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The Battle of Words and the Reality of Never Events in Breast Reconstruction: Incidence, Risk Factors Predictive of Occurrence, and Economic Cost Analysis

Adetayo, Oluwaseun A. M.D.; Salcedo, Samuel E. B.A.; Biskup, Nataliya I. M.D.; Gupta, Subhas C. M.D., Ph.D.

Plastic and Reconstructive Surgery: July 2012 - Volume 130 - Issue 1 - p 23–29
doi: 10.1097/PRS.0b013e3182547b74
Breast: Original Articles

Background: The Centers for Medicare and Medicaid Services has a list of 10 hospital-acquired conditions for which hospitals and physicians will not be reimbursed because it deems such conditions are preventable and should be considered “never events.” To evaluate the validity of this premise, the authors conducted a real-life analysis of the incidence and categories of never events occurring in a breast reconstruction cohort of a multisurgeon plastic surgery practice. Cost analysis of estimated revenue loss and risk factors associated with the development of never events are enumerated.

Methods: A retrospective chart review of postmastectomy patients undergoing breast reconstruction from 2008 to August of 2010 was conducted. A total of 297 patients were identified and International Classification of Diseases, Ninth Revision codes corresponding to the never events of interest were applied to the study population.

Results: Of the 297 patients, 24 (8.08 percent) developed never events in two categories: surgical-site infections (7.74 percent) and catheter-related urinary tract infections (0.34 percent). There were no complications in the remaining eight categories. Overweight body mass index and diabetes were strong independent risk factors for the development of never events (p < 0.0001). Cost estimates of associated revenue loss and economic analysis reveal substantial financial burdens to physicians and hospitals as a result of nonreimbursement.

Conclusions: The “one-size-fits-all” approach of the Centers for Medicare and Medicaid Services may be misplaced and misleading. Certain risk factors are independent predictors of developing a never event, making it impossible to classify certain outcomes as “never” occurrences. The never events pendulum may have swung immensely to the left, and it is time to attain a much-needed equilibrium.


Loma Linda, Calif.

From the Department of Plastic Surgery, Loma Linda University Medical Center.

Received for publication July 21, 2011; accepted January 20, 2012.

Presented in part at the 90th Annual Meeting of the American Association of Plastic Surgeons, in Boca Raton, Florida, April 9 through 12, 2011; the 56th Annual Meeting of the Plastic Surgery Research Council, in Louisville, Kentucky, April 27 through 30, 2011; and the 61st Annual Meeting of the California Society of Plastic Surgeons, in Monterey, California, May 27 through 30, 2011.

Disclosure: The authors have no financial interests to disclose. No funding was received for this work.

Subhas C. Gupta, M.D., Ph.D.; Department of Plastic Surgery, Loma Linda University, Loma Linda, Calif. 92354,

©2012American Society of Plastic Surgeons