The volume-outcome relationship for immediate breast reconstruction.

Background: Efforts to improve the quality of surgical care in the United States have led many organizations to advocate the use of high-volume hospitals for complex surgical procedures and/or comprehensive multidisciplinary care. The benefits, if any, of selective referral to high-volume hospitals for immediate breast reconstruction are relatively unknown. It is this gap in knowledge that forms the basis for the current study.

Methods: Using California's Office of Statewide Health Planning and Development discharge database, all patients undergoing immediate breast reconstruction from January 1, 1998, to December 31, 1999, were identified. Information regarding demographic, comorbidity, complication, and hospital volume characteristics was obtained. Patient comorbidity was graded using a modified version of the Charlson score. Annual hospital volume was categorized into patient quartiles. Multivariate logistic regression was performed to identify predictors of surgical complications.

Results: A total of 2691 patients were included: 1271 had immediate autogenous tissue reconstruction and 1420 had immediate tissue expander placement. The complication rate was 11.6 percent among patients undergoing autogenous reconstruction and 2.4 percent among patients receiving tissue expanders. For autogenous reconstruction, complications were more likely in patients with comorbidities (odds ratio, 2.24) and in patients receiving care at very-low-volume (less than eight) and medium-volume (20 to 41) hospitals (odds ratio,1.81 and 1.90, respectively). For tissue expander reconstruction, patient comorbidity (odds ratio, 2.42) was the only significant predictor of complications.

Conclusions: Hospital volume appears to be an important predictor of patient outcome with regard to autogenous reconstruction but not tissue expander reconstruction. Patient comorbidity predicts complications for both autogenous and tissue expander reconstruction.

Clinical Question/level Of Evidence: Risk, III.