AAPS Main SitePerioperative Outcomes of Autologous Breast Reconstruction Surgery in Teaching versus Non-teaching Hospitals
Hossein Masoomi, MD, Garrett A. Wirth, MD, MS, FACS, Keyianoosh Z. Paydar, MD, FACS, Brandon K. Richland, MD, Gregory RD Evans, MD, FACS.
Aesthetic & of Plastic Surgery Institute, University of California, Irvine Medical Center, Orange, CA, USA.
PURPOSE: (1) To evaluate the frequency of various reconstructive techniques for autologous breast reconstructions and (2) to compare perioperative outcomes of autologous breast reconstructions in teaching vs. non-teaching hospitals using the Nationwide Inpatient Sample (NIS) database.
METHODS: We analyzed clinical data of patients who underwent autologous breast reconstructive surgery from January 2009 to December 2010 using the Nationwide Inpatient Sample (NIS) database. Autologous breast reconstruction operations included latissimus dorsi myocutaneous flap (LDF), pedicled transverse rectus abdominis myocutaneous (P-TRAM), free transverse rectus abdominis myocutaneous flap (F-TRAM), free deep inferior epigastric artery perforator flap (DIEP), free superficial inferior epigastric artery flap (SIEA), and free gluteal artery perforator flap (GAP). Outcome measurements included postoperative complications, in-hospital mortality, total hospital charges and length of hospital stay.
RESULTS: A total of 35,883 patients underwent autologous breast reconstructive surgery from January 2009 to December 2010. The majority were performed in the teaching hospital group (74%), and the remainder in the non-teaching hospital group (26%). The two most common breast reconstruction types in the teaching hospital group were LDF (26%) and DIEP (26%) compared with LDF (39%) and P-TRAM (22%) in the non-teaching hospital group. In addition, the rate of free flap breast reconstruction was significantly higher in teaching hospitals (46%) compared with non-teaching hospitals (31%), (p<0.01). There was no statistically significant difference for total in-hospital complication rate (teaching: 6.9% vs. non-teaching: 7.1%; p=0.54) or total in-hospital mortality rate (teaching: 0.04% vs. non-teaching: 0.05%; p=0.56). The teaching hospital group had higher total hospital charges (teaching: $63,015 vs. non-teaching: $58,572; p<0.01) where the higher rate of free flap breast reconstructions occurred. Although the teaching hospital group had a longer mean length of hospital stay (teaching: 3.9 days vs. non-teaching: 3.7 days; p<0.01), this difference was not clinically significant.
CONCLUSION: When looking at autologous breast reconstructions performed in the United States from January 2009 to December 2010, almost three fourths were performed in teaching hospitals, with the remainder being performed in non-teaching hospitals. Free flap breast reconstructions were more likely to be performed in teaching hospitals, while pedicled flap breast reconstructions such as the LDF and P-TRAM were more likely to be performed in non-teaching hospitals. Despite performing more complex free flap breast reconstructions in teaching hospitals, there was no statistically significant difference in perioperative outcomes (morbidity and mortality) between teaching and non-teaching hospitals. Teaching hospitals remain an integral part of the health care system and the data suggests that it is not only safe, but appropriate to have residents involved in the operations and care for patients undergoing autologous breast reconstruction.
| Teaching hospitals | Non-teaching hospitals | P-value | |
| Autologous breast reconstruction | 74.3% | 25.7% | <0.01 |
| Autologous breast reconstruction types | Teaching hospitals (%) | Non-teaching hospitals (%) |
| Latissimus dorsi flap | 26.2 | 38.9 |
| Pedicled TRAM flap | 19.6 | 21.9 |
| Free TRAM flap | 18.6 | 17.0 |
| Free DIEP flap | 26.0 | 13.2 |
| Free SIEA flap | 1.1 | 0.15 |
| Free GAP flap | 0.56 | 0.47 |
| Total pedicled flaps | 45.8 | 60.9 |
| Total free flaps | 46.2 | 30.8 |
| Not otherwise specified | 8.0 | 8.3 |
| Outcomes | Teaching hospitals | Non-teaching hospitals | P-value/ confidence interval |
| Overall complication rate | 6.90% | 7.09% | p=0.54 |
| Overall in-hospital mortality rate | 0.04% | 0.05% | p=0.56 |
| Risk adjusted overall complication rate | CI: 0.90 (0.82-1.0) p=0.05 | ||
| Risk adjusted overall in-hospital mortality rate | CI: 0.63 (0.16-2.46) p=0.50 | ||
| Mean total hospital charges | $63,015 | $58,572 | p<0.01 |
| Mean length of stay | 3.94 days | 3.70 days | p<0.01 |
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