Margaret A. Olsen

Breast reconstruction is increasingly performed after mastectomy in women with breast cancer^1,2 and for prophylaxis in women at high risk for breast cancer. Steadily increasing use of mastectomy in women with early breast cancer has been reported in the past decade, along with increasing use of bilateral mastectomy, even for unilateral disease.³ Coinciding with this trend is increased use of immediate breast reconstruction (IR), particularly in women undergoing bilateral mastectomy, more than half of whom undergo reconstruction.^3,4 Using the Nationwide Inpatient Sample, the proportion of women undergoing mastectomy for cancer or prophylaxis with IR increased by almost 1.5-fold from 28.5% in 2005 to 42% in 2011 (M.A.O., unpublished data; November 2015).

Objective: To determine the impact of surgical site infections (SSIs) on health care costs following common ambulatory surgical procedures throughout the cost distribution. Background: Data on costs of SSIs following ambulatory surgery are sparse, particularly variation beyond just mean costs. Methods: We performed a retrospective cohort study of persons undergoing cholecystectomy, breast-conserving surgery, anterior cruciate ligament reconstruction, and hernia repair from December 31, 2004 to December 31, 2010 using commercial insurer claims data. SSIs within 90 days post-procedure were identified; infections during a hospitalization or requiring surgery were considered serious. We used quantile regression, controlling for patient, operative, and postoperative factors to examine the impact of SSIs on 180-day health care costs throughout the cost distribution. Results: The incidence of serious and nonserious SSIs was 0.8% and 0.2%, respectively, after 21,062 anterior cruciate ligament reconstruction, 0.5% and 0.3% after 57,750 cholecystectomy, 0.6% and 0.5% after 60,681 hernia, and 0.8% and 0.8% after 42,489 breast-conserving surgery procedures. Serious SSIs were associated with significantly higher costs than nonserious SSIs for all 4 procedures throughout the cost distribution. The attributable cost of serious SSIs increased for both cholecystectomy and hernia repair as the quantile of total costs increased ($38,410 for cholecystectomy with serious SSI vs no SSI at the 70th percentile of costs, up to $89,371 at the 90th percentile). Conclusions: SSIs, particularly serious infections resulting in hospitalization or surgical treatment, were associated with significantly increased health care costs after 4 common surgical procedures. Quantile regression illustrated the differential effect of serious SSIs on health care costs at the upper end of the cost distribution.

Noninfectious wound complications (NIWCs) after mastectomy are not routinely tracked and data are generally limited to single-center studies. Our objective was to determine the rates of NIWCs among women undergoing mastectomy and assess the impact of immediate reconstruction (IR). We established a retrospective cohort using commercial claims data of women aged 18 to 64 years with procedure codes for mastectomy from January 2004 through December 2011. Noninfectious wound complications within 180 days after operation were identified by ICD-9-CM diagnosis codes and rates were compared among mastectomy with and without autologous flap and/or implant IR. There were 18,696 procedures (10,836 [58%] with IR) among 18,085 women identified. The overall NIWC rate was 9.2% (1,714 of 18,696); 56% required surgical treatment. The NIWC rates were 5.8% (455 of 7,860) after mastectomy only, 10.3% (843 of 8,217) after mastectomy plus implant, 17.4% (337 of 1,942) after mastectomy plus flap, and 11.7% (79 of 677) after mastectomy plus flap and implant (p < 0.001). Rates of individual NIWCs varied by specific complication and procedure type, ranging from 0.5% for fat necrosis after mastectomy only, to 7.2% for dehiscence after mastectomy plus flap. The percentage of NIWCs resulting in surgical wound care varied from 50% (210 of 416) for mastectomy plus flap, to 60% (507 of 843) for mastectomy plus implant. Early implant removal within 60 days occurred after 6.2% of mastectomy plus implant; 66% of the early implant removals were due to NIWCs and/or surgical site infection. The rate of NIWC was approximately 2-fold higher after mastectomy with IR than after mastectomy only. Noninfectious wound complications were associated with additional surgical treatment, particularly in women with implant reconstruction, and with early implant loss.

Little data are available regarding individual patients’ risk of surgical site infection (SSI) following mastectomy with or without immediate reconst

Background Cytomegalovirus (CMV) replication and disease commonly occur in lung transplant recipients after stopping anti-CMV prophylaxis. The epidemiology of CMV disease is not well studied, given the difficulties in assembling representative study populations with prolonged follow-up. We hypothesized that delayed-onset CMV disease (>100 days after transplantation) occurs more commonly than early-onset CMV disease in lung transplant recipients, and is associated with an increased risk of death. Methods We assembled a large cohort of lung transplant recipients using 2004 to 2010 International Classification of Diseases, Ninth Revision, Clinical Modification billing data from 3 Agency for Healthcare Research and Quality State Inpatient Databases, and identified demographics, comorbidities, CMV disease coded during hospital readmission and inpatient death. We used Cox proportional hazard multivariate analyses to assess for an independent association between delayed-onset CMV disease and death. Results In the cohort of 1528 lung transplant recipients from 12 transplant centers, delayed-onset CMV disease occurred in 13.7% (n = 210) and early-onset CMV disease occurred in 3.3% (n = 51). Delayed-onset CMV pneumonitis was associated with inpatient death longer than 100 days after transplantation (adjusted hazard ratio, 1.6; 95% confidence interval [95% CI], 1.1-2.5), after adjusting for transplant failure/rejection (aHR, 2.5; 95% CI, 1.5-4.1), bacterial pneumonia (aHR, 2.8; 95% CI, 2.0-3.9), viral pneumonia (aHR, 1.5; 95% CI, 1.1-2.1), fungal pneumonia (aHR, 1.8; 95% CI, 1.3-2.3), single lung transplant (aHR, 1.3; 95% CI, 1.0-1.7), and idiopathic pulmonary fibrosis (aHR, 1.4; 95% CI, 1.0-1.8). Conclusions Delayed-onset CMV disease occurred more commonly than early-onset CMV disease among lung transplant recipients. These results suggest that delayed-onset CMV pneumonitis was independently associated with an increased risk of death.

OBJECTIVE: The National Healthcare Safety Network classifies breast operations as clean procedures with an expected 1%–2% surgical site infection (SSI) incidence. We assessed differences in SSI incidence following mastectomy with and without immediate reconstruction in a large, geographically diverse population.DESIGN: Retrospective cohort studyPATIENTS: Commercially insured women aged 18–64 years with ICD-9-CM procedure or CPT-4 codes for mastectomy from January 1, 2004 through December 31, 2011METHODS: Incident SSIs within 180 days after surgery were identified by ICD-9-CM diagnosis codes. The incidences of SSI after mastectomy with and without immediate reconstruction were compared using the χ² test.RESULTS: From 2004 to 2011, 18,696 mastectomy procedures among 18,085 women were identified, with immediate reconstruction in 10,836 procedures (58%). The incidence of SSI within 180 days following mastectomy with or without reconstruction was 8.1% (1,520 of 18,696). In total, 49% of SSIs were identified within 30 days post-mastectomy, 24.5% were identified 31–60 days post-mastectomy, 10.5% were identified 61–90 days post-mastectomy, and 15.7% were identified 91–180 days post-mastectomy. The incidences of SSI were 5.0% (395 of 7,860) after mastectomy only, 10.3% (848 of 8,217) after mastectomy plus implant, 10.7% (207 of 1,942) after mastectomy plus flap, and 10.3% (70 of 677) after mastectomy plus flap and implant (P<.001). The SSI risk was higher after bilateral compared with unilateral mastectomy with immediate reconstruction (11.4% vs 9.4%, P=.001) than without (6.1% vs 4.7%, P=.021) immediate reconstruction.CONCLUSIONS: SSI incidence was twice that after mastectomy with immediate reconstruction than after mastectomy alone. Only 49% of SSIs were coded within 30 days after operation. Our results suggest that stratification by procedure type facilitates comparison of SSI rates after breast operations between facilities.Infect Control Hosp Epidemiol 2015;36(8):907–914