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Evaluation Of Never Events In A Breast Reconstructive Plastic Surgery Practice: Incidence, Risk Factors Predictive Of Occurrence, And Economic Cost Analysis
Oluwaseun A. Adetayo, MD, Samuel E. Salcedo, BA, Nataliya I. Biskup, MD, Subhas C. Gupta, MD, PhD.
Loma Linda University Medical Center, Loma Linda, CA, USA.
In 2002, the National Quality Forum (NQF) endorsed a list of serious reportable events (SRE) consisting of 28 events described under 6 categories. In October 2008, the Centers for Medicare and Medicaid Service (CMS) adapted a list of 10 hospital-acquired conditions (HAC), also referred to as “never events,” from the original NQF SRE list. The impetus for this act was based on the premise that these conditions are preventable, and as such, CMS currently does not reimburse physicians and hospitals when these events do occur. This study evaluates the incidence and categories of HAC occurring in the breast reconstruction population in a multi-surgeon plastic surgery practice starting from when CMS adopted its HAC list in 2008, until August 2010. In addition, a cost analysis of estimated revenue loss is generated for these events and risk factors that could predispose to the development of HAC are investigated.
A retrospective chart review of post-mastectomy breast cancer patients who underwent breast reconstruction from January 2008-August 2010 was conducted and 297 patients were identified. From this cohort, a list of patients with International Classification of Diseases (ICD) 9 codes corresponding to the CMS adapted HAC of interest was generated. Risk factors predisposing to the development of HAC, and associated cost analysis of these non-reimbursed HAC are presented. The HAC examined are vascular-catheter associated infections (VCAI), deep venous thrombosis (DVT)/ pulmonary embolism (PE), retained foreign body (RFB), catheter-related urinary tract infection (CR-UTI), postoperative hyperglycemia (PH), and surgical site infections (SSI).
Of the 297 patients who underwent post-mastectomy breast reconstruction, 24 (8.08%) developed HAC in 2 categories (SSI: 7.74%, CR-UTI: 0.34%). There were no complications in the remaining 8 categories, although non-HAC events of interest such as wound dehiscence (4.38%), flap necrosis (0.67%), and pneumothorax (0.67%) are noted. The following risk factors were studied to determine correlation with the development of HAC: age, ASA class, BMI, smoking, diabetes, chemotherapy, and radiation. There was a statistically significant difference with regards to diabetes (p=0.001) and BMI (p<0.0001) between patients who developed HAC when compared to patients without these events. Cost estimates and economic analysis of revenue loss in patients with HAC was $633,940. This does not include anesthesia fees or the cost of tissue expanders and implants.
The incidence of HAC in this series is 8.08%, the most common being SSI. Despite this relatively low incidence, the cost is high and will be even higher as anesthesia fees and cost of expanders and implant materials are taken into account. The “one-size-fits-all” approach of CMS, while well intended, may be misplaced and misleading. Awareness needs to be brought to the discussion forefront regarding the impact on patient care, health care, and hospital reimbursement. As quality improvement benchmarks continue to impose higher standards on medicine, these measures will become invaluable to practitioners and hospitals caring for such patients from a medical, financial and economic standpoint. The SRE and never events pendulum has swung immensely to the left and it is time to attain a much-needed equilibrium.
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