Subscribe to RSS
DOI: 10.1055/s-0041-1740128
Economic Impact of Refinements in ERAS Pathways in DIEP Flap Breast Reconstruction
Funding None.![](https://www.thieme-connect.de/media/jrm/202207/lookinside/thumbnails/10-1055-s-0041-1740128_210160-1.jpg)
Abstract
Introduction Enhanced recovery after surgery (ERAS) protocols at our institution have led to an expected decrease in hospital length of stay and opioid consumption for patients treated with deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. We look to examine the economic patterns across these years to see the impact of costs for the patient and institution.
Methods This study retrospectively evaluated consecutive patients treated with bilateral DIEP flaps for breast reconstruction between October 2015 and August 2020. We categorized the cases into three categories: pre-ERAS, ERAS, ERAS + bupivacaine. Primary outcomes observed included the contribution margin per operating suite case minute and total cost to the patient. An analysis of variance determined whether there was a difference between the three groups and a Tukey post-hoc analysis made pairwise comparisons. A p-value < 0.05 was significant.
Results A total of 268 cases of bilateral DIEPs performed by the two senior authors were analyzed in this study. Seventy-four cases were pre-ERAS, 72 were ERAS, and 122 were ERAS + bupivacaine. There was a statistical difference between the contribution margin per operating minute. A Tukey post hoc test revealed that the average contribution margin per operating suite case minute was significantly higher for the ERAS and ERAS + bupivacaine compared with the pre-ERAS groups.
There was a statistically significant difference between the total cost to the patients. A Tukey post hoc test revealed that the average total cost to the patient was statistically significantly lower for the ERAS and ERAS + bupivacaine compared with the pre-ERAS group.
Conclusion Implementation of ERAS and continued improvements in ERAS resulted in significantly decreased costs for the patient and increased profitability for the hospital. Investing in improvements to ERAS protocols can improve profitability for the institution while simultaneously improving costs and access to care for patients in need of breast reconstruction.
Publication History
Received: 06 July 2021
Accepted: 26 September 2021
Article published online:
06 December 2021
© 2021. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 2011; 149 (06) 830-840
- 2 Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J. Enhanced Recovery After Surgery Study Group. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 2011; 146 (05) 571-577
- 3 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78 (05) 606-617
- 4 Kehlet H. Multimodal approach to postoperative recovery. Curr Opin Crit Care 2009; 15 (04) 355-358
- 5 Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183 (06) 630-641
- 6 McDonald R. Enhanced recovery clinical education programme improves quality of post-operative care. BMJ Qual Improv Rep 2015; 4 (01) u208370.w3387
- 7 Mertz BG, Kroman N, Williams H, Kehlet H. Fast-track surgery for breast cancer is possible. Dan Med J 2013; 60 (05) A4615
- 8 Offodile II AC, Gu C, Boukovalas S. et al. Enhanced recovery after surgery (ERAS) pathways in breast reconstruction: systematic review and meta-analysis of the literature. Breast Cancer Res Treat 2019; 173 (01) 65-77
- 9 Schneider S, Armbrust R, Spies C, du Bois A, Sehouli J. Prehabilitation programs and ERAS protocols in gynecological oncology: a comprehensive review. Arch Gynecol Obstet 2020; 301 (02) 315-326
- 10 Soteropulos CE, Tang SYQ, Poore SO. Enhanced recovery after surgery in breast reconstruction: a systematic review. J Reconstr Microsurg 2019; 35 (09) 695-704
- 11 Haddock NT, Garza R, Boyle CE, Liu Y, Teotia SS. Defining Enhanced Recovery Pathway with or without Liposomal Bupivacaine in DIEP Flap Breast Reconstruction. Microsurgery Under Revision. 2020
- 12 Corp I. IBM SPSS Statistics for Windows. Version 26.0 ed.. Armonk, NY: IBM Corp; 2019
- 13 Pacella SJ, Comstock MC, Kuzon Jr WM. Facility cost analysis in outpatient plastic surgery: implications for the academic health center. Plast Reconstr Surg 2008; 121 (04) 1479-1488
- 14 Macario A, Dexter F, Traub RD. Hospital profitability per hour of operating room time can vary among surgeons. Anesth Analg 2001; 93 (03) 669-675
- 15 Rosenberg BL, Comstock MC, Butz DA, Taheri PA, Williams DM, Upchurch Jr GR. Endovascular abdominal aortic aneurysm repair is more profitable than open repair based on contribution margin per day. Surgery 2005; 137 (03) 285-292
- 16 Taheri PA, Butz DA, Watts CM, Griffes LC, Greenfield LJ. Trauma services: a profit center?. J Am Coll Surg 1999; 188 (04) 349-354
- 17 Haddock NT, Kayfan S, Pezeshk RA, Teotia SS. Co-surgeons in breast reconstructive microsurgery: what do they bring to the table?. Microsurgery 2018; 38 (01) 14-20
- 18 Haddock NT, Teotia SS. Deconstructing the reconstruction: evaluation of process and efficiency in deep inferior epigastric perforator flaps. Plast Reconstr Surg 2020; 145 (04) 717e-724e
- 19 Afonso A, Oskar S, Tan KS. et al. Is enhanced recovery the new standard of care in microsurgical breast reconstruction?. Plast Reconstr Surg 2017; 139 (05) 1053-1061
- 20 Batdorf NJ, Lemaine V, Lovely JK. et al. Enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2015; 68 (03) 395-402
- 21 Knackstedt R, Gatherwright J, Ghaznavi A. et al. Comparison of local anesthetic infusion pump bupivacaine versus transversus abdominis plane (TAP) block liposomal bupivacaine for pain management after bilateral deep inferior epigastric perforator free flap reconstruction. J Plast Reconstr Aesthet Surg 2017; 70 (12) 1779-1781
- 22 Momeni A, Ramesh NK, Wan D, Nguyen D, Sorice SC. Postoperative analgesia after microsurgical breast reconstruction using liposomal bupivacaine (Exparel). Breast J 2019; 25 (05) 903-907
- 23 Alderman AK, Storey AF, Nair NS, Chung KC. Financial impact of breast reconstruction on an academic surgical practice. Plast Reconstr Surg 2009; 123 (05) 1408-1413
- 24 Patel A, Clune JE, Forte A, Chang CC. The impact of the Medicare sustainable growth rate formula on reconstructive plastic surgery. Plast Reconstr Surg 2010; 126 (05) 270e-271e
- 25 Sando IC, Chung KC, Kidwell KM, Kozlow JH, Malay S, Momoh AO. Comprehensive breast reconstruction in an academic surgical practice: an evaluation of the financial impact. Plast Reconstr Surg 2014; 134 (06) 1131-1139
- 26 Hu ES, Pusic AL, Waljee JF. et al. Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship Period. Plast Reconstr Surg 2009; 124 (01) 1-8
- 27 Yueh JH, Slavin SA, Adesiyun T. et al. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg 2010; 125 (06) 1585-1595
- 28 Matros E, Albornoz CR, Razdan SN. et al. Cost-effectiveness analysis of implants versus autologous perforator flaps using the BREAST-Q. Plast Reconstr Surg 2015; 135 (04) 937-946
- 29 Parsa AA, Sprouse-Blum AS, Jackowe DJ, Lee M, Oyama J, Parsa FD. Combined preoperative use of celecoxib and gabapentin in the management of postoperative pain. Aesthetic Plast Surg 2009; 33 (01) 98-103
- 30 Sun T, Sacan O, White PF, Coleman J, Rohrich RJ, Kenkel JM. Perioperative versus postoperative celecoxib on patient outcomes after major plastic surgery procedures. Anesth Analg 2008; 106 (03) 950-958 table of contents.
- 31 Zhong T, Ojha M, Bagher S. et al. Transversus abdominis plane block reduces morphine consumption in the early postoperative period following microsurgical abdominal tissue breast reconstruction: a double-blind, placebo-controlled, randomized trial. Plast Reconstr Surg 2014; 134 (05) 870-878
- 32 Bamba R, Wiebe JE, Ingersol CA. et al. Do patient expectations of discharge affect length of stay after deep inferior epigastric perforator flap for breast reconstruction?. J Reconstr Microsurg 2021
- 33 Teotia SS, Dickey RM, Liu Y, Jayaraman AP, Haddock NT. Intraoperative microvascular complications in autologous breast reconstruction: the effects of resident training on microsurgical outcomes. J Reconstr Microsurg 2021; 37 (04) 309-314