morbidity and mortality and unplanned primary or secondary takeback operations were both significantly higher in all 3 groups peri-pandemic. Median time to primary or secondary takeback operation was also significantly greater peri-pandemic. CONCLUSION Patients undergoing flap procedures peri-pandemic had an overall increase in median morbidity and mortality, unplanned primary or secondary takebacks, and median number of days to takebacks compared to the pre-pandemic period. This is concerning given that any future protocols instituted can have detrimental effects on patients who receive a free tissue transfer procedure.
Collapse
Affiliation(s)
- Cynthia T Yusuf
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher D Lopez
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Salih Colakoglu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carisa M Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Damon S Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
4
|
Onoda S, Satake T, Katsuragi R, Kobayashi K, Tsukura K, Tachibana G. A Novel Doppler Flowmetry Shaft for Postoperative Monitoring after Head and Neck Reconstructive Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5312. [PMID: 37799438 PMCID: PMC10550020 DOI: 10.1097/gox.0000000000005312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/21/2023] [Indexed: 10/07/2023]
Abstract
Doppler flowmetry is one of the most popular methods of monitoring Doppler signals during reconstructive surgery of the body surface. However, because of the thick and straight structure of the shaft, it is difficult to perform in areas with limited space, such as the oral cavity. We used a new type of Doppler flowmetry shaft to postoperatively monitor the flap in the oral cavity. Compared with conventional Doppler flowmetry, the new type uses a thinner metal probe shaft that can easily be inserted in narrow and limited spaces, such as the oral cavity. Additionally, the tip of the metal probe is gently bent, thereby allowing the Doppler tip to be placed perpendicular to the surface of the skin flap. We used this new type of Doppler flowmetry shaft for 30 patients after head and neck reconstruction using free flap transfer because Doppler signals were difficult to hear using conventional Doppler flowmetry. For all 30 patients, the new Doppler flowmetry shaft was able to monitor free flaps. Vascular thrombosis or vascular spasm occurred in three patients; two patients had inadequate arterial flow caused by vasospasm and arterial thrombus, and one patient had a venous thrombus. These three patients required re-exploration, and all flaps survived. This new type of Doppler flowmetry is simple and noninvasive. Furthermore, it can easily be performed by nonphysician medical personnel, and is useful for monitoring patients after head and neck reconstructive surgery.
Collapse
Affiliation(s)
- Satoshi Onoda
- From the Department of Plastic and Reconstructive, Aesthetic Surgery, Toyama University Hospital, Toyama, Japan
| | - Toshihiko Satake
- From the Department of Plastic and Reconstructive, Aesthetic Surgery, Toyama University Hospital, Toyama, Japan
| | - Ryohei Katsuragi
- From the Department of Plastic and Reconstructive, Aesthetic Surgery, Toyama University Hospital, Toyama, Japan
| | - Kohta Kobayashi
- From the Department of Plastic and Reconstructive, Aesthetic Surgery, Toyama University Hospital, Toyama, Japan
| | - Kahori Tsukura
- From the Department of Plastic and Reconstructive, Aesthetic Surgery, Toyama University Hospital, Toyama, Japan
| | - Gaku Tachibana
- From the Department of Plastic and Reconstructive, Aesthetic Surgery, Toyama University Hospital, Toyama, Japan
| |
Collapse
|
5
|
Araya S, Webster TK, Egleston B, Amadio GM, Panichella JC, Elmer NA, Patel SA. Significant Reduction in Length of Stay in Deep Inferior Epigastric Perforator Flap Breast Reconstruction With Implementation of Multimodal ERAS Protocol. Ann Plast Surg 2023; 91:90-95. [PMID: 37450866 PMCID: PMC10575614 DOI: 10.1097/sap.0000000000003578] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) implementation achieves earlier recovery, reduced hospital length of stay (LOS) and improved outcomes in patients undergoing deep inferior epigastric perforator (DIEP) free flaps. We sought to review our ERAS protocols and their impact on our patients' LOS compared with the literature. METHODS This was a retrospective review of a single surgeon's experience from 2017 to 2021 of patients undergoing DIEP free-flap breast reconstruction with LOS as the primary outcome. Complication rates and patient demographics are described as secondary outcomes. RESULTS One hundred twenty-one patients underwent DIEP free-flap breast reconstruction. After adapting ERAS protocols, there has been a 0.98 [SD, 0.17; confidence interval [CI], -1.3 to -0.64; P < 0.001) day decrease in length of stay comparing pre-ERAS to post-ERAS implementation. Length of stay has routinely decreased from an average discharge on day 4.17 (SD, 1.1; range, 3-8 days) in 2017 to discharge on day 2.91 (SD, 1.1; range, 1-5 days) in 2021. Seventy-five percent of patients in 2021 were hospitalized for 3 or fewer days compared with 75% of patients in 2017 hospitalized for 4 or more days. One patient experienced a flap failure. Our study supports successful discharge on postoperative days 2-3 compared with postoperative days 3-4 in the current literature. CONCLUSIONS The implementation of our ERAS protocol for DIEP free-flap breast reconstruction has resulted in a shorter LOS compared with contemporary literature. The ERAS protocols can be efficiently adopted in microsurgical DIEP breast reconstruction to achieve a shorter LOS without jeopardizing patient outcomes.
Collapse
Affiliation(s)
- Sthefano Araya
- Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA
| | | | - Brian Egleston
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA
| | - Grace M. Amadio
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | | | | | - Sameer A. Patel
- Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA
| |
Collapse
|
6
|
Sultan DL, Atamian E, Tarr J, Feingold R, Kasabian AK, Tanna N, Smith ML, Moon V. A Prospective Cohort Study Re-examining Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction. Ann Plast Surg 2023; 90:580-584. [PMID: 37157150 DOI: 10.1097/sap.0000000000003555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND The goal of inpatient monitoring after microsurgical breast reconstruction is to detect vascular compromise before flap loss. Near-infrared tissue oximetry (NITO) is commonly used for this purpose, but recent reports challenge its specificity and utility in current practice. Fifteen years after Keller published his initial study using this technology at our institution, we re-evaluate the role and limitations of this popular monitoring device. METHODS A 1-year prospective study was performed for patients undergoing microsurgical breast reconstruction and monitored postoperatively using NITO. Alerts were evaluated, and clinical endpoints relating to an unplanned return to the operating room or flap loss were recorded. RESULTS A total of 118 patients reconstructed with 225 flaps were included within the study. There were no cases of flap loss at the time of discharge. There were 71 alerts relating to a drop in oximetry saturation. Of these, 68 (95.8%) were deemed to be of no significance. In 3 cases (positive predictive value of 4.2%), the alert was significant, and there were concerning clinical signs apparent at that point. A sensor in an inframammary fold position was associated with nearly twice the average number of alerts as compared with areolar or periareolar positions ( P = 0.01). In 4 patients (3.4%), a breast hematoma required operative evacuation, and these cases were detected by nursing clinical examination. CONCLUSIONS The monitoring of free flaps after breast reconstruction through tissue oximetry shows a poor positive predictive value for flap compromise and requires clinical corroboration of alerts but missed no pedicle-related adverse events. With a high sensitivity for pedicle-related issues, NITO may be helpful postoperatively, but the exact timeframe for use must be weighed at the institutional level.
Collapse
Affiliation(s)
| | | | | | - Randall Feingold
- New York Breast Reconstruction and Aesthetic Plastic Surgery, Private Practice, Great Neck, NY
| | | | | | | | | |
Collapse
|
7
|
Atamian EK, Suydam R, Hardy TN, Clappier M, Barnett S, Caulfield D, Jelavic M, Smith ML, Tanna N. Financial Implications of Enhanced Recovery After Surgery Protocols in Microsurgical Breast Reconstruction. Ann Plast Surg 2023; 90:S607-S611. [PMID: 36752405 DOI: 10.1097/sap.0000000000003412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Surgical advancements in breast reconstruction have allowed a shift toward optimizing patient-reported outcomes and efficiency measures. The enhanced recovery after surgery (ERAS) protocol has been instrumental in improving outcomes, but the effect of these protocols on health care spending has not been examined. This study aims to assess the effect of ERAS protocols on the length of hospital stay and costs associated with microsurgical breast reconstruction. METHODS In 2018, the authors implemented an ERAS protocol for patients undergoing microsurgical breast reconstruction that included perioperative procedures involving patient education and care. Subjects included patients who underwent deep inferior epigastric perforator flap breast reconstruction at the authors' institution between 2016 and 2019. Data were gathered from the electronic medical record and the hospital system's finance department, and patients were divided into pre-ERAS and ERAS cohorts. A 2-sample t test was used for statistical analysis. RESULTS The study included 269 patients with no statistically significant differences in demographic data between the cohorts. The average length of hospitalization was 3.46 days for the pre-ERAS group and 2.45 days for the ERAS group ( P = 0.000). In a linear regression, the ERAS protocol predicted a 1.04-day decrease in the length of stay ( P = 0.000). Overall, total direct cost decreased by 7.5% with the ERAS protocol. CONCLUSION The rising cost of health care presents a challenge for providers to reduce the cost burden placed on our health system while providing the highest-quality care. This study demonstrates that the use of standardized ERAS protocols can achieve this 2-fold goal.
Collapse
Affiliation(s)
| | - Rebecca Suydam
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY
| | - Taylor N Hardy
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY
| | - Mona Clappier
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY
| | - Sarah Barnett
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY
| | - Dana Caulfield
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY
| | - Matthew Jelavic
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY
| | - Mark L Smith
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY
| | - Neil Tanna
- Division of Plastic and Reconstructive Surgery, Northwell Health, Great Neck, NY
| |
Collapse
|
8
|
Subramaniam S, Tanna N, Smith ML. Operative Efficiency in Deep Inferior Epigastric Perforator Flap Reconstruction: Key Concepts and Implementation. Clin Plast Surg 2023; 50:281-288. [PMID: 36813406 DOI: 10.1016/j.cps.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The deep inferior epigastric perforator flap has become one of the most popular approaches for autologous breast reconstruction after mastectomy. As much of health care has moved to a value-based approach, reducing complications, operative time, and length of stay in deep inferior flap reconstruction is becoming increasingly important. In this article, we discuss important preoperative, intraoperative, and postoperative considerations to maximize efficiency when performing autologous breast reconstruction and offer tips on how to handle certain challenges.
Collapse
Affiliation(s)
- Sneha Subramaniam
- Friedman Center, Northwell Health System, 600 Northern Boulevard, Suite 310, Great Neck, NY 11021, USA
| | - Neil Tanna
- Friedman Center, Northwell Health System, 600 Northern Boulevard, Suite 310, Great Neck, NY 11021, USA
| | - Mark L Smith
- Friedman Center, Northwell Health System, 600 Northern Boulevard, Suite 310, Great Neck, NY 11021, USA.
| |
Collapse
|
9
|
Odorico SK, Reuter Muñoz K, J Nicksic P, Gunderson KA, Wood K, H Nkana Z, Bond E, Poore SO. Surgical and demographic predictors of free flap salvage after takeback: A systematic review. Microsurgery 2023; 43:78-88. [PMID: 35611652 PMCID: PMC10084419 DOI: 10.1002/micr.30921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/21/2022] [Accepted: 05/13/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Microsurgical free tissue transfer (FTT) is a widely employed surgical modality utilized for reconstruction of a broad range of defects, including head and neck, extremity, and breast. Flap survival is reported to be 90%-95%. When FTT fails, salvage procedures aim at establishing reperfusion while limiting ischemia time-with salvage rates between 22% and 67%. There are limited data-driven predictors of successful salvage present in the literature. This systematic review aims to identify predictors of flap salvage. METHODS A systematic literature review was conducted per PRISMA guidelines. Articles included in the final analysis were limited to those investigating FTT salvage procedures and included factors impacting outcomes. Cohort and case series (>5 flaps) studies up until March 2021 were included. Chi-square tests and linear regression modeling was completed for analysis. RESULTS The patient-specific factors significantly associated with salvage included the absence of hypercoagulability (p < .00001) and no previous salvage attempts (p < .00001). Case-specific factors significantly associated with salvage included trunk/breast flaps (p < .00001), fasciocutaneous/osteocutaneous flaps (p = .006), venous compromise (p < .00001), and shorter time from index procedure to salvage attempt (R = .746). Radiation in the head and neck population was significantly associated with flap salvage failure. CONCLUSIONS Given the complexity and challenges surrounding free flap salvage procedures, the goal of this manuscript was to present data helping guide surgical decision-making. Based on our findings, patients without documented hypercoagulability, no previous salvage attempts, fasciocutaneous/osteocutaneous flaps, trunk/breast flaps, and a shorter time interval post-index operation are the best candidates for a salvage attempt.
Collapse
Affiliation(s)
- Scott K Odorico
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Katie Reuter Muñoz
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Peter J Nicksic
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kirsten A Gunderson
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kasey Wood
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Zeeda H Nkana
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Evalina Bond
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Samuel O Poore
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| |
Collapse
|
10
|
Muacevic A, Adler JR, Osaki T, Sakakibara S. Simple and Easily Interpretable Flap Monitoring Method Using a Commercial Pulse Oximeter and a Widely Used Bedside Patient Monitor. Cureus 2022; 14:e32549. [PMID: 36654599 PMCID: PMC9840461 DOI: 10.7759/cureus.32549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Background Various methods for monitoring after free flap surgery have been reported in the literature. Among them, pulse oximetry shows a sensitive reaction to vascular issues, and it is easy to interpret visually. However, previous reports used special equipment that was less commonly used and difficult to generalize. In this study, we used a commercial pulse oximeter and a widely used bedside patient monitor to monitor transplanted free tissue and lower extremities of healthy subjects with impaired circulation. Methods A reflectance pulse oximeter sensor was attached on the flap after free tissue transplantation. The sensor was connected to a bedside patient monitor, and the flap oxygen saturation (SpO2) levels and arterial waveforms were continuously monitored. Additionally, blood circulation disorder was induced in the lower limbs of healthy volunteers using pressure cuff inflation on the thigh, and the waveform and SpO2 levels on the pulse oximeter attached to the lower leg were monitored. Results Twenty-two patients were included in this study. No postoperative vascular issues were observed in any case. Pulse oximeters showed normal rhythmic wavelengths, and the flap SpO2 level ranged approximately >90%. The pulse oximeter waveform rapidly disappeared during arterial occlusion in the thigh pressure cuff inflation test, and the waveform flattened and the SpO2 level decreased slightly during venous congestion. Conclusion Flap monitoring using a commercially available pulse oximeter and a bedside patient monitor is a versatile, easy-to-interpret, and useful method. Changes in waveform and SpO2 levels appear during arterial and venous circulation disorders, and these changes can be differentiated.
Collapse
|
11
|
The Optimal Length-of-Stay After Microvascular Breast Reconstruction: A Cost-Utility Analysis. Plast Reconstr Surg 2022; 150:279e-289e. [PMID: 35653514 DOI: 10.1097/prs.0000000000009316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Length-of-stay (LOS) can have a large impact on overall surgical costs. Several studies have demonstrated that a shortened LOS is safe and effective after microvascular breast reconstruction (MBR). The optimal LOS from a cost-utility perspective is not known. METHODS The authors used a decision tree model to evaluate the cost-utility, from the perspective of the hospital, of a variety of LOS strategies. Health state probabilities were estimated from an institutional chart review. Expected costs and quality-adjusted life-years (QALY) were assess using Monte Carlo simulation and sensitivity analyses. RESULTS Over a ten-year period, our overall flap loss and take-back rates were 1.6% and 4.9%, respectively. After rollback, a 3-day LOS was identified as the most cost-effective strategy, with an expected cost of $41,680.19 and an expected health utility of 25.68 QALYs. Monte Carlo sensitivity analysis confirmed that discharge on POD3 was the most cost-effective strategy in the majority of simulations when the willingness-to-pay threshold varied from $50,000-$130,000/QALY gained. CONCLUSION This cost-utility analysis suggests that a 3-day LOS is the most cost-effective strategy after MBR.
Collapse
|
12
|
Elmaraghi S, Israel JS, Gander B. Systematic Review of Replant Salvage and Cost Utility Analysis of Inpatient Monitoring After Digit Replantation. J Hand Surg Am 2022; 47:32-42.e1. [PMID: 34548183 DOI: 10.1016/j.jhsa.2021.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 05/30/2021] [Accepted: 07/28/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Digit replantation is a high-stakes procedure that has been shown to be cost-effective, especially for multiple-digit replantation. However, it is associated with prolonged lengths of stay (LOS) for monitoring and attempts at salvage. The cost-effectiveness of prolonged inpatient stays presumes that this is necessary and inherent to the replantation. We hypothesized that prolonged monitoring of replanted digits, in the hope of possible salvage after primary failure, is cost-ineffective due to the low rates of vascular compromise and salvage after replantation. METHODS Using previously published data comparing quality adjusted life years lost after traumatic digit amputation versus digit replantation, we devised a cost utility model to evaluate the incremental cost-effectiveness ratio of inpatient monitoring. To determine rates of vascular compromise and salvage after digit replantation, we performed a systematic review of the literature through MEDLINE and SCOPUS database searches to identify relevant articles on digital replantation since 1990. Cost-effectiveness was stratified based on the number of digits replanted. RESULTS Fewer than 9% of replanted digits both experience vascular compromise and are successfully salvaged. Adjusting for this, inpatient monitoring for single-digit and thumb replantation becomes cost-ineffective after 1 day of admission and monitoring for multiple-digit replantation becomes cost-ineffective after 2 days of admission. CONCLUSIONS In the United States, prolonged admissions for inpatient monitoring quickly become cost-ineffective, especially with relatively low rates of salvage. Surgeons should avoid extended hospitalizations for replant monitoring and should pursue enhanced recovery protocols for replantation, especially considering burgeoning health care costs in the United States. TYPE OF STUDY/LEVEL OF EVIDENCE Economic/Decision Analysis III.
Collapse
Affiliation(s)
- Shady Elmaraghi
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Jacqueline S Israel
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Brian Gander
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| |
Collapse
|
13
|
Schoenbrunner A, Hackenberger PN, DeSanto M, Chetta M. Cost-Effectiveness of Vioptix versus Clinical Examination for Flap Monitoring of Autologous Free Tissue Breast Reconstruction. Plast Reconstr Surg 2021; 148:185e-189e. [PMID: 34133372 DOI: 10.1097/prs.0000000000008154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Vioptix is a near-infrared spectroscopy tissue oximetry technology that allows for noninvasive monitoring of flap perfusion. Despite the reported benefits of Vioptix, the cost-effectiveness of this flap monitoring technology has not been compared to clinical examination alone. METHODS A cost-effectiveness model, from the patient perspective, was constructed with two treatment arms: clinical examination versus clinical examination combined with Vioptix for flap monitoring after autologous, free flap breast reconstruction. Costs, utilities, and other model inputs were identified from the literature. One-way and probabilistic sensitivity analyses were performed. Gamma distributions were created for cost variables, and beta distributions were created for probability variables. An incremental cost-effectiveness ratio under $50,000 per quality-adjusted life-year (QALY) was considered cost-effective. All analyses were performed using TreeAge Pro (Williamstown, Mass.). RESULTS Mean cost of autologous free tissue transfer breast reconstruction with clinical examination-based flap monitoring was found to be $37,561 with an effectiveness of 0.79, whereas the mean cost of clinical examination with Vioptix for flap monitoring was $39,361 with effectiveness of 0.82. This yielded an incremental cost-effectiveness ratio of $60,507 for clinical examination combined with Vioptix for flap monitoring. One-way sensitivity analysis revealed that clinical examination with Vioptix became cost-effective when the cost of Vioptix was less than $1487. Probabilistic sensitivity analysis found that clinical examination was cost-effective in 86.5 percent of cases. CONCLUSION Although clinical examination combined with Vioptix is minimally more effective for flap monitoring after autologous, free flap breast reconstruction, clinical examination alone is the more cost-effective flap monitoring option.
Collapse
Affiliation(s)
- Anna Schoenbrunner
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center; The Ohio State University College of Medicine; and the Ohio University Heritage College of Osteopathic Medicine
| | - Paige N Hackenberger
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center; The Ohio State University College of Medicine; and the Ohio University Heritage College of Osteopathic Medicine
| | - Marisa DeSanto
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center; The Ohio State University College of Medicine; and the Ohio University Heritage College of Osteopathic Medicine
| | - Matthew Chetta
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center; The Ohio State University College of Medicine; and the Ohio University Heritage College of Osteopathic Medicine
| |
Collapse
|
14
|
Discussion: A Critical Examination of Length of Stay in Autologous Breast Reconstruction: A National Surgical Quality Improvement Program Analysis. Plast Reconstr Surg 2021; 147:34-36. [PMID: 33370045 DOI: 10.1097/prs.0000000000007421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
15
|
Articulating the "So, What?" in Clinical Research: Insight from the M-CHOIR Group. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2848. [PMID: 33133904 PMCID: PMC7572177 DOI: 10.1097/gox.0000000000002848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/23/2020] [Indexed: 11/25/2022]
Abstract
With the academic culture of "publish or perish," authors must ensure that they are delivering high-quality data with a meaningful impact on clinical practice. Even for physician-scientists at the top of their fields, establishing the relevance of a study to clinical practice is a challenge. Thus, it is essential that research proposals ask questions that are clinically important, use appropriate methodologies, and examine outcomes that are relevant to both the physicians and the patients. The question of "so, what?" or in other words, "who cares?" is one that can make or break a study's impact on clinical practice. Researchers should use models such as PICOS (Population, Intervention, Comparison, Outcomes, and Study design) and FINER (Feasible, Interesting, Novel, Ethical, Relevant) and ask why readers will care about their study's findings before the study is conducted. By doing so, researchers can ensure the successful execution of their study and a meaningful impact of their findings, in both academia and clinical practice. This Special Topic article aims to guide researchers in producing relevant, impactful conclusions of their studies by providing input and resources from the Michigan Center for Hand Outcomes and Innovation (M-CHOIR) group.
Collapse
|
16
|
Reply: A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay. Plast Reconstr Surg 2020; 145:1098e-1099e. [PMID: 32464027 DOI: 10.1097/prs.0000000000006872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
17
|
Knackstedt R, Gatherwright J. A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay. Plast Reconstr Surg 2020; 145:1097e-1098e. [PMID: 32464026 DOI: 10.1097/prs.0000000000006871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
18
|
Discussion: A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay. Plast Reconstr Surg 2019; 144:552e-553e. [PMID: 31568280 DOI: 10.1097/prs.0000000000006013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
19
|
Discussion: A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay. Plast Reconstr Surg 2019; 144:550e-551e. [PMID: 31568279 DOI: 10.1097/prs.0000000000006014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|