Financial Toxicity in Breast Reconstruction: The Role of the Surgeon-Patient Cost-of-Care Discussion.

The financial burden of breast cancer treatment and reconstruction is a significant concern for patients. Patient desire for preoperative cost-of-care counseling while navigating the reconstructive process remains unknown. A cross-sectional survey of women from the Love Research Army was conducted. An electronic survey was distributed to women over 18 years of age and at least 1 year after postmastectomy breast reconstruction. Descriptive statistics and multivariable modeling were used to determine desire for and occurrence of cost-of-care discussions, and factors associated with preference for such discussions. Secondary outcomes included the association of financial toxicity with desire for cost discussions. Among 839 women who responded, 620 women (74.1%) did not speak to their plastic surgeon and 480 (57.4%) did not speak to a staff member regarding costs of breast reconstruction. Of the 550 women who reported it would have been helpful to discuss costs, 315 (57.3%) were not engaged in a financial conversation initiated by a health care provider. A greater proportion of women who reported financial toxicity, compared to those who did not, would have preferred to discuss costs with their plastic surgeon (65.2% vs. 43.5%, p < 0.001) or a staff member (75.5% vs. 59.3%, p < 0.001). Among women with financial toxicity, those who had some form of insurance (private, Medicaid, Medicare, "other") were significantly more likely to prefer a cost-of-care discussion ( p < 0.001, p = 0.02, p = 0.05, p = 0.01). Financial discussions about the potential costs of breast reconstruction seldom occurred in this national cohort. Given the reported preference and unmet need for financial discussions by a majority of women, better cost transparency and communication is needed.

Teamwork Makes the Dream Work: Maximizing Surgical Intervention at the Time of Living Donor Renal Transplantation.

BACKGROUND: Patients with obesity and end-stage renal disease represent a surgical population with multiple comorbidities and high risk for postoperative complications. One method for reducing the incidence of postoperative adverse events in this patient population is to limit the number of operations through combining operations into 1 operative encounter. METHODS: We conducted a retrospective review of adult patients at a single institution who underwent renal transplant, panniculectomy, and at least 1 additional abdominal or pelvic surgery concurrently. For those patients, we collected demographics, intraoperative variables, and postoperative data and analyzed surgical outcomes and postoperative complications. RESULTS: Thirteen patients met inclusion criteria. Most of the patients were female (85%) with ages ranging 33 to 70 years old and mean body mass index of 36.5 (SD 4.7). Three quarters of patients (77%) underwent 3 procedures and the remaining underwent 4 or 5 procedures with a median hospital length of stay of 5 days (range, 3-10 days). There was a single mortality. Overall, 8 patients (61.5%) experienced complications in the first 90 postoperative days. The wound complication rate was 46.2%, the overall readmission rate within 90 days was 38.5%, and the reoperation rate was 30.8%. All patients experienced immediate graft function, and the 12 patients that survived to postoperative day 90 maintained survival at 1 year. CONCLUSION: This study demonstrates that the combination of more than 2 surgical procedures with living donor renal transplant is a possible treatment option in high-risk obese patients in need of multiple operations.

Outcomes of complex abdominal wall reconstruction at the time of CRS and HIPEC.

INTRODUCTION: Cytoreduction Surgery with Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) is a treatment option for patients with peritoneal metastatic cancer. This procedure has been shown to improve survival, however, patients are often left with abdominal wall and soft tissue defects requiring further surgical correction. We aim to assess the safety and clinical outcomes of abdominal reconstruction performed concurrent with CRS/HIPEC. METHODS: We conducted a retrospective chart review on patients with peritoneal metastases who received CRS/HIPEC therapy and abdominal wall reconstruction at tertiary center from 2012 to 2018. Records were evaluated for the patient characteristics, oncologic history, operative details, and postoperative course. Complications were graded with the Clavien-Dindo classification. RESULTS: Five patients aged 29-54 years old met the inclusion criteria. The most common type of cancer within this cohort was colorectal cancer. To close the abdomen, four patients underwent component release, biologic mesh placement, and primary fascial closure. The last patient was closed with adjacent tissue transfer. Two patients experienced Grade I complications: deep vein thrombosis and leukocytosis (both self-resolved). Three patients experienced Grade II complications: atrial fibrillation, anemia, and a wound infection which required readmission. No patients experienced grades III, IV or V complications. The follow up period was a median of 5.3 months [r: 2.6-21.9 months]. CONCLUSION: The patients benefitted therapeutically from combined abdominal reconstruction and CRS/HIPEC with minimal complications and good long-term survival. We advocate for the coupling of these procedures as the benefits outweigh the risks, and allows wound closure at the time of surgery.

Investigating the Gender Pay Gap in Industry Contributions to Academic Neurosurgeons.

BACKGROUND: A large gender gap exists in industry funding for academic neurosurgeons. Selection criteria for funding distribution remain unclear. However, academic rank, scholarly productivity, and experience have been suggested as determining factors. METHODS: We conducted a cross-sectional study of industry payments to US academic neurosurgeons. We used online faculty listings to determine academic rank and gender, then used the Center for Medicare and Medicaid Services Open Payment Database to identify industry contributions. Details were collected on H-index and length of time in practice was used as a proxy for experience. RESULTS: Of the 1481 academic neurosurgeons included, men were in the majority (91% vs. 9%, P = 0.0001). Relative to their male colleagues, female assistant and associate professors received fewer payments (4 vs. 8, P = 0.0040; 2 vs. 7, P = 0.0067) at lower median values ($409 vs. $437, P = 0.0490; $163 vs. $260, P = 0.0089). H-index was more strongly associated with general payment receipt for women academic neurosurgeons (r = 0.20, P = 0.0201) than men academic neurosurgeons (r = 0.06, P = 0.0301). Experience trended toward a significant association with industry funding in men (r = 0.05, P = 0.0601). After adjustment for scholarly productivity and experience, gender-based funding inequalities became insignificant. CONCLUSIONS: In academic neurosurgery, substantial gender disparities exist in industry payments and metrics of academic success. There may be an industry selection bias toward recruitment of key opinion and thought leaders, as identified by scholarly productivity and experience. Despite the objective gender inequalities, industry funding to academic neurosurgeons appears to be equitable when metrics of academic success are considered.

Psychoactive Drugs in Plastic Surgery.

BACKGROUND: Psychoactive drug use is on the rise in the United States, with plastic surgery patients a potentially susceptible group. This study aimed to determine the incidence of cosmetic and reconstructive patients in our practice taking psychoactive drugs and to compare those values with the national average. Furthermore, we discuss the patient safety concerns when patients withhold their medical history information over the course of their treatment. METHODS: Urban private plastic practice patients who underwent surgery in a closed practice from 2009 to 2016 were divided into cosmetic and reconstructive cohorts. Review for drug use was medical scripts, history, and Surescripts drug reporting. Extracted information includes age, race, procedure, psychoactive medications, and whether or not they stated a mental health diagnosis on their medical history forms. Only patients with complete records were included. RESULTS: A total of 830 patients were included in statistical analysis. Due to minimal cohort number, 70 men were excluded, as there were no comparative national data. Our analysis found that 33.6% cosmetic patients and 46.3% reconstructive patients used at least one psychoactive drug. CONCLUSION: There is a statistically significant difference between psychoactive drug use at our practice compared with the general population and a significantly larger percentage of reconstructive patients taking drugs compared with the cosmetic cohort.