BREAST Process Outcomes in Breast Reconstruction and the Impact of a Comprehensive Breast Center Albert H. Chao, Ibrahim Khansa, William B. Farrar, Michael J. Miller,
M.D. M.D. M.D. M.D.
Columbus, Ohio
Background: Processes outcomes for breast reconstruction (related to access, efficiency, and sustainability) have not been well described. These processes are likely to be impacted by the centralization of breast cancer care into comprehensive breast centers. The authors’ study objectives were to define measures for breast reconstruction processes of care and to determine a breast center’s effect on these measures. Methods: All patients evaluated for postmastectomy breast reconstruction between 2009 and 2013 (2 years before to 2 years after opening of the authors’ breast center) were reviewed. Consultation, surgical, and financial data were compared between the two periods. Results: A total of 614 (45.0 percent) and 750 patients (55.0 percent) were treated before and after, respectively, formation of the authors’ breast center. Between the two periods, the internal referral rate for postmastectomy reconstruction increased from 27.1 percent to 46.0 percent (p < 0.001). The delay between surgical oncology and plastic surgery consultation decreased from 10.5 days to 3.6 days (p < 0.001), as did the delay between plastic surgery consultation and surgery for both autologous (from 45.1 days to 32.6 days; p = 0.003) and implant-based reconstruction (from 34.9 days to 25.5 days; p = 0.004). The immediate breast reconstruction rate increased from 40.1 percent to 52.7 percent (p < 0.001), including autologous reconstruction (from 13.1 percent to 20.8 percent; p < 0.001). Conclusions: In breast reconstruction, a comprehensive breast center improves processes of care. The authors describe their strategy for integration of reconstructive surgery into a breast center. (Plast. Reconstr. Surg. 134: 675e, 2014.)
O
ver the past few decades, breast cancer care has experienced dramatic improvements. The disease is now largely survivable, in part because of earlier detection and multidisciplinary treatment approaches.1 Increased emphasis has also been placed on quality of life, which has been shown to be improved by undergoing breast reconstruction.2 A major process that has helped frame this evolution is the establishment of breast centers.3 The main concept of a breast center is that of a group of highly specialized practitioners dedicated to the care of breast cancer patients, usually based at the same physical location.4,5 The National Consortium of Breast Centers has defined the services that must be provided to qualify as a comprehensive breast From the Department of Plastic Surgery and the Department of Surgery, Division of Surgical Oncology, The Ohio State University. Received for publication February 23, 2014; accepted May 7, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000614
center6 (Table 1). Breast centers are accredited by the National Accreditation Program for Breast Centers, founded by the American College of Surgeons, which outlines 17 required components7 (Table 2). Plastic surgery represents one of several components required by both organizations. The stated goals of a breast center fall into two main categories3: 1. Improve patient care: By emphasizing early detection and expeditious treatment, breast centers can improve outcomes.8–11 Several studies in the surgical oncology literature have defined and examined pertinent outcome measures before and after opening of a breast center (e.g., access to screening mammography).12 Disclosure: The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for this work.
www.PRSJournal.com
675e
Plastic and Reconstructive Surgery • November 2014 2. Improve care delivery: By centralizing patient care in one physical location, coordination of multidisciplinary care is enhanced, which reduces fragmentation of care, with potential benefits to patients. For instance, the ability to perform a biopsy quickly after an abnormal mammogram in a breast center has been shown to reduce patient anxiety.3,8,13 A third goal is financial sustainability of a subspecialty within a breast center, which is essential to its viability.5 To our knowledge, there are no studies in plastic surgery examining the impact of a breast center on these aspects of breast reconstruction. Although surgical outcomes for breast reconstruction have been well defined and studied, processes outcomes (particularly those related to access, timeliness of treatment, and financial sustainability) have not. These are the outcomes most likely to be affected by integration of reconstructive Table 1. National Consortium of Breast Centers Comprehensive Breast Center Components* Outreach and education Imaging Needle biopsy Pathology Surgical care Plastic surgery Radiation therapy medical oncology Rehabilitation High-risk clinic Research *From the National Consortium of Breast Centers. Breast center types. Available at: http://www.breastcare.org/BCTypes/centertypes.html. Accessed February 9, 2014.
Table 2. National Accreditation Program for Breast Centers Breast Center Accreditation Components* Imaging Needle biopsy Pathology Interdisciplinary conference Patient navigation Genetic evaluation and management Surgical care Plastic surgery consultation/treatment Nursing Medical oncology consultation/treatment Radiation oncology consultation/treatment Data management Research Education, support, and rehabilitation Outreach and education Quality improvement Survivorship program *From the National Accreditation Program for Breast Centers. NAPBC components. Available at: http://napbc-breast.org/standards/standards.html. Accessed February 9, 2014.
676e
surgery into a comprehensive breast center. In 2011, a comprehensive breast center was formed at our institution, and it subsequently housed all breast cancer–related specialties, including reconstructive surgery. The purpose of this study was to evaluate the effect of our comprehensive breast center on process outcomes in breast reconstruction by comparing patients treated before and after its establishment. Access to breast reconstruction was evaluated by examining referral rates and postmastectomy immediate reconstruction rates. Quality of breast reconstruction was assessed by evaluating timeliness of both evaluation and treatment, and based on National Consortium of Breast Centers criteria. In addition, billing records were analyzed to determine the impact of a comprehensive breast center on the financial performance of breast reconstruction. Lastly, we propose our findings as metrics by which breast reconstruction programs may evaluate their own processes of care, and describe the strategy we used to improve these metrics at our institution.
PATIENTS AND METHODS After institutional review board approval, a retrospective analysis was performed of all patients who were evaluated for a newly diagnosed breast cancer and underwent mastectomy with or without immediate reconstruction at our institution between January of 2009 and January of 2013. Patients undergoing delayed reconstruction after mastectomy were also reviewed. The study period spans from 2 years before opening of our comprehensive breast center to 2 years after its opening. Patients who were treated before our comprehensive breast center opened were compared to patients who were treated after its establishment. Our comprehensive breast center is a standalone facility accredited by the National Accreditation Program for Breast Centers, and provides the following services: breast imaging, chemotherapy, genetic counseling, laboratory, medical oncology, nutrition, psychosocial, radiation oncology, reconstructive surgery, rehabilitation, surgical oncology, and survivorship. Measures analyzing access to care were rate of referral from surgical oncology to plastic surgery, and percentage of patients undergoing mastectomy who received immediate breast reconstruction. Measures used to evaluate quality of care were time from surgical oncology consultation to plastic surgery consultation, and time from plastic surgery consultation to surgery. In addition, based on National Consortium of Breast Centers criteria,
Volume 134, Number 5 • Process Outcomes in Breast Reconstruction outcome measures used to broadly examine quality of care were rates of total flap loss and tissue expander infection. Billing records were reviewed to determine hospital and surgeon revenues and net income from breast reconstruction. Revenues were defined as the amount of money collected for services rendered. Net incomes were obtained by subtracting the total cost from revenues. Revenues and net income were categorized into those collected by the medical center (hospital), and those collected by the surgeon (professional). Because of the proprietary nature of the financial information, only indices and percentages are reported, and exact dollar amounts are omitted. Chi-square analysis was used to perform comparisons between the two time periods, using p < 0.05 as a threshold for significance. All statistical tests were performed using the Minitab 16 statistical software (Minitab, Inc., State College, Pa.).
RESULTS Between January of 2009 and January of 2013, 1364 patients met inclusion criteria, of which 614 (45.0 percent) were treated before the formation of our comprehensive breast center and 750 (55.0 percent) were treated after its formation. Between the two study periods, the number of breast surgical oncologists decreased from seven to six, and the number of breast reconstructive surgeons was unchanged at five (although there was a change in one plastic surgeon). Accepted insurances (which includes governmental insurance) and block time did not change. Patient Volume When the two periods were compared, the number of surgical oncology consultations for patients with newly diagnosed breast cancer remained nearly the same (from 1303 to 1268, −2.7 percent), whereas the number of plastic surgery consultations for breast reconstruction increased by 66.0 percent (from 365 to 606). This included a 38.0 percent increase in consultations for immediate reconstruction (from 353 to 487) and an 892.7 percent increase in consultations for delayed reconstruction (from 12 to 119). Access to Care The referral rate of patients with newly diagnosed breast cancer by surgical oncology to plastic surgery increased from 27.1 percent to 46.0 percent between the two study periods (p < 0.001). The percentage of patients undergoing mastectomy who underwent immediate breast
reconstruction increased from 40.1 percent to 52.7 percent between the two study periods (p < 0.001). Before formation of our comprehensive breast center, 27.0 percent of patients underwent immediate implant-based reconstruction, 13.1 percent of patients underwent immediate autologous reconstruction, and 59.9 percent did not undergo immediate reconstruction. Following formation of our comprehensive breast center, 31.9 percent of patients underwent immediate implant-based reconstruction, 20.8 percent of patients underwent immediate autologous reconstruction, and 47.3 percent did not undergo immediate reconstruction. Before and after our comprehensive breast center, there were a total of 246 and 395 immediate breast reconstructions (p < 0.001), respectively. Quality of Care Between the two study periods, the time between surgical oncology consultation and plastic surgery consultation decreased from 10.5 days to 3.6 days (p
M.D. M.D. M.D. M.D.
Columbus, Ohio
Background: Processes outcomes for breast reconstruction (related to access, efficiency, and sustainability) have not been well described. These processes are likely to be impacted by the centralization of breast cancer care into comprehensive breast centers. The authors’ study objectives were to define measures for breast reconstruction processes of care and to determine a breast center’s effect on these measures. Methods: All patients evaluated for postmastectomy breast reconstruction between 2009 and 2013 (2 years before to 2 years after opening of the authors’ breast center) were reviewed. Consultation, surgical, and financial data were compared between the two periods. Results: A total of 614 (45.0 percent) and 750 patients (55.0 percent) were treated before and after, respectively, formation of the authors’ breast center. Between the two periods, the internal referral rate for postmastectomy reconstruction increased from 27.1 percent to 46.0 percent (p < 0.001). The delay between surgical oncology and plastic surgery consultation decreased from 10.5 days to 3.6 days (p < 0.001), as did the delay between plastic surgery consultation and surgery for both autologous (from 45.1 days to 32.6 days; p = 0.003) and implant-based reconstruction (from 34.9 days to 25.5 days; p = 0.004). The immediate breast reconstruction rate increased from 40.1 percent to 52.7 percent (p < 0.001), including autologous reconstruction (from 13.1 percent to 20.8 percent; p < 0.001). Conclusions: In breast reconstruction, a comprehensive breast center improves processes of care. The authors describe their strategy for integration of reconstructive surgery into a breast center. (Plast. Reconstr. Surg. 134: 675e, 2014.)
O
ver the past few decades, breast cancer care has experienced dramatic improvements. The disease is now largely survivable, in part because of earlier detection and multidisciplinary treatment approaches.1 Increased emphasis has also been placed on quality of life, which has been shown to be improved by undergoing breast reconstruction.2 A major process that has helped frame this evolution is the establishment of breast centers.3 The main concept of a breast center is that of a group of highly specialized practitioners dedicated to the care of breast cancer patients, usually based at the same physical location.4,5 The National Consortium of Breast Centers has defined the services that must be provided to qualify as a comprehensive breast From the Department of Plastic Surgery and the Department of Surgery, Division of Surgical Oncology, The Ohio State University. Received for publication February 23, 2014; accepted May 7, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000614
center6 (Table 1). Breast centers are accredited by the National Accreditation Program for Breast Centers, founded by the American College of Surgeons, which outlines 17 required components7 (Table 2). Plastic surgery represents one of several components required by both organizations. The stated goals of a breast center fall into two main categories3: 1. Improve patient care: By emphasizing early detection and expeditious treatment, breast centers can improve outcomes.8–11 Several studies in the surgical oncology literature have defined and examined pertinent outcome measures before and after opening of a breast center (e.g., access to screening mammography).12 Disclosure: The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for this work.
www.PRSJournal.com
675e
Plastic and Reconstructive Surgery • November 2014 2. Improve care delivery: By centralizing patient care in one physical location, coordination of multidisciplinary care is enhanced, which reduces fragmentation of care, with potential benefits to patients. For instance, the ability to perform a biopsy quickly after an abnormal mammogram in a breast center has been shown to reduce patient anxiety.3,8,13 A third goal is financial sustainability of a subspecialty within a breast center, which is essential to its viability.5 To our knowledge, there are no studies in plastic surgery examining the impact of a breast center on these aspects of breast reconstruction. Although surgical outcomes for breast reconstruction have been well defined and studied, processes outcomes (particularly those related to access, timeliness of treatment, and financial sustainability) have not. These are the outcomes most likely to be affected by integration of reconstructive Table 1. National Consortium of Breast Centers Comprehensive Breast Center Components* Outreach and education Imaging Needle biopsy Pathology Surgical care Plastic surgery Radiation therapy medical oncology Rehabilitation High-risk clinic Research *From the National Consortium of Breast Centers. Breast center types. Available at: http://www.breastcare.org/BCTypes/centertypes.html. Accessed February 9, 2014.
Table 2. National Accreditation Program for Breast Centers Breast Center Accreditation Components* Imaging Needle biopsy Pathology Interdisciplinary conference Patient navigation Genetic evaluation and management Surgical care Plastic surgery consultation/treatment Nursing Medical oncology consultation/treatment Radiation oncology consultation/treatment Data management Research Education, support, and rehabilitation Outreach and education Quality improvement Survivorship program *From the National Accreditation Program for Breast Centers. NAPBC components. Available at: http://napbc-breast.org/standards/standards.html. Accessed February 9, 2014.
676e
surgery into a comprehensive breast center. In 2011, a comprehensive breast center was formed at our institution, and it subsequently housed all breast cancer–related specialties, including reconstructive surgery. The purpose of this study was to evaluate the effect of our comprehensive breast center on process outcomes in breast reconstruction by comparing patients treated before and after its establishment. Access to breast reconstruction was evaluated by examining referral rates and postmastectomy immediate reconstruction rates. Quality of breast reconstruction was assessed by evaluating timeliness of both evaluation and treatment, and based on National Consortium of Breast Centers criteria. In addition, billing records were analyzed to determine the impact of a comprehensive breast center on the financial performance of breast reconstruction. Lastly, we propose our findings as metrics by which breast reconstruction programs may evaluate their own processes of care, and describe the strategy we used to improve these metrics at our institution.
PATIENTS AND METHODS After institutional review board approval, a retrospective analysis was performed of all patients who were evaluated for a newly diagnosed breast cancer and underwent mastectomy with or without immediate reconstruction at our institution between January of 2009 and January of 2013. Patients undergoing delayed reconstruction after mastectomy were also reviewed. The study period spans from 2 years before opening of our comprehensive breast center to 2 years after its opening. Patients who were treated before our comprehensive breast center opened were compared to patients who were treated after its establishment. Our comprehensive breast center is a standalone facility accredited by the National Accreditation Program for Breast Centers, and provides the following services: breast imaging, chemotherapy, genetic counseling, laboratory, medical oncology, nutrition, psychosocial, radiation oncology, reconstructive surgery, rehabilitation, surgical oncology, and survivorship. Measures analyzing access to care were rate of referral from surgical oncology to plastic surgery, and percentage of patients undergoing mastectomy who received immediate breast reconstruction. Measures used to evaluate quality of care were time from surgical oncology consultation to plastic surgery consultation, and time from plastic surgery consultation to surgery. In addition, based on National Consortium of Breast Centers criteria,
Volume 134, Number 5 • Process Outcomes in Breast Reconstruction outcome measures used to broadly examine quality of care were rates of total flap loss and tissue expander infection. Billing records were reviewed to determine hospital and surgeon revenues and net income from breast reconstruction. Revenues were defined as the amount of money collected for services rendered. Net incomes were obtained by subtracting the total cost from revenues. Revenues and net income were categorized into those collected by the medical center (hospital), and those collected by the surgeon (professional). Because of the proprietary nature of the financial information, only indices and percentages are reported, and exact dollar amounts are omitted. Chi-square analysis was used to perform comparisons between the two time periods, using p < 0.05 as a threshold for significance. All statistical tests were performed using the Minitab 16 statistical software (Minitab, Inc., State College, Pa.).
RESULTS Between January of 2009 and January of 2013, 1364 patients met inclusion criteria, of which 614 (45.0 percent) were treated before the formation of our comprehensive breast center and 750 (55.0 percent) were treated after its formation. Between the two study periods, the number of breast surgical oncologists decreased from seven to six, and the number of breast reconstructive surgeons was unchanged at five (although there was a change in one plastic surgeon). Accepted insurances (which includes governmental insurance) and block time did not change. Patient Volume When the two periods were compared, the number of surgical oncology consultations for patients with newly diagnosed breast cancer remained nearly the same (from 1303 to 1268, −2.7 percent), whereas the number of plastic surgery consultations for breast reconstruction increased by 66.0 percent (from 365 to 606). This included a 38.0 percent increase in consultations for immediate reconstruction (from 353 to 487) and an 892.7 percent increase in consultations for delayed reconstruction (from 12 to 119). Access to Care The referral rate of patients with newly diagnosed breast cancer by surgical oncology to plastic surgery increased from 27.1 percent to 46.0 percent between the two study periods (p < 0.001). The percentage of patients undergoing mastectomy who underwent immediate breast
reconstruction increased from 40.1 percent to 52.7 percent between the two study periods (p < 0.001). Before formation of our comprehensive breast center, 27.0 percent of patients underwent immediate implant-based reconstruction, 13.1 percent of patients underwent immediate autologous reconstruction, and 59.9 percent did not undergo immediate reconstruction. Following formation of our comprehensive breast center, 31.9 percent of patients underwent immediate implant-based reconstruction, 20.8 percent of patients underwent immediate autologous reconstruction, and 47.3 percent did not undergo immediate reconstruction. Before and after our comprehensive breast center, there were a total of 246 and 395 immediate breast reconstructions (p < 0.001), respectively. Quality of Care Between the two study periods, the time between surgical oncology consultation and plastic surgery consultation decreased from 10.5 days to 3.6 days (p
