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Individualized Risk of Surgical-Site Infection: An Application of the Breast Reconstruction Risk Assessment Score

Kim, John Y. S. M.D.; Khavanin, Nima B.S.; Jordan, Sumanas W. M.D., Ph.D.; ver Halen, Jon P. M.D.; Mlodinow, Alexei S. B.A.; Bethke, Kevin P. M.D.; Khan, Seema A. M.D.; Hansen, Nora M. M.D.; Losken, Albert M.D.; Fine, Neil A. M.D.

Plastic and Reconstructive Surgery: September 2014 - Volume 134 - Issue 3 - p 351e–362e
doi: 10.1097/PRS.0000000000000439
Breast: Outcomes Article

Background: Risk factors for surgical-site infection following beast reconstruction have been thoroughly investigated at a population level. However, traditional population-based measures may not always capture the nuances of individual patients. The authors aimed to develop a validated breast reconstruction risk assessment calculator for surgical-site infection that informs risk at an individual level.

Methods: Mastectomies with immediate reconstruction (n = 16,069) from 2005 to 2011 were identified from the National Surgical Quality Improvement Program database. A multiple logistic regression model was created for postoperative surgical-site infection. Hosmer-Lemeshow, C statistic, and Brier score were computed to assess model performance. Bootstrap analysis validated the model.

Results: A robust, validated risk model for surgical-site infection was developed using 11 covariates. The model Hosmer-Lemeshow p value was 0.371, the Brier score was 0.0357, and the C statistic was 0.682 (optimism-corrected C statistic, 0.678). The distribution of individual risks demonstrated a positive skew. Population-derived risk underestimated or overestimated individual risk by at least 1.5-fold in nearly one-fifth of all patients.

Conclusions: The breast reconstruction risk assessment score risk calculator for surgical-site infection mitigates the potentially inaccurate interpolation of population-based risk to individual patients. The authors concomitantly developed an online interface—accessible by patients and surgeons alike—to quantify a patient’s risk for surgical-site infection, better informing evidence-based decisions and managing patient expectations.


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Chicago, Ill.; Memphis, Tenn.; and Atlanta, Ga.

From the Division of Plastic and Reconstructive Surgery and the Lynn Sage Comprehensive Breast Center, Northwestern University, Feinberg School of Medicine; the Department of Plastic and Reconstructive Surgery, Baptist Cancer Center/Vanderbilt Ingram Cancer Center; and the Division of Plastic and Reconstructive Surgery, Emory University Hospital.

Received for publication October 17, 2013; accepted February 10, 2014.

The first two authors contributed equally to this article.

Disclosure: Dr. Kim receives research funding from the Musculoskeletal Transplant Foundation. Dr. Fine receives research funding from Allergan. Dr. Khan has received research funding from Repros Pharmaceuticals and from Amgen. All other authors have no relevant financial relationships to disclose. This particular research received no external funding.

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John Y. S. Kim, M.D., Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, 675 North St. Clair Street, Galter Suite 19-250, Chicago, Ill. 60611,

©2014American Society of Plastic Surgeons