The NSQIP 30-Day Challenge: Reliability of Outcomes in Breast Reconstruction
Austin D. Chen1, Parisa Kamali, MD2, Anmol S. Chattha, BA1, Alexandra Bucknor, MBBS, MRCS, MSc1, Patrick P. Bletsis, BSc1, Renata Flecha-Hirsch1, Adam M. Tobias, MD, FACS1, Bernard T. Lee, MD, MBA, MPH, FACS1, Samuel J. Lin, MD, MBA, FACS1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Radboud University Medical Center, Nijmegen, Netherlands.
BACKGROUND:
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database has proven useful in the evaluation of outcomes after flap reconstruction; however, it has come under scrutiny due to its 30-day outcomes' cutoff. The aim of this study is to report on early and late complications in immediate, free-tissue transfer breast reconstruction (IFTBR), comparing the ACS NSQIP database with our own institutional data.
METHODS:
Data were retrieved for consecutive patients undergoing IFTBR from a single-center institutional database (2010-2015) and from the ACS NSQIP database (2011-2014). Variables of interest were patient and operative characteristics, and early (≤30 day) and late (>30 day) outcomes, which were surgical site infection (SSI), wound dehiscence (WD), reoperation (RO), and readmission (RA). Multiple logistic regressions were performed to adjust for patient characteristics while comparing outcomes between institutional and NSQIP data for early and late complications.
RESULTS:
In total, data for 305 patients undergoing IFTBR were retrieved from our institutional database and 2,158 patients undergoing IFTBR were retrieved from the ACS NSQIP database. Analysis of institutional vs. NSQIP total complications revealed no differences for SSI (5.2% vs. 4.1%, p=0.375), WD (2.3% vs. 1.5%, p=0.506), and RA (5.2% vs. 5.6%, p=0.790). There was a significant difference in RO (6.6% vs. 13.0%, p=0.002). When comparing early institutional vs. ACS NSQIP data, there were no differences in SSI (3.6% vs. 4.1%, p=0.905), WD (1.3% vs. 1.5%, p=0.572), or RA (3.0% vs. 5.6%, p=0.127). There was a significant difference in RO (3.6% vs. 13.0%, p<0.001). When RO was analyzed in further detail, we found there were differences in 30-day and total institutional vs. 30-day ACS NSQIP hematoma rates (1.0% vs. 4.1%, p=0.009 and 1.3% vs. 4.1%, p=0.015, respectively). There were also differences in total institutional vs. 30-day ACS NSQIP seroma rates (1.3% vs. 0.3%, p=0.028).
CONCLUSIONS:
A large percentage of complications, 31.3% of superficial surgical site infections, 42.9% of wound dehiscences, 25.0% of reoperations and 43.8% of readmissions, in our institutional database occurred after 30 days. However, there was not a significant difference in institutional (early and late) vs. NSQIP (early) complication rates, except for reoperation. Reoperation differences were attributed to the increase in national hematoma rates and the institutional increase in late development of seroma. ACS NSQIP may be reliable in assessing complications for immediate free tissue breast reconstruction, but users should exercise caution when examining reoperation rates, hematoma and seroma.
TABLES:
Table 1. Early and Late Complications
| Patient Characteristics | Overall | Early | Late | |||
| n= | (%) | n= | (%) | n= | (%) | |
| SSI | 16 | (100) | 11 | (68.8) | 5 | (31.3) |
| Wound dehiscence | 7 | (100) | 4 | (57.1) | 3 | (42.9) |
| Reoperation | 20 | (100) | 11 | (55.0) | 9 | (45.0) |
| Readmission | 16 | (100) | 9 | (56.3) | 7 | (43.8) |
| SSI, Surgical Site Infection | ||||||
Table 2. Outcomes (total and ≤30 days) Institutional vs. NSQIP
| Patient Outcomes | Institutional | NSQIP | P* | ||||||
| n= | (%) | n= | (%) | ||||||
| SSI | |||||||||
| Total | 16 | (5.2) | 88 | (4.1) | 0.375 | ||||
| ≤30 | 11 | (3.6) | 88 | (4.1) | 0.905 | ||||
| Wound dehiscence | |||||||||
| Total | 7 | (2.3) | 32 | (1.5) | 0.506 | ||||
| ≤30 | 4 | (1.3) | 32 | (1.5) | 0.572 | ||||
| Reoperation | |||||||||
| Total | 20 | (6.6) | 280 | (13.0) | 0.002 | ||||
| ≤30 | 11 | (3.6) | 280 | (13.0) | <0.001 | ||||
| Readmission | |||||||||
| Total | 9 | (3.0) | 121 | (5.6) | 0.790 | ||||
| ≤30 | 16 | (5.2) | 121 | (5.6) | 0.127 | ||||
| SSI, Surgical Site Infection | |||||||||
Table 3. Institutional (total and ≤30 days) vs. NSQIP Reoperations
| Patient Outcomes | Institutional | NSQIP | p-value | ||
| n= | (%) | n= | (%) | ||
| Reoperation | |||||
| Total | 17 | (5.6) | 179 | (9.5) | 0.011 |
| ≤30 | 11 | (3.6) | 179 | (9.5) | <0.001 |
| Flap complication | |||||
| Total | 5 | (1.6) | 43 | (2.3) | 0.606 |
| ≤30 | 5 | (1.6) | 43 | (2.3) | 0.606 |
| Hemorrhage | |||||
| Total | 1 | (0.3) | 5 | (0.3) | 0.848 |
| ≤30 | 1 | (0.3) | 5 | (0.3) | 0.848 |
| Hematoma | |||||
| Total | 4 | (1.3) | 77 | (4.1) | 0.015 |
| ≤30 | 3 | (1.0) | 77 | (4.1) | 0.009 |
| Seroma | |||||
| Total | 4 | (1.3) | 6 | (0.3) | 0.028 |
| ≤30 | 2 | (0.7) | 6 | (0.3) | 0.378 |
| Infection | |||||
| Total | 2 | (0.7) | 15 | (0.8) | 0.930 |
| ≤30 | 0 | (0.0) | 15 | (0.8) | - |
| Wound complication | |||||
| Total | 6 | (2.0) | 42 | (2.2) | 0.804 |
| ≤30 | 3 | (1.0) | 42 | (2.2) | 0.102 |
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