National Variations in Fibula Free Flaps and the Role of Institutional Volume in Costs and Surgical Complication Rates

Presentation: AHNS007
Topic: Quality of Care and Clinical Pathways
Type: Oral
Date: Wednesday, April 18, 2018
Session: 10:30 AM - 11:20 AM Reconstruction and Rehabilitation
Authors: Rance J Fujiwara, BS, Elliot Morse, BS, Saral Mehra, MD, MBA
Institution(s): Yale University School of Medicine

Importance: Recognition of cost variations may uncover avenues to decrease health expenditures. While variations in costs and complications have been measured for head and neck cancer patients in general, no studies have been conducted to quantify these differences or the importance of surgical volume in patients undergoing fibula free flap reconstruction.

Objective: To measure variations in costs and surgical complications for fibula free flap reconstruction, and to measure the association of costs and complications with hospital surgical volume

Design: Cross-sectional analysis, 2001-2011

Setting: Healthcare Cost and Utilization Project National Inpatient Sample

Participants: Patients undergoing fibula free flap with primary admission diagnosis of head and neck cancer

Main Outcome(s) and Measure(s): Main outcomes were hospital costs and postoperative surgical complications. Explanatory variables included patient- and hospital-level demographics. This study employed a generalized linear model to quantify the significance of patient- and hospital-level factors with costs, and binary logistic regression to measure associations with surgical complications.

Results: A total of 504 patients with median age 60.5 years (interquartile range, 54-69) met inclusion criteria. Most were treated at academic institutions (95.8%), and 106 (21.0%) were treated at high-volume hospitals, defined as the 95th percentile among hospitals (>5 cases per year). High-volume institutions were associated with a $10,617.04 (95% confidence interval [CI] 2,308.27–18,295.80, p=0.01) decrease in costs compared to low-volume institutions. The Northeast ($20,965,86 [CI 1,1241.58–30,690.14], p<0.001) and West ($9,075.30 [CI 1079.07–17,071.53], p=0.03) had decreased costs relative to the South. Microvascular complications were responsible for a $39,050.25 (CI 23,167.69–54,932.82, p<0.001) cost increase in costs. High-volume hospitals had significantly decreased surgical complication rates (OR 0.43 [CI 0.24-0.76], p=0.004), though no geographic variations in complications were observed.

Conclusions and Relevance: Significant cost variation exists among patients undergoing fibula free flap reconstruction for head and neck cancer. High institutional volume was associated with decreased costs and improved postoperative outcomes. However, geographic cost differences did not correspond with surgical complication rates, suggestive of unmeasured variables or differences in patterns of care. In the context of rising healthcare costs, further efforts should be conducted to identify opportunities to decrease costs and improve value of care.