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A Nationwide Analysis Of The Relationship Between Hospital Volume And Outcome For Autologous Breast Reconstruction
Evan Matros, MD MMSc, Claudia R. Albornoz, MD MSc, Babak J. Mehrara, MD, Lauren Hishon, ., Andrea L. Pusic, MD MHS, Colleen M. McCarthy, MD MS, Joseph J. Disa, MD, Peter G. Cordeiro, MD.
Memorial Sloan-Kettering Cancer Center, New York, NY, USA.

Purpose: Although the volume outcome relationship has been evaluated for many complex surgical procedures, it has not been specifically measured for US autologous breast reconstruction. The aim of the current study is to:1) provide a benchmark for in-hospital complication rates following autologous reconstruction, and 2) to evaluate the relationship between hospital volume and complication rates.
Methods: The Nationwide Inpatient Sample Database was used to identify patients who underwent total mastectomy with immediate autologous reconstruction from 1998-2010 and a subset of microsurgical cases from 2008-2010. Hospitals were categorized into quartiles based on number of yearly procedures. Outcomes included surgery-specific and systemic complications. A multivariable model was used to analyze the volume outcome relationship after adjusting for other variables.
Results: National surgery-specific and systemic complication rates were 11.6% and 7.5% respectively. Ninety-two percent of centers perform a very-low (<9 cases/yr) or low (9-20 cases/yr) number of procedures. The highest-volume centers (>44 cases/yr) are located in metropolitan areas (Figure 1). An inverse relationship between reconstructive volume and surgery-specific and systemic complications was identified (p<0.01) (Figures 2 & 3). In the multivariable analysis, very-low, low and medium-volume centers were more likely to have surgery-specific complications than high-volume centers (p<0.01). Very-low compared to high-volume centers were more likely to have systemic complications for autologous reconstruction (p<0.01).
Conclusion: A benchmark for national complication rates following autologous reconstruction serves as a point of reference for comparison. The volume outcome relationship is stronger for surgery-specific than systemic complications. Geographic disparities are present in the distribution of high volume centers. Such information can be used to determine best practices and improve access to care.
Figure 1.

Figure 2.

Figure 3.

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