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Common Comorbid Chronic Pain Diagnoses Lead To Longer Length Of Stay, But Not Increased Cost, In Oncologic Breast Reconstruction
Aaron L. Wiegmann, MD1, Syed I. Khalid, MD2, Jennifer N. Akin, BS3, Samantha L. Terranella, MD1, Thomas Q. Xu, MD1, 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, 3Rush Medical College, Chicago, IL, USA.

PURPOSE - Roughly 28% of all cancer patients report chronic pain symptoms. Breast cancer is one of the most common cancers in the United States and an estimated 110,000 women undergo breast reconstruction each year bringing the total cost of breast cancer treatment to an estimated $16.5 billion annually. Chronic pain is also incredibly expensive with the total incremental health care costs due to chronic pain ranging from $261 to $300 billion each year. Our purpose was to evaluate if comorbid chronic pain diagnoses lead to increased length of stay and total cost in patients undergoing oncologic breast reconstruction.
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 back pain, chronic pain syndrome, fibromyalgia, migraine, and osteoarthritis at the time of their reconstruction (Table 1). Means of total charges and length of stay were compared between patients with and without chronic pain 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 chronic pain comorbidities was 2.73 days. Patients with back pain, chronic pain syndrome, fibromyalgia, and osteoarthritis had statistically significant increases in length of stay. Mean length of stay in patients with migraine was longer, but did not reach statistical significance when compared to patients without a pain diagnosis. However, in terms of total charges in U.S. Dollars, no comorbid chronic pain diagnosis group incurred a significantly different cost than those patients without any of the pain diagnoses.CONCLUSIONS - For operative admissions in patients undergoing oncologic breast reconstruction, patients with back pain, chronic pain syndrome, fibromyalgia, and osteoarthritis have longer hospital stays that do not lead to significantly increased total admission cost. These data would suggest that patients with chronic pain comorbidities are slower to leave the hospital after reconstruction, but do not undergo significantly increased diagnostic testing or complication managementórepresented by increased costówhen compared to the reconstructed population without chronic pain comorbidities.

Table 1: Reconstruction Procedure Types and Chronic Pain Diagnoses By ICD-9 Code
Procedure/DiagnosisICD-9 Code
Total autologous reconstruction​85.7
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
Chronic Pain Syndrome338.4
Migraine339.00, 339.01, 339.02, 339.03, 339.04, 346.00, 346.01, 346.02, 346.03, 346.10, 346.11, 346.12, 346.13, 346.20, 346.21, 346.22, 346.23, 346.30, 346.31, 346.32, 346.33, 346.40, 346.41, 346.42, 346.43, 346.50, 346.51, 346.52, 346.53, 346.70, 346.71, 346.72, 346.73, 346.80, 346.81, 346.82, 346.83, 346.90, 346.91, 346.92, 346.93
Osteoarthritis715.00, 715.04, 715.09, 715.10, 715.11, 715.12, 715.13, 715.14, 715.15, 715.16, 715.17, 715.18, 715.20, 715.21, 715.22, 715.23, 715.24, 715.25, 715.26, 715.27, 715.28, 715.30, 715.31, 715.32, 715.33, 715.34, 715.35, 715.36, 715.37, 715.38, 715.80, 715.89, 715.90, 715.91, 715.92, 715.93, 715.94, 715.95, 715.96, 715.97, 715.98, V13.4
Back pain721.0, 721.1, 721.2, 721.3, 721.41, 721.42, 721.5, 721.6, 721.7, 721.8, 721.90, 721.91, 722.0, 722.10, 722.11, 722.2, 722.30, 722.31, 722.32, 722.39, 722.4, 722.51, 722.52, 722.6, 722.70, 722.71, 722.72, 722.73, 722.80, 722.81, 722.82, 722.83, 722.90, 722.91, 722.92, 722.93, 724.02, 724.03, 724.2, 724.3
Fibromyalgia729.1

Table 2: Mean Charges and Length of Stay by Comorbid Chronic Pain Diagnosis
Total Charges (USD)Length of Stay (Days)
ConditionNMeanP-ValueNMeanP-Value
None27400$73,971.73278472.73
Back Pain535$74,741.090.76525623.210.0008
Fibromyalgia466$72,548.790.53614733.070.0009
Chronic Pain Syndrome48$84,845.850.1442504.420.0006
Osteoarthritis870$70,862.640.07168992.970.0291
Migraine1047$74,594.220.699610752.840.0674


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