Plastic Surgery Research Council

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Safety and Financial Outcomes of Breast Reduction Mammoplasty as an Inpatient or Outpatient Procedure: A Propensity-Score Matched Analysis of 18,780 Cases
Nicholas A. Calotta, MD1, David Merola, PharmD2, Devin O'Brien-Coon, MD, MSE1.
1Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2Harvard T.H. Chan School of Public Health, Bos, MA, USA.

Purpose
Breast reduction mammoplasty (BRM) is one of the most commonly performed plastic surgery procedures. Historically, patients were admitted as inpatients for post-operative monitoring; more recently, surgeons have increasingly utilized 23 hour observation or even true outpatient status for patients undergoing BRM. Despite this trend, nearly 20% of BRM operations are still performed with formal admission. We hypothesize that this practice confers no benefit in terms of safety outcomes and engenders a substantial financial burden for patients and the larger healthcare system.
Methods
We reviewed the Truven Health Analytics MarketScan Commercial Claims and Encounters database and identified patients using the Common Procedural Terminology (CPT) code for BRM. This allowed for the construction of three cohorts: inpatients, 23 hour observation, and outpatient; comparisons were made between inpatients and outpatients and observation patients and outpatients. Medical morbidities were identified using CPT codes. A propensity score match was utilized to balance covariates across the cohorts. The primary outcome variable was 14 day representation rate, either to the emergency department or admission to the hospital. Secondary outcomes include specific surgical complication rates. Financial data regarding net payments for the surgical encounter and gross payments to the surgical provider were collected.
Results
In the comparison of inpatient surgery to outpatient surgery, each cohort is composed of 1,237 patients (N = 2,474 total patients). The cohorts comparing 23 hour observational status with true outpatients included 8,153 patients each (N = 16,306 total patients). The distributions of Charlson comorbidity index, individual medical morbidities, and obesity were similar across all comparisons. In the comparison of inpatients and outpatients, the 14 day representation rate was 1.4% for inpatients and 0.3% for outpatients (p < 0.01). The overall surgical complication rate was significantly higher for inpatients (7.8%) than for outpatients (4.9%) (p < 0.01). With regard to outpatients compared to 23 hour observation patients, there was no significant difference in 14 day representation rates (0.5% observation versus 0.3% outpatient; p = 0.10). The overall complication rate was significantly higher for observation patients (4.8%) than outpatients (3.2%) (p < 0.01). When compared to outpatients (median cost $9,077), inpatient service (median cost $19,975) resulted in $10,898 more in services paid for. Similarly, observation services (median cost $12,451) generated $4,050 more in payments than outpatients (median cost $8,401) (p < 0.01). There was no difference in surgeon professional fee between the care settings.
Conclusions
Outpatient BRM is equivalent to post-operative observation or admission with regard to safety outcomes. Furthermore, avoiding observation or admission represents a potent opportunity to save thousands of dollars per patient. This data suggests that outpatient BRM represents the optimal balance of safety and cost effectiveness whereas observation services should be discouraged. Inpatient admission, though most expensive, may still be indicated in select, medically complex patients.


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