By Crystal Phend, Senior Staff Writer,
MedPage Today Published: July 05, 2011 Reviewed by Zalman S. Agus, MD;
Emeritus Professor University of Pennsylvania School of Medicine and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner Action Points Point out that this study indicates that obesity is a significant, major risk factor for postoperative complications following undergoing medically indicated elective breast surgery. Note that the majority of patients in this study underwent breast reduction surgery, which had the highest rate of complications, with a relatively fewer number of patients undergoing other types of surgery.
Obese women who are considering elective breast surgery may face a nearly 12-fold higher risk of complications, according to a claims database study. Surgical complication claim rates reached 18.3% among obese patients compared with only 2.2% among non-obese controls (P<0.001), Martin A. Makary, MD, MPH, of Johns Hopkins University in Baltimore, and colleagues found. This risk from elective breast reduction, lift, augmentation, or reconstruction procedures remained 11.8-fold higher with obesity after adjustment for other variables, the group reported online in Plastic and Reconstructive Surgery. Patients should be informed about the quantitative risk of obesity at the preoperative evaluation for such procedures, the researchers recommended. The results also have implications for quality of care reporting and reimbursement, they suggested. Obesity isn’t accounted for in pay-for-performance metrics, but should be based on these findings, Makary’s group argued. "Failure to do so can result in discrimination against obese patients when evaluating surgical candidates who may lower quality scores and reimbursements, or inappropriately penalizing physicians who continue to provide care to this population," they wrote in the paper.
The study included elective breast surgery claims from seven Blue Cross and Blue Shield private insurance plans covering residents of Hawaii, Iowa, Michigan, North Carolina, Pennsylvania, Tennessee, and South Dakota. Almost all the 2,403 obese patients were identified as such due to a diagnosis of obesity, while 4% had a self-reported body mass index over 30 kg/m2. They were compared with 5,597 control-group patients with a BMI of 30 kg/m2or less or no diagnostic codes indicating obesity. The most common procedure was breast reduction, which accounted for 80.7% of surgeries in the obese group and 63.8% in the non-obese group. Breast reconstruction followed at 10.3% and 24.2%, augmentation at 4.0% and 8.9%, and breast lift with or without augmentation at 5.0% and 3.2%, respectively. "The procedures were mostly done for medical as opposed to cosmetic indications as the database only included procedures covered by insurance," the researchers noted in the paper. Complications were most common with breast augmentation among obese patients at 50.5% (P<0.001 compared with controls at 4.4%).
Each other type of plastic surgery also showed a higher complication rate for obese patients: For breast lift, 24.1% among obese and 11.4% among non-obese patients (P=0.022) For breast lift with augmentation, 38.9% among obese and 5.6% among non-obese patients (P<0.001) For reconstruction, 29.4% among obese and 1.8% among non-obese patients (P<0.001) For breast reduction, 14.6% among obese and 1.7% among non-0bese patients (P<0.001) Obese patients saw higher odds for experiencing complications with the biggest differences in the following: Inflammation (odds ratio 22.2) Infection (OR 13.4) Pain (OR 11.7) Seroma (OR 11.4) Hematoma (OR 10.9) Other factors that added to complication risk, though more modestly, included diabetes, significant weight loss prior to the procedure (largely affecting non-obese patients), and prior chest wall irradiation. Reasons for the higher risk with obesity may be greater space for infection to set in from larger surgical wounds and slower healing due to poorer blood flow in fat tissue than in other types of tissue, Makary noted in a press release. The researchers cautioned that reliance on administrative claims may have led to some misclassification of BMI and outcomes, as well as precluded correlating complications with factors like procedure duration or volume of tissue removed. The higher risk of complications associated with obesity in the study may apply generally to elective breast surgeries paid out-of-pocket as well as other types of elective procedures in the obese population, they suggested.
The analysis was funded by The Mr. and Mrs. Chad and Nissa Richison Foundation. The dataset used was originally created to study patterns of obesity care within selected Blue Cross and Blue Shield Plans. The previous study was funded by unrestricted research grants from Ethicon Endo- Surgery, Pfizer, and GlaxoSmithKline.
The researchers reported having no conflicts of interest. Primary source: Plastic and Reconstructive Surgery Source reference: Chen CL, et al "The impact of obesity on breast surgery complications" Plast Reconstr Surg 2011; DOI: 10.1097/PRS.0b013e3182284c05