Breast Cancer Research and Treatment

, Volume 178, Issue 1, pp 177–183 | Cite as

The impact of hospital volume on patient safety indicators following post-mastectomy breast reconstruction in the US

  • Clifford C. Sheckter
  • Danielle Rochlin
  • Harriet Kiwanuka
  • Catherine Curtin
  • Arash MomeniEmail author



Despite the growing spotlight on value-based care and patient safety, little is known about the influence of patient-, reconstruction-, and facility-level factors on safety events following breast reconstruction. The purpose of this study is to characterize postoperative complications in light of hospital-level risk factors.


Using the National Inpatient Sample, all patients who underwent free flap and prosthetic breast reconstruction from 2012 to 2014 were identified. Predictor variables included patient demographic and clinical characteristics, type and timing of reconstruction, annual hospital reconstructive volume, hospital bed size, hospital setting (rural vs. urban), and length of stay. Patient safety indicators (PSIs) were based on the Agency for Healthcare Research and Quality’s designation of preventable hospital complications: venous thromboembolism, bleeding, wound complications, pneumonia, and sepsis. Logistic models were used to analyze outcomes.


The sample included 103,301 women, of which 27,695 (26.8%) underwent free flap reconstruction. 3.6% of patients experienced ≥ 1 PSI, most commonly wound PSI (4.9% and 2.5% for free flap and prosthetic reconstruction, respectively). Significant predictors of PSIs included rural setting (p < 0.01) and Elixhauser score ≥ 4 (p < 0.01) for the free flap group, and delayed reconstruction (p < 0.01) for the prosthetic group. Annual reconstructive facility volume was not associated with increased odds of PSIs in either prosthetic or free flap reconstruction (p > 0.05).


PSIs were associated with rural hospitals and greater comorbidities for patients undergoing reconstruction with free flaps. Annual reconstructive facility volume was not associated with adverse inpatient outcomes with either method of reconstruction.


Breast reconstruction Patient safety Patient safety indicator Hospital volume Procedural volume 


Compliance with ethical standards

Conflict of interest

Dr. Momeni is a consultant for Allergan, AxoGen, Sientra, and Stryker. No payment or compensation was received for this study. Dr. Sheckter, Dr. Rochlin, and Ms. Kiwanuka, and Dr. Curtin have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

No consent was indicated given de-identified national database (Nationwide Inpatient Sample). Data were accessed by Dr. Sheckter who holds a data use agreement with the Healthcare Cost and Utilization Product.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Clifford C. Sheckter
    • 1
  • Danielle Rochlin
    • 1
  • Harriet Kiwanuka
    • 1
  • Catherine Curtin
    • 1
    • 2
  • Arash Momeni
    • 1
    Email author
  1. 1.Division of Plastic and Reconstructive SurgeryStanford University School of MedicinePalo AltoUSA
  2. 2.Division of Plastic and Reconstructive SurgeryVeterans Affairs Palo AltoPalo AltoUSA

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