Are 30-Day Outcomes Enough? Late Infectious Readmissions following Prosthetic-Based Breast Reconstruction

Abstract

Background: Surgical-site infection is a major concern in prosthetic-based breast reconstruction. Thirty-day postoperative readmission rates are a common quality metric, but little is known about readmission rates for later infections. Methods: Using the 2013 to 2014 Nationwide Readmissions Database, the authors identified breast cancer patients undergoing breast reconstruction with implants and tissue expanders who had an infectious readmission. The authors used univariate and multivariate logistic regression models to identify predictors of infectious readmission and explantation within the early (0 to 30 days) and late (31 to 90 days) postoperative periods. Results: In the weighted sample, the authors identified 18,338 patients undergoing prosthetic-based breast reconstruction. The overall infectious readmission rate was 4.1 percent (n = 759): 49.3 percent occurred early and 50.7 percent occurred late. Of the infectious readmissions, 39.5 percent required explantation, 55.1 percent of which occurred during a late infectious readmission. Seventy-five percent of these infectious readmissions and explantations occurred within 49 days of initial surgery. Median annual household income less than $40,000 (p = 0.035), diabetes (p = 0.038), and obesity (p = 0.004) were independent predictors of infectious readmission. Diabetes (p = 0.049) and hypertension (p = 0.011) were independent predictors of early readmission. Median annual household income less than $40,000 (p = 0.049), obesity (p = 0.006), and increasing length of stay during the index procedure (p = 0.028) were independent predictors of late readmission. No statistically significant independent predictors for explantation were identified. Conclusions: Traditional 30-day readmission rates are not an adequate quality metric for breast reconstruction given the number of late postoperative readmissions, many of which lead to explantation. Early and late infectious readmissions have different predictors. Interventions targeting these predictors may decrease the number of readmissions, thus reducing cost and improving quality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Mastectomy and Prepectoral Reconstruction in an Ambulatory Surgery Center Reduces Major Infectious Complication Rates

“…Despite these advances, infections, resulting in reconstructive failure, have a documented rate between 2.5% and 24%. 18 , 19 , 21 – 23 , 32 Khansa et al 20 and others 21 – 23 have published standardized best-practice protocols for preoperative, intraoperative, and postoperative measures to reduce infections. Despite following these protocols, we had a reconstructive failure rate secondary to infection of 10%.…”

Predictive risk factors of complications in different breast reconstruction methods

“…There are many studies evaluating postoperative complications and comorbidities associated with breast reconstructions [11][12][13][14][15][16][17][18], but only few have assessed the predictive risk factors for postoperative complications. It is common that only one or two surgical techniques are compared to or the follow-up time is 30 days postoperatively [14,19,20].…”

“…It is common that only one or two surgical techniques are compared to or the follow-up time is 30 days postoperatively [14,19,20]. It has been concluded that traditional 30-day readmission rates are not an adequate quality metric for breast reconstruction given the number of late postoperative readmissions in breast reconstructions [11,18]. In order to describe reliable data concerning complications in breast reconstructive surgery, it is important to systematically analyze and compare complications from different reconstructive methods.…”

Early Expander-to-Implant Exchange after Postmastectomy Reconstruction Reduces Rates of Subsequent Major Infectious Complications

“…We advocate the early exchange approach for patients who require postmastectomy chemotherapy and radiotherapy because we feel these adjuvant treatments compromise healing and allow for indolent infections to eventually manifest. Radiotherapy and obesity have been demonstrated to be risk factors for late infections, 23 and our findings suggest a strategy that may help reduce this complication in these patients. We perform the exchange surgery 3 weeks after the mastectomy and TE placement and then allow for an additional 3 weeks of healing before chemotherapy or radiotherapy begins, because more significant delays in adjuvant treatment have been shown to decrease survival.…”

“…The low rates of infectious complications seen in the CG and EEG after second-stage exchange surgery in comparison with the higher rates observed after immediate reconstruction have been described by others. 23 , 33 …”