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A Nationwide Analysis of the Relationship between Hospital Volume and Outcome for Autologous Breast Reconstruction

Albornoz, Claudia R. M.D., M.Sc.; Cordeiro, Peter G. M.D.; Hishon, Lauren; Mehrara, Babak J. M.D.; Pusic, Andrea L. M.D., M.H.S.; McCarthy, Colleen M. M.D., M.S.; Disa, Joseph J. M.D.; Matros, Evan M.D., M.M.Sc.

Plastic and Reconstructive Surgery: August 2013 - Volume 132 - Issue 2 - p 192e–200e
doi: 10.1097/PRS.0b013e31829586c1
Breast: Outcomes Articles

Background: The volume-outcome relationship has not been specifically measured for U.S. autologous breast reconstruction. The authors studied whether there is a relationship between hospital procedural volume and perioperative complication rates.

Methods: The authors identified (1) patients who underwent total mastectomy with immediate autologous reconstruction from 1998 to 2010 and (2) a subset of microsurgical cases from 2008 to 2010. Hospitals were categorized into quartiles based on number of yearly procedures. Outcomes included surgery-specific and systemic complications. A multivariable model was used to analyze the volume-outcome relationship after adjusting for other variables.

Results: Over the 13-year study period, 21,016 immediate autologous reconstructions were recorded. Surgery-specific and systemic complication rates were 13.0 and 7.5 percent, respectively. Ninety-two percent of centers perform a very low (fewer than nine cases per year) or low (nine to 20 cases per year) number of procedures. The highest-volume centers (>44 cases per year) are located in metropolitan areas. An inverse relationship between reconstructive volume and surgery-specific and systemic complications was identified (p < 0.01). In the multivariable analysis, centers with very low, low, and medium case volumes were more likely to have surgery-specific complications than high-volume centers (p < 0.01). Very-low-volume compared with high-volume centers were more likely to have systemic complications (p < 0.01).

Conclusions: Higher volume autologous breast reconstruction centers have lower complication rates. The volume-outcome relationship is stronger for surgery-specific than for systemic complications. Geographic disparities are present in the distribution of high-volume centers. Such information can be used to inform best practices and improve access to care.


Supplemental Digital Content is available in the text.

New York, N.Y.

From the Plastic and Reconstructive Surgical Service, Memorial Sloan-Kettering Cancer Center.

Received for publication October 2, 2012; accepted February 13, 2013.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. This work had no specific funding.

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Evan Matros, M.D., M.M.Sc.Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, MRI 1036, New York, N.Y. 10065,

©2013American Society of Plastic Surgeons