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Common Comorbid Mental Health Diagnoses Lead To Longer Length Of Stay And Increased Cost In Oncologic Breast Reconstruction
Aaron L. Wiegmann, MD1, Syed I. Khalid, MD2, Thomas Q. Xu, MD1, Samantha L. Terranella, MD1, Michelle Seu, BA3, Anuja K. Antony, MD1.
1Rush University Medical Center, Department of Surgery, Division of Plastic & Reconstructive Surgery, Chicago, IL, USA, 2Rush University Medical Center, Department of Surgery, Chicago, IL, USA, 3Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA.

PURPOSE The U.S. population is significantly burdened by mental health comorbidities, with over seventeen million people having suffered from depression in 2017 and anxiety disorders affecting some forty million people annually. Depression has been linked to worse surgical outcomes, and is starting to show an association with increased post-operative complications in breast reconstruction. Many patients undergoing oncologic breast reconstruction suffer from depression and anxiety, however no study has evaluated if common comorbid mental health diagnoses are associated with longer and more expensive post-operative hospital stays.
METHODS The 2012-2015 National Inpatient Sample (NIS) was queried, with institutional IRB approval, for patients undergoing all types of oncologic breast reconstruction (Table 1). This population was then further analyzed to elucidate which patients had the comorbid diagnoses of anxiety, adult attention-deficit/hypersensitivity disorder (ADHD), depression, and bipolar disorder at the time of their reconstruction (Table 1). Means of total charges and length of stay were compared between patients with and without comorbid mental health diagnoses using t-tests. To control for diagnostic overlap, the control population had none of the studied comorbid diagnoses. The SURVEYMEANS procedure in SAS (SAS Institute Inc., USA) was used to account for the survey design when calculating variance for statistical tests.
RESULTS Length of stay and cost data are shown in Table 2. The average length of stay for all types of oncologic breast reconstruction in patients without mental health comorbidities was 2.69 days. Patients with anxiety, depression, and bipolar disorders had statistically significant increases in length of stay when compared to patients without mental health comorbidities. Mean length of stay in patients with ADHD was longer, but did not reach statistical significance when compared to patients without a mental health comorbidity. On average, patients with mental health comorbidities had higher breast reconstruction costs. However, in terms of total charges in U.S. Dollars, depression and anxiety were the only comorbidities to incur a statistically significant increase in total cost when compared to those patients without any mental health diagnoses.
CONCLUSIONS Patients undergoing oncologic breast reconstruction who suffer from anxiety and depression have significant increases in both length of stay and total cost of their surgical admission. This would suggest that these patients have more complicated post-operative courses requiring the expenditure of healthcare resources. Reconstructive surgeons should ensure that treatment of a patient's anxiety and/or depression is optimized prior to their breast reconstruction.

Table 1. Breast Reconstruction Procedures and Mental Health Diagnoses
ProcedureICD-9 Code
Total autologous reconstruction85.7
TRAM, pedicled85.72
Latissimus dorsi85.71
Perforator flap, free85.7
TRAM, free85.73
DIEP, free85.74
SIEA, free85.75
GAP, free85.76
Other total reconstruction85.79
Pedicled graft to breast85.85
Muscle graft to breast85.84
Tissue expander85.95
Bilateral implant85.35
Unilateral implant85.33
Mental Health DiagnosisICD-9 Code
Anxiety disorders293.84, 300.00, 300.01, 300.02, 300.09, 300.10, 300.20, 300.21, 300.22, 300.23, 300.29, 300.3, 300.5, 300.89, 300.9, 308.0, 308.1, 308.2, 308.3, 308.4, 308.9, 309.81, 313.0, 313.1, 313.21, 313.22, 313.3, 313.82, 313.83
Attention deficit disorder (ADD) and Attention deficit hyperactivity disorder (ADHD)314.00, 314.01, 314.1, 314.2, 314.8, 314.9
Bipolar disorders296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.10, 296.11, 296.12, 296.13, 296.14, 296.15, 296.16, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.81, 296.82, 296.89, 296.90, 296.99
Depressive disorders293.83, 296.20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.26, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35, 296.36, 300.4, 311.0

Table 2. Total Charges (US Dollars) and Length of Stay in Breast Reconstruction
Mental Health DiagnosisPatientsMean Total CostP-ValueMean Length of Stay (Days)P-Value
None24426$ 73,288.082.69
Anxiety3415$ 76,843.340.0011*2.98<0.0001*
ADD/ADHD167$ 74,235.690.79902.860.2759
Depression3286$ 77,042.650.0034*3.13<0.0001*
Bipolar270$ 76,902.030.36073.630.0016*
*Statistically significant finding

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