Discussion: Assessing the Quality of Microvascular Breast Reconstruction Performed in the Urban Safety-Net Setting: A Doubly Robust Regression Analysis

TY - JOUR

T1 - Discussion

T2 - Assessing the Quality of Microvascular Breast Reconstruction Performed in the Urban Safety-Net Setting: A Doubly Robust Regression Analysis

AU - Haddock, Nicholas T.

AU - Teotia, Sumeet S.

N1 - Funding Information: Haddock Nicholas T. M.D. Teotia Sumeet S. M.D. Dallas, Texas From the Department of Plastic Surgery, University of Texas Southwestern. Received for publication June 25, 2018; accepted July 9, 2018. Disclosure: The authors have no financial interest to declare in relation to the content of this Discussion or of the associated article . Nicholas T. Haddock, M.D., University of Texas Southwestern, Department of Plastic Surgery, 1801 Inwood Road, Dallas, Texas 75390 February 2019 143 2 371 372 Copyright © 2019 by the American Society of Plastic Surgeons 2019 Safety-net hospitals are a critical part of the health system in the United States. As physicians, we have a societal drive and obligation to offer equivalent access to care to all patients, all the while minimizing health care disparities among population groups; because of this, a great deal of interest has developed in evaluating the quality of care across all types of facilities. Defining, gathering data for, and ultimately reimbursing for quality of care has shaped part of the modern health care conversation. Parameters of quality of care—outcome, safety, and service—are continually being debated and aimed at evaluating the value of care delivered by a health care system and finally how that translates to patients. Even though actual cost analysis from the data obtained from the National Inpatient Sample was not the aim of the article by Dr. Offodile and colleagues, one could infer from the undertone that cost is crucial when it comes to delivering health care, particularly as it relates to value of care delivered at safety-net hospitals versus non–safety-net hospitals. The article by Dr. Offodile et al. specifically compares safety-net hospitals to non–safety-net hospital settings, with subgroup analysis focused on three outcomes of interest: medical complications, surgical inpatient complications, and prolonged hospital stay. 1 Using a propensity-matched data set from the National Inpatient Sample, the authors showed that odds of medical and surgical complications do not differ significantly between the safety-net hospital and the non–safety-net hospital setting, a finding that is encouraging and reassuring because safety-net hospitals are continually under financial stress given their inherent funding sources. Although the article here does not directly make the argument for increased funding secondary to worse outcomes, it does allow for a meaningful persuasion away from reductions in overall funding to safety-net hospitals, as they play a crucial role in our communities and could help deflate some stress away from non–safety-net hospital systems. Given the obvious concerns over nonrandom population differences, the authors use propensity score matching to create a well-balanced group and a multivariate logistic regression model to reduce bias. Of a total of 3000 patients identified between 2012 and 2014 from the National Inpatient Sample database, 496 patients (propensity-matched) from safety-net hospitals were identified after exclusion from an initial of 510 safety-net hospital patients (unmatched), and compared to 2490 non–safety-net hospital patients (unmatched), a number that was reduced to 362 non–safety-net hospital patients (matched). The reduction in non–safety-net hospital patients for data set analysis after propensity matching was quite impressive, signifying that a much smaller percentage of types of patients treated at safety-net hospitals are treated in a non–safety-net hospital setting. The complex statistical analysis is ingrained in the backbone of this article but is necessary to support the conclusion, and we would emphasize that for most fast readers, this could be a difficult initial read. Flap loss (partial or complete) constitutes one of the most worrisome complications in microsurgery. In this study, flap loss is indirectly evaluated by using International Classification of Diseases, Ninth Revision , codes. This precedent has been established in previous literature; however, this could lead to error in results and analysis because the National Inpatient Sample data set relies on specific codes that may not always be used if a flap is removed without attempt at salvage. In addition, although flap-related complications are the most perioperatively feared early in the course of microsurgical breast reconstruction (and thus are captured in the inpatient setting according to the authors), the most common complications are related to the donor site, with honest reported rates above 20 percent (minor and major). 2 Even though the authors attempted to elucidate that comparing inpatient complication rates is to some degree reflective of overall quality of microvascular immediate breast reconstruction, all breast reconstructive surgeons understand that delayed complications such as donor-site wound dehiscence and morbidity and readmission for complications contribute equally to overall patient well-being and also reflect the overall satisfaction and quality of life obtained by means of breast reconstruction. When comparing outcomes between facility types, it is difficult to omit the aforementioned most common complication and ultimately this is a weakness of the data set even though the authors do their best to overcome it with clear explanation. Donor-site wound complications lead to increased morbidity and cost to the patient and any system. Hospital length of stay remains an important part of discussion regarding patient recovery and overall health care costs, and in this regard, the findings are intuitive. High-volume centers often have protocols (e.g., enhanced recovery after surgery, as stated in the article) that ensure timely discharge. Lower income patients, Medicaid patients, and patients treated at safety-net hospitals generally constitute a similar group and thus it is not surprising that length of stay would be greater in these patients for a number of reasons, including lack of resources at home and inadequate in-hospital or out-of-hospital support. Overall, the findings are encouraging in that odds of inpatient complications are not increased in the safety-net hospital setting. We agree that this is likely secondary to the selective nature of those performing these procedures in an effort to ensure good outcomes. The subgroup analysis also showed that black patients and uninsured/charity-care patients were found to have increased odds of inpatient complications—a troubling finding. Unfortunately, with this data set, there is no clear explanation, which we hope is addressed in future studies looking at improving outcomes in this patient cohort. This study adds to the importance of safety-net hospitals in our communities and the need for securing and maintaining crucial funding while balancing quality of care and reducing costs in an effort to deliver high value that all patients deserve regardless of economic discrepancies.

PY - 2019/2/1

Y1 - 2019/2/1

UR - http://www.scopus.com/inward/record.url?scp=85060600378&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85060600378&partnerID=8YFLogxK

U2 - 10.1097/PRS.0000000000005221

DO - 10.1097/PRS.0000000000005221

M3 - Comment/debate

C2 - 30688875

AN - SCOPUS:85060600378

SN - 0032-1052

VL - 143

SP - 371

EP - 372

JO - Plastic and reconstructive surgery

JF - Plastic and reconstructive surgery

IS - 2

ER -