Impact of Obesity on Breast Surgery Complications – article review

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

Obesity is an ever increasing presence in today’s world.  Thirty-four percent of U.S. adults are now estimated to be obese (BMI>30), up from just 15% three decades ago.

Obesity increases the risk of complications in many medical/surgical situations which has pushed some Ob-Gyns in Florida to refuse to care for pregnant women over a certain weight.

Martin A. Makary, MD and colleagues designed a study to measure the impact on complication rates in obese patients presenting for a set of elective breast procedures.

The PRS journal article referenced below has been published online ahead of print and looks at the impact obesity has on breast surgery complication.

The researchers used claims data from seven Blue Cross and Blue Shield Plans covering individuals with employer-provided coverage and residing in Hawaii, Iowa, Michigan, North Carolina, Pennsylvania, Tennessee, and South Dakota to identify a cohort of obese patients and a non-obese control group who underwent elective breast procedures covered by insurance between 2002-2006.

Criteria for the patient  to be included:
Enrolled in the insurance plan for at least one month before and after surgery

Have a paid claim for breast augmentation, breast reduction, breast lift (mastopexy), or breast reconstruction during the period between 2002-2006

Have either 1) a BMI of 30 kg/m2 or greater, 2) a diagnosis of obesity (using ICD 278.x or V85.x code closest to the date of surgery), or 3) at least one comorbidity associated with obesity (diabetes, hypertension, metabolic syndrome, obstructive sleep apnea, hyperlipidemia, or gallbladder disease) within one year of undergoing the breast procedure

There were 2,403 patients (mean age 42.1 yrs)  in the obese group who were compared to a non-obese control group of 5,597 patients (mean age 48.4 yrs).  Breast reduction was the most commonly performed procedure in the obese and control groups (80.7% vs 63.8%), followed by breast reconstruction (10.3% vs 24.2%), augmentation (4.0% vs 8.9%), and mastopexy with or without augmentation (5.0% vs 3.2%).

Overall, 18.3% of obese patients had a complication compared to only 2.2% in the control group (p<0.001). After adjusting for other variables, the researchers found obesity status increased the odds of experiencing a complication by 11.8 times.

Among the obese patients, at least one complication was observed in 50.5% of patients undergoing breast augmentation (vs. 4.4% of controls), 24.1% undergoing mastopexy (vs. 11.4%), 38.9% mastopexy with augmentation (vs. 5.6%), 29.4% of reconstruction (vs. 1.8%), and 14.6% of breast reduction patients (vs. 1.7%).

The differences between the two groups were most pronounced
in complications such as inflammation (OR=22.2), infection (OR=13.4), pain (OR=11.7), the development of seroma (OR=11.4) and hematoma (OR=10.9).

Obesity status  increased the odds of experiencing a complication (OR = 10.1, adjusted 11.8).  Diabetes (OR = 1.37, adjusted 1.16) and a history of prior chest wall irradiation (adjusted OR = 1.4) were associated with a higher odds of complication.

Hypertension, COPD, a history of neoadjuvant chemotherapy and undergoing a bilateral procedure were not significantly associated with the development of complications.

Makary and colleagues write in their discussion (bold emphasis is mine):

Our data demonstrate that obesity is a major risk factor for complications following elective breast procedures. In light of current trends towards pay-for-performance-based reimbursement, although obesity is currently not accounted for in quality metrics, based on our study, it increases the odds of experiencing any complication within a 30-day postoperative period by 11.8 times. This is in marked contrast to previous studies, which showed either no significant difference in complications between
obese and non-obese patients undergoing elective breast surgery, or just a slight increase.

Although pay-for-performance strives to reward healthcare providers for meeting certain performance measures for quality and efficiency, there is no guarantee that the measures being used accurately reflect the quality of surgical care being provided. For example, the current assumption behind pay-for-performance is that high-quality care reduces surgical
complications.  Our results suggest that variations seen in the rate of complications may be, in part, related to the characteristics of the population--in this case, body habitus. These complications could even occur despite adherence to process measures such as administering appropriate antibiotic prophylaxis. Thus, any measure of quality should consider the effect of obesity on these measures.

REFERENCES
The Impact of Obesity on Breast Surgery Complications; Chen, Catherine L.; Shore, Andrew D.; Johns, Roger; Clark, Jeanne M.; Manahan, Michele; Makary, Martin A.; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 9 June 2011; doi: 10.1097/PRS.0b013e3182284c05