A nationwide analysis of the relationship between hospital volume and outcome for autologous breast reconstruction.

BACKGROUND

The volume-outcome relationship has not been specifically measured for U.S. autologous breast reconstruction. The authors studied whether there is a relationship between hospital procedural volume and perioperative complication rates.

METHODS

The authors identified (1) patients who underwent total mastectomy with immediate autologous reconstruction from 1998 to 2010 and (2) a subset of microsurgical cases from 2008 to 2010. Hospitals were categorized into quartiles based on number of yearly procedures. Outcomes included surgery-specific and systemic complications. A multivariable model was used to analyze the volume-outcome relationship after adjusting for other variables.

RESULTS

Over the 13-year study period, 21,016 immediate autologous reconstructions were recorded. Surgery-specific and systemic complication rates were 13.0 and 7.5 percent, respectively. Ninety-two percent of centers perform a very low (fewer than nine cases per year) or low (nine to 20 cases per year) number of procedures. The highest-volume centers (>44 cases per year) are located in metropolitan areas. An inverse relationship between reconstructive volume and surgery-specific and systemic complications was identified (p<0.01). In the multivariable analysis, centers with very low, low, and medium case volumes were more likely to have surgery-specific complications than high-volume centers (p<0.01). Very-low-volume compared with high-volume centers were more likely to have systemic complications (p<0.01).

CONCLUSIONS

Higher volume autologous breast reconstruction centers have lower complication rates. The volume-outcome relationship is stronger for surgery-specific than for systemic complications. Geographic disparities are present in the distribution of high-volume centers. Such information can be used to inform best practices and improve access to care.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.