Using Quality Data to Improve Breast Reconstruction Outcomes

Since 2007, the American College of Surgeons National Surgical Quality Improvement Program database has tracked 30-day surgical outcomes and complications longitudinally. Researchers from the University of California, San Francisco; and the Division of Plastic and Reconstructive Surgery, University of Rochester have looked at a subset of data—outcomes for immediate breast reconstruction from 2007 to 2011—to determine if national outcomes have improved and to identify areas where additional improvement is warranted. Immediate breast reconstruction is now the most commonly performed method of breast reconstruction nationally.

The researchers identified almost 16,000 patients who had had mastectomies followed by immediate reconstruction. They identified several trends:

• Fewer smokers underwent immediate reconstruction over time.
• Patients were more likely to be obese or American Society of Anesthesiologists class 3 and 4 (that is, with severe systemic disease or with severe systemic disease that is a constant threat to life) than patients who underwent these procedures in the past.
• The incidence of superficial surgical-site infection increased from 1.7% to 2.3%.
• Wound dehiscence increased in incidence, but implant loss and flap loss decreased over time.
• Mean operative times and complications related to prosthetic and autologous reconstruction increased.

The authors attribute the increase in complications for immediate breast reconstruction to a higher number of comorbid patients and longer operative times.

The authors recommend delaying the reconstructive procedure in American Society of Anesthesiologists class 3 and 4 patients. Before beginning surgery, the medical team should work with the patient to optimize health and reverse medical comorbidities before elective reconstruction. Ultimately, this would reduce the overall length of the eventual reconstructive operation.

Continuously tracking and assessing outcomes ensures that performance standards are met and areas for improvement are identified and addressed. Increased operative time is a significant independent risk factor for post-operative morbidity. Improving patient selection criteria and identifying ways to improve efficiency in the operative suite can decrease mortality and morbidity.