Discussion: A Critical Examination of Length of Stay in Autologous Breast Reconstruction: A National Surgical Quality Improvement Program Analysis.

From the Section of Plastic Surgery, University of Michigan; National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation; and the Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center. Received for publication May 6, 2020; accepted July 1, 2020. Copyright © 2020 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000007421 I this issue, Kotha et al. sought to perform a critical examination of length of stay following autologous breast reconstruction using administrative data from the National Surgical Quality Improvement Program.1 Between 2005 and 2017, the authors demonstrated that approximately 34 percent of patients were admitted for more than 5 days postoperatively following autologous breast reconstruction. In multivariable models adjusting for clinical characteristics, the authors also identified independent drivers of extended length of stay, which included body mass index, presence of diabetes, malignancy history, and operative time. As surgeons and hospitals face increasing pressure to improve health care value, investigations into drivers of resource use such as this one may provide key insights for operational strategies to reduce postoperative spending. Before considering the independent drivers of extended length of stay identified in this study, readers must first appreciate the major limitations of the National Surgical Quality Improvement Program to provide critical insights into this topic. As a retrospective cohort study intended to evaluate outcomes following general and vascular surgery procedures, the National Surgical Quality Improvement Program is inherently prone to errors and missing variables at both the hospital and patient levels that may be pertinent to autologous breast reconstruction.2,3 Most notably, the National Surgical Quality Improvement Program does not include hospital identifiers that allow researchers to adjust for annual case volume or other hospital characteristics known to be associated with extended length of stay. Several previous studies have shown that annual hospital case volume of autologous breast reconstruction is independently associated with extended length of stay, microvascular complications, and total complications.4–6 At the patient level, factors related to socioeconomic status play an important and underappreciated role in postoperative length of stay, yet these factors are also not available in the National Surgical Quality Improvement Program. These limitations are inherent in the program and must be considered by the reader when interpreting the study findings. Although administrative data from the National Surgical Quality Improvement Program may overcome the power and sample size limitations of single-center/single-surgeon studies, data availability is often delayed and may not reflect current practice patterns. It should be noted that this study does not appear to account for a recent surge in use of enhanced postoperative recovery protocols following autologous breast reconstruction. These standardized clinical pathways have been shown to reduce length of stay, decrease narcotic use, and reduce spending without increasing postoperative complication rates.7–10 The mean length of stay in this study by Kotha et al. was 4.3 days. In studies of enhanced recovery protocols, the mean length of stay tends to be between 3 and 4 days after autologous breast reconstruction.7–9 With the recent introduction of enhanced recovery protocols, it is not surprising that procedures from the final year of the study period (year 2017) were far less likely to have an extended length of stay (OR, 0.2; p = 0.02). However, without data after 2017, the generalizability of the authors’ predictive models Discussion: A Critical Examination of Length of Stay in Autologous Breast Reconstruction: A National Surgical Quality Improvement Program Analysis