Analysis of risk factors associated with unplanned reoperations following pediatric plastic surgery

Accepted Manuscript Analysis of Risk Factors Associated with Unplanned Re-Operations following Pediatric Plastic Surgery Kevin T. Jubbal, BS, Dmitry Zavlin, MD, Edward P. Buchanan, MD, Larry H. Hollier, Jr., MD, FACS PII:

S1748-6815(17)30180-8

DOI:

10.1016/j.bjps.2017.05.008

Reference:

PRAS 5306

To appear in:

Journal of Plastic, Reconstructive & Aesthetic Surgery

Received Date: 21 November 2016 Revised Date:

24 February 2017

Accepted Date: 9 May 2017

Please cite this article as: Jubbal KT, Zavlin D, Buchanan EP, Hollier Jr. LH, Analysis of Risk Factors Associated with Unplanned Re-Operations following Pediatric Plastic Surgery, British Journal of Plastic Surgery (2017), doi: 10.1016/j.bjps.2017.05.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Title: Analysis of Risk Factors Associated with Unplanned Re-Operations following Pediatric Plastic Surgery

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Short Title: Unplanned Re-Operation in Pediatric Plastic Surgery

Authors:

Kevin T. Jubbal, BS1; Dmitry Zavlin, MD2; Edward P. Buchanan, MD3; Larry H. Hollier, Jr., MD,

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FACS3

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Affiliation: 1

University of California, San Diego School of Medicine. La Jolla, CA

2

Houston Methodist Hospital. Houston, TX

3

Baylor College of Medicine. Houston, TX

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Corresponding Author: Larry H. Hollier, Jr., MD. FACS 6701 Fannin St. Suite 610.00 Houston, TX. 77030

Fax: 832-825-3192

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[email protected]

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Phone: 832-822-3190

Keywords:

Re-operation, pediatric, plastic surgery, outcomes

Conflicts of Interest/Financial Disclosures: None

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Abstract: Background/Purpose

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Unplanned re-operation (UR) is an outcome measure with multiple advantages that can be used as a standardized tool to assess an institution’s quality and safety of medical care. The goal of our study was to identify parameters associated with an increased likelihood of UR

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following plastic surgery in patients less than eighteen years of age using a large validated

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national multi-center database.

Methods/Description

We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database between years 2012 and 2014 to

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identify pediatric patients undergoing primary plastic surgery procedures. Two cohorts were compared: patients who experienced UR and those who did not. Multiple logistic regression

Results

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analysis was utilized to identify independent risk factors associated with UR.

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A total of 18,106 patients were identified in this analysis, with an overall UR rate of 0.8% (n = 137) within 30 days after surgery. Patients were on average 5.59 ± 5.27 years of age with 9,522 boys (52.6%) and 8,584 girls (47.4%). The procedures most commonly associated with UR were excision of skin and subcutaneous tissue for hiradenitis (UR = 10.3%), forehead and/or supraorbital rim reconstruction with grafts (allograft or prosthetic material, UR = 6.1%), use of multiplane external fixators (UR = 5.6%), mastectomy for gynecomastia (UR = 4.4%), and

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forehead and/or supraorbital rim reconstruction with autograft (3.3%). The average number of relative value units per case was 10.01 ± 7.91. Independent risk factors for UR include inpatient

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procedure (p < 0.001), ASA class 3 or higher (p = 0.03), prolonged operative time (p < 0.001), and prior open wound or wound infection (p = 0.05). The most significant predictors of UR were

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postoperative medical and surgical complications (OR, 18.92 and 39.98, respectively, p < 0.001).

Conclusions

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With increasing focus on outcomes-driven healthcare, unplanned reoperation may be useful for monitoring quality across hospitals and identifying opportunities for quality improvement. This study provides the first analysis of risk factors associated with 30-day unplanned reoperations in pediatric plastic surgery. These results may aid in the informed consent process, improve

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patient risk assessment, counseling, and surgical planning.

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Introduction: Unplanned re-operation (UR) is an outcome measure with multiple advantages and can be used as a standardized tool to assess an institution’s quality and safety of medical care.1,2 By its

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nature, UR is associated with readmission, which is a metric utilized to assess hospital safety.3,4 Across the world, UR has demonstrated association with increased burden on the healthcare

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system, resulting in increased resource utilization, longer hospital stays, and higher costs.5-7

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The literature has previously explored predictors for re-operations in adults and re-admissions in children after plastic surgery.8,9 However, there is a void with regards to UR after pediatric plastic surgery operations. Due to the detrimental effects of UR on patient safety and outcomes, it is imperative to identify pediatric patients at higher risk of UR in order to optimize

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clinical decision-making and outcomes.

The goal of this study was to identify parameters associated with an increased likelihood of UR

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following plastic surgery in patients less than eighteen years of age. The validated American College of Surgeons’ National Surgical Quality Improvement Program Pediatric (ACS NSQIP

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Pediatric) database was utilized. These findings will assist medical professionals to improve patient care, identify those at increased risk of UR, and decrease resource utilization in our healthcare sector.

Methods: Data Source

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The American College of Surgeons National Surgical Quality Improvement Program pediatric website (http://www.acsnsqip.org/) provided the patient data from 2012 through 2014. The

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database is updated prospectively on a regular basis from U.S. institutions that participate in this program. Specialist nurse reviewers, termed surgical clinical reviewers, accumulate data as each patient progresses from preoperative, intraoperative, and postoperative phases of surgical

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treatment. Surgical clinical reviewers undergo comprehensive training and NSQIP conducts inter-rater reliability audits to ensure data quality and reliability. Patient demographics, pre-

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operative comorbidities, information about the operative procedures, and mortality/morbidity outcomes within a 30-day post-operative timeframe are included. No patient or center identifiers are included in the database. Additional details for data collection methods are available through the program.10 The institutional review board of our hospital approved our

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study. The authors of this report adhered to the Declaration of Helsinki at all times. Patient information is de-identified in accordance with the United States Health Insurance Portability

Patient Selection

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and Accountability Act of 1996 (HIPAA).

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Children who received primary pediatric plastic surgery between 2012 and 2014 were included in our retrospective database review. Patients were subdivided into two cohorts based on UR. UR was defined as any unplanned return to the operating room within 30 days postoperatively, regardless of whether the patient was discharged home or remained an inpatient during this period10.

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Variables Variables and their definitions can be found at the program’s website

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(http://www.pediatric.acsnsqip.org/). Composite variables were created to assist with analysis of comorbidities on reoperation. Respiratory history included ventilator use, pneumonia,

asthma, cystic fibrosis, history of chronic lung disease, oxygen supplementation, tracheostomy,

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and structural pulmonary abnormality. Gastrointestinal history included

esophageal/gastric/intestinal disease or liver/biliary/pancreatic disease. Cardiac history

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included history of cardiac disease or previous cardiac surgery. Genitourinary history included history of renal failure or dialysis. Neurologic history included coma, cerebrovascular accident, tumor, impaired cognitive status, seizure, cerebral palsy, neuromuscular disorder, or structural central nervous system abnormality. Immune history included organ transplant, bone marrow

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transplant, steroid use, or immune disorder. Nutritional history included history of weight loss, diabetes, or nutritional support. Hematologic history included bleeding disorder or hematologic disorder. Cancer history included history of chemotherapy, radiation therapy, current cancer, or

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history of cancer.

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Postoperative outcomes were divided into surgical and medical complications. Surgical complications were defined as wound complication or infection, occurrence of bleeding/transfusion, and prosthetic, allogeneic, or autologous graft/implant failure. Medical complications encompassed respiratory, genitourinary, and central nervous system endpoints in addition to sepsis, bloodstream infections, and cardiac arrest. Unplanned reoperation rates were calculated for procedures with one or more unplanned reoperations.

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Statistical Analysis

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The authors calculated descriptive statistics, as well as complication profiles, of the study participants. Univariate analysis compared the two cohorts with perioperative risk factors and patient comorbidities. For all tests, the statistical level of significance was set at 5% (p < 0.05)

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using the unpaired sample t-test for continuous and the chi-square test for categorical

variables. All factors with p values less than 0.10, in addition to clinically pertinent factors, were

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gathered for a multivariate logistical regression analysis in order to control for confounders and to determine the effect of co-morbidities on UR. Analyses were conducted using SPSS version 24.0 (IBM Corp., Armonk, N.Y.).

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Results:

A total of 18,110 patients were operated on between the years of 2012 and 2014 in the pediatric American College of Surgeons National Surgical Quality Improvement Program

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database. Four patients were excluded for death within 30 days after surgery, resulting in a total of 18,106 used in this analysis. The overall unexpected reoperation rate was 0.8% (n =

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137) within 30 days after surgery. Of these, 109 (79.6%) were deemed related to the principal operative procedure or concurrent procedure performed under the same anesthesia as the principal procedure. Patients were stratified by the procedures by CPT code with the highest reoperation rates (Table 1). These procedures included skin and subcutaneous tissue excision for hidradenitis, forehead and/or supraorbital rim reconstruction with grafts (allograft or

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prosthetic material), multiplane external fixator use, mastectomy with gynecomastia, and

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forehead and/or supraorbital rim reconstruction with autograft.

The cohort was on average 5.59 ± 5.27 years of age with 9,522 boys (52.6%) and 8,584 girls (47.4%). Demographic characteristics, intraoperative factors, and comorbidities stratified by

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reoperation are displayed in Tables 2 and 3. Patients in the UR cohort were more likely to have comorbidities as follows: respiratory history, gastrointestinal cardiac history, central nervous

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system (CNS) history, immunologic history, nutritional history, and hematologic history. They were also more likely to have a congenital malformation. There was no statistically significant difference between the groups with regards to age, BMI, gender, race, or previous operations within 30 days. The distribution of procedure type varied between the two cohorts, with

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greatest differences in musculoskeletal, integumentary, and nervous system procedure types. The UR cohort consisted of a greater proportion of American Society of Anesthesiologists (ASA) class 3, inpatient procedures, surgical complications, medical complications, and a higher

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average relative value units (RVU). RVU are a measurement of value used in the United States medical reimbursement formula and have been used as a surrogate marker for operation

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complexity.11

Regression analysis of preoperative, intraoperative, and postoperative factors demonstrated the following factors as significantly associated with UR: inpatient procedures, ASA class of 3 or higher, operative time, and prior open wound or wound infection (Table 4). Congenital

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malformations were associated with a lower rate of UR. UR was also strongly associated with

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surgical complications and medical complications (Table 5).

Discussion:

This study provides the first critical analysis of risk factors for 30-day UR in pediatric plastic

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surgery and identifies factors that can be used to create risk-reduction measures to improve care to this patient population. In our multi-institutional analysis with 18,106 patients, the

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overall UR rate for pediatric plastic surgery operations was 0.8%, lower than other figures reported in prior studies. In the pediatric literature, Madsen et al. reported a re-operation rate of 5.6% in cleft palate repairs during humanitarian missions.12 Lim et al. explored reoperations restricted to adult outpatient procedures in plastic surgery, resulting in a UR rate of 1.9%.8 Byrd

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et al., examining reoperation rates in healthy adult patients undergoing cosmetic surgery, demonstrated a low UR rate of 0.7%, which is reflective of the lower risk in this patient population and procedure types.13 The UR rate in our study of 0.8% remains lower than rates in

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other pediatric specialties (3.5 – 17.0%).4,12,14-22 However, it is important to note that this analysis evaluated early UR rates within 30 days, whereas other studies utilized variable lengths

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of follow-up. Additionally, is important to note that the UR rate is dependent on the procedure type, emphasized elsewhere15,22 and illustrated in Table 1. Palatoplasty for cleft palate and repair of cleft lip/nasal deformity both resulted in comparatively lower rates of UR (0.7%), whereas craniosynostosis reconstruction procedures demonstrated relatively higher rates (2.0, 2.4%).

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Our analysis identifies multiple risk factors associated with UR, including inpatient procedures, ASA class of 3 or higher, prolonged operative time, and prior open wound or wound infection.

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Additionally, patients who experienced surgical or medical postoperative complications, not surprisingly, are also significantly more likely to require UR. These perioperative factors

intuitively make sense, as more complex patients would be more likely to require UR. Inpatient

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procedures, higher ASA class, prior open wound or wound infection, and prolonged operative time can be considered surrogate markers for case complexity. These findings are consistent

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with prior findings in the pediatric literature.14,21 Across different specialties, various risk factors have been identified as associated with UR, including procedures involving the CSF, emergency cases, inpatient procedures, higher ASA classes, preexisting comorbidities, longer operative times, more complex surgeries, deep wound infections, malformations, prematurity, and case

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volume of the operating surgeon and hospital.4,14-18,20,21,23 It has been demonstrated in the adult plastic surgery literature and elsewhere that increasing RVU is correlated with overall complications and surgical site complications.24,25 However, our analysis demonstrated no

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significant association of work RVU with rates of UR. Interestingly, congenital malformation was associated with lower rates of unplanned reoperation. This may be due to procedure type

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performed on these patients, more careful preoperative optimization, or closer intraoperative monitoring.

Not surprisingly, the factors with the strongest associations with UR were surgical complications and medical complications with adjusted OR of 39.98 and 18.92, respectively. These postoperative complications trump procedure type or complexity as predictive factors

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for UR. However, in the pediatric literature, specific comorbidities and procedure types were found to have the largest association with UR. Mukerji et al. reported CSF diversion as a strong factor (Odds ratio (OR) = 7.08), with urgency and emergency also reaching significance (OR =

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2.49 and 2.28, respectively).4 Pugely et al. reported that a history of hepatobiliary disease

carried the highest odds ratio (OR = 7.50), as did impaired cognitive status (OR = 1.79), ASA

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class 3 (OR = 2.73), ASA class 4 (OR = 4.08), and prolonged operative time (OR = 1.002).14 In spinal surgery, Jain et al. reported a history of genetic and syndromic scoliosis as associated

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with UR (OR = 10.00), in addition to cerebral palsy, neuromuscular disorders, congenital scoliosis, and Scheuermann kphyosis.15 Interestingly, Lu et al. found that surgeon caseload was a strong inverse predictor of UR in urologic hypospadias surgery (OR = 0.04) as was the type of hypospadias (OR = 3.97).8 Our analysis did not demonstrate statistical significance by procedure

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type. This divergence in results between our study and the pediatric literature is due to inherent differences in study approach. The broad nature of our analysis necessitate grouping of procedures by broad categories (Table 2), whereas the prior studies cited differentiated

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between specific approaches to treat similar pathologies. Additionally, given the nature of the NSQIP database, we were unable to assess the influence of case load or institutional

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differences.

Our study is the first multi-center analysis examining the risks associated with UR in pediatric plastic surgery. However, this analysis is not without limitations. By its nature, the NSQIP database is multi-centric and dependent on the input of many healthcare institutions, its quality and integrity is therefore dependent on several inputs. As a result, our results may not

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directly apply to all settings, so great attention must be paid to see how a local and small patient group can be evaluated based on this nation-wide data. In addition, the NSQIP database

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tracks outcomes data for up to 30 days postoperatively, restricting our ability to analyze longterm complications and late surgical revisions and artificially deflating UR rates. Furthermore, our analysis is based on variables included in the database, preventing exploration of additional

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relevant variables. The findings presented in this retrospective analysis have an associative character and the risk factors identified cannot be deemed causative. Prospective clinical trials

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remain necessary to definitely demonstrate cause and effect relationship for specific hypotheses. Lastly, information on hospital teaching status is not included in the database, thus we were unable to control for hospital-level effects. This may introduce a bias due to

Conclusion:

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differences in case mix at various institutions.

With increasing focus on outcomes-driven healthcare, unplanned reoperation is a standardized

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tool to assess healthcare quality. This study provides the first analysis of risk factors associated with 30-day unplanned reoperations in pediatric plastic surgery and identifies risk factors and

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variables which may be used to implement risk-reducing policies to improve surgical care to pediatric plastic surgery patients. Factors which were independently associated with increased rates of UR included inpatient procedures, ASA class of 3 or higher, prior open wound or wound infection, and prolonged operative time. Additionally, medical and surgical complications were the strongest predictors of UR.

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Disclosure American College of Surgeons National Surgical Quality Improvement Program and the

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hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions

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derived by the authors.

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References: 1.

Kroon HM, Breslau PJ, Lardenoye JWHP. Can the Incidence of Unplanned Reoperations

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Be Used as an Indicator of Quality of Care in Surgery? American Journal of Medical Quality. 2007;22(3):198-202. 2.

McSorley S, Lowndes C, Sharma P, Macdonald A. Unplanned reoperation within 30 days

3.

SC

of surgery for colorectal cancer in NHS Lanarkshire. Colorectal Dis. 2013;15(6):689-694. Patient Protection and Affordable Care Act, HR 3590, 111th Cong (2009–2010).

Accessed 08/28/2016. 4.

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http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf.

Mukerji N, Jenkins A, Nicholson C, Mitchell P. Unplanned reoperation rates in pediatric neurosurgery: a single center experience and proposed use as a quality indicator.

5.

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Journal of neurosurgery Pediatrics. 2012;9(6):665-669.

Froschl U, Sengstbratl M, Huber J, Fugger R. Unplanned reoperations for infection complications: a survey for quality control. Surg Infect (Larchmt). 2006;7(3):263-268. Palmer SJ, Parker MJ, Hollingworth W. The cost and implications of reoperation after

EP

6.

surgery for fracture of the hip. The Journal of bone and joint surgery British volume.

7.

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2000;82(6):864-866.

Birkmeyer JD, Hamby LS, Birkmeyer CM, Decker MV, Karon NM, Dow RW. Is unplanned return to the operating room a useful quality indicator in general surgery? Arch Surg. 2001;136(4):405-411.

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8.

Lim S, Jordan SW, Jain U, Kim JY. Predictors and causes of unplanned re-operations in outpatient plastic surgery: a multi-institutional analysis of 6749 patients using the 2011

9.

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NSQIP database. J Plast Surg Hand Surg. 2014;48(4):270-275. Tahiri Y, Fischer JP, Wink JD, et al. Analysis of risk factors associated with 30-day

and reconstructive surgery. 2015;135(2):521-529. 10.

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readmissions following pediatric plastic surgery: a review of 5376 procedures. Plastic

American College of Surgeons. User Guide for the 2014 ACS NSQIP Pediatric. 2015;

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https://www.facs.org/~/media/files/quality

programs/nsqip/peds_acs_nsqip_puf_userguide_2014.ashx. Accessed 08/25/2016. 11.

Baadh A, Peterkin Y, Wegener M, Flug J, Katz D, Hoffmann JC. The Relative Value Unit: History, Current Use, and Controversies. Curr Probl Diagn Radiol. 2016;45(2):128-132. Madsen C, Lough D, Lim A, Harshbarger RJ, 3rd, Kumar AR. Cleft and Craniofacial Care

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12.

During Military Pediatric Plastic Surgery Humanitarian Missions. The Journal of craniofacial surgery. 2015;26(4):1097-1101. Byrd HS, Barton FE, Orenstein HH, et al. Safety and efficacy in an accredited outpatient

EP

13.

plastic surgery facility: a review of 5316 consecutive cases. Plastic and reconstructive

14.

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surgery. 2003;112(2):636-641; discussion 642-636.

Pugely AJ, Martin CT, Gao Y, Ilgenfritz R, Weinstein SL. The incidence and risk factors for short-term morbidity and mortality in pediatric deformity spinal surgery: an analysis of

the NSQIP pediatric database. Spine. 2014;39(15):1225-1234. 15.

Jain A, Puvanesarajah V, Menga EN, Sponseller PD. Unplanned Hospital Readmissions and Reoperations After Pediatric Spinal Fusion Surgery. Spine. 2015;40(11):856-862.

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16.

Mazur MD, Sivakumar W, Riva-Cambrin J, Jones J, Brockmeyer DL. Avoiding early complications and reoperation during occipitocervical fusion in pediatric patients.

17.

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Journal of Neurosurgery: Pediatrics. 2014;14(5):465-475. Zhang Q, Chen Y, Hou D, Guo W. Analysis of Postoperative Reoperation for Congenital Duodenal Obstruction. Asian Journal of Surgery. 2005;28(1):38-40.

Raitio A, Green PA, Fawkner-Corbett DW, Wilkinson DJ, Baillie CT. Malrotation: Age-

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18.

Related Differences in Reoperation Rate. Eur J Pediatr Surg. 2016;26(01):034-037. Koivusalo AI, Pakarinen MP, Lindahl HG, Rintala RJ. Revisional surgery for recurrent

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19.

tracheoesophageal fistula and anastomotic complications after repair of esophageal atresia in 258 infants. Journal of pediatric surgery. 2015;50(2):250-254. 20.

Lu YC, Huang WY, Chen YF, et al. Factors associated with reoperation in hypospadias

Association. 2016. 21.

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surgery - A nationwide, population-based study. Asian journal of surgery / Asian Surgical

Phan J, Stanford S, Zaritsky JJ, DeUgarte DA. Risk factors for morbidity and mortality in

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pediatric patients with peritoneal dialysis catheters. Journal of pediatric surgery. 2013;48(1):197-202.

Fiorentino F, Stickley J, Dorobantu D, et al. Early Reoperations in a 5-Year National

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22.

Cohort of Pediatric Patients With Congenital Heart Disease. The Annals of thoracic surgery. 2016;101(4):1522-1529.

23.

Nandipati K, Lin E, Husain F, et al. Factors predicting the increased risk for return to the operating room in bariatric patients: a NSQIP database study. Surg Endosc. 2013;27(4):1172-1177.

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24.

Nguyen KT, Gart MS, Smetona JT, Aggarwal A, Bilimoria KY, Kim JY. The relationship between relative value units and outcomes: a multivariate analysis of plastic surgery

Davenport DL, Henderson WG, Khuri SF, Mentzer RM, Jr. Preoperative risk factors and surgical complexity are more predictive of costs than postoperative complications: a

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case study using the National Surgical Quality Improvement Program (NSQIP) database.

EP

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Ann Surg. 2005;242(4):463-468; discussion 468-471.

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25.

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procedures. Eplasty. 2012;12:e60.

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Table 1. UR Rates by CPT Code for Top Five Most Common UR CPT Code

No. of UR

Procedure

Reoperation

11450

3

Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair

21179

2

Reconstruction, entire or majority of forehead and/or supraorbital

2

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rims; with grafts (allograft or prosthetic material) 20692

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Rate (%)

Application of a multiplane (pins or wires in more than 1 plane),

10.3

6.1

5.6

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unilateral, external fixation system (eg, Ilizarov, Monticelli type) 19300

6

Mastectomy for gynecomastia

4.4

21180

2

Reconstruction, entire or majority of forehead and/or supraorbital

3.3

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rims; with autograft (includes obtaining grafts)

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Table 2. Comparison of demographics and intraoperative factors

n (17,969) 5.6 ± 5.3

BMI kg/m2 (mean ± SD)

18.4 ± 4.5

Total operative time, minutes (mean ± SD)

90.7 ± 81.4

Work RVU (mean ± SD)

10.0 ± 7.9

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P value

n (137)

5.2 ± 5.3

0.36

18.8 ± 6.0

0.32

175.5 ± 134.5

<0.001*

14.5 ± 9.8

<0.001*

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Age, years (mean ± SD)

Yes

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No

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Unplanned Reoperation

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Table 3. Comparison of demographics, comorbidities, and intraoperative factors Total cases

Unplanned

Percent

N = 18,106

reoperation

(%)

P value

Sex

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n = 137 0.81

9,522

74

Female

8,584

63

Race 12,435

African American

1,715

0.8 0.7

0.54

90

0.7

19

1.1

1,169

9

0.8

52

0

0.0

83

0

0.0

2,652

19

0.7

7,150

39

0.5

0.01*

1,849

23

1.2

0.01*

824

5

0.6

0.61

7,373

52

0.7

0.51

16

0

0.0

0.73

Urinary

12

0

0.0

0.76

Nervous System

588

16

2.7

<0.001*

Auditory

294

2

0.7

0.88

Respiratory history

1,749

27

1.5

<0.001*

Gastrointestinal history

1,151

15

1.3

0.02*

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White

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Male

Asian Pacific Islander Native American

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Not available Type of procedure Integumentary

Respiratory Digestive

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Male genital

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Musculoskeletal

Comorbidities

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21

1.8

<0.001*

GU history

2

0

0.0

0.90

CNS history

2,228

35

1.6

<0.001*

Immunologic history

159

4

2.5

0.01*

Nutritional history

585

15

Hematologic history

156

5

Cancer history

92

2

9,299

Congenital malformation Prior operation within 30 days

28

Clean Clean-contaminated Contaminated

Class 2 Class 3 Class 4

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Class 5

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Class 1

<0.001*

3.2

<0.001*

2.2

0.12

88

0.9

0.01*

0

0.0

0.63 0.89

9,722

72

0.7

8,211

64

0.8

101

1

1.0

61

0

0.0

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Infected ASA Class

2.6

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Wound class

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1,163

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Cardiac history

<0.001*

8,400

33

0.4

8,091

68

0.8

1,449

34

2.3

38

0

0.0

1

0

0.0

Procedure setting

<0.001*

Inpatient

5,870

92

1.6

Outpatient

12,236

45

0.4

214

43

20.1

Complication Surgical

<0.001*

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Medical

11

14.3

<0.001*

17,732

89

0.5

<0.001*

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No complication

77

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Table 4. Logistic Regression Analysis for Perioperative Risk Factors for Reoperation OR

95% CI

Inpatient

2.76

1.78 – 4.28

Respiratory history

1.31

0.80 – 2.16

GI history

0.70

0.36 – 1.36

Cardiac history

1.31

0.75 – 2.31

0.34

CNS history

0.98

0.62 – 1.56

0.94

Immunologic history

1.44

0.49 – 4.29

0.51

Nutritional history

1.49

0.74 – 2.99

0.26

Hematologic history

2.05

0.77 – 5.47

0.15

1.07 – 3.03

0.03*

1.00 – 1.01

<0.001*

0.66

0.44 – 0.99

0.05*

3.82

1.01 – 14.46

0.05*

0.35

0.04 – 3.15

0.35

1.00

0.97 -1.02

0.67

Operative Time

1.01

Congenital malformation Open wound/Wound

Wound classification

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Infection

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1.80

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a

ASA Class 3 or higher

P value

RI PT

Variable

<0.001* 0.28 0.70

contaminated or infected

a

AC C

Work RVU

In comparison to ASA Class 1 and 2

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Table 5. Logistic Regression Analysis for Causes of UR

Surgical complication Surgical site infection

95% CI

P value

39.98

22.64 – 70.59

<0.001*

1.25

0.62 – 2.53

18.92

8.55 – 41.86

AC C

EP

TE D

M AN U

SC

Medical complication

OR

RI PT

Variable

0.53

<0.001*