Breast surgeons should take special care with obese patients because they are 12 times more likely to suffer complications, a Johns Hopkins study of elective breast surgery, has found.
That fact alone may prompt some surgeons to avoid accepting obese patients, since reporting and financial reward may be reduced if higher complications in their patients result, the authors said.
The study used claims data from seven Blue Cross and Blue Shield Plans to identify cohorts of 2,403 obese versus 5,597 non-obese patients who underwent elective, medically indicated breast procedures, such as breast reduction, breast reconstruction (mastopexy,) or breast lift surgery.
The researchers found that 18.3% of obese patients had a complication compared with 2.2% of the non-obese cohort.
Also, the average age of the obese patient was about six years younger than the age of the controls, further strengthening the finding in this report.
The study was led by Marty Makary, MD, associate professor of surgery at the Johns Hopkins University School of Medicine. It was published in the journal Plastic and Reconstructive Surgery.
Highest rates of complications included breast pain, deformities such as scars, delayed wound healing, and infection, all of which were much more frequent in obese patients compared with non-obese patients. Also more frequent were seromas, inflammation, capsular contractures, necrosis, implant removal, hematomas, flap failures, bleeding and revisions.
The authors of the study wrote that they have concerns because "surgical outcomes are increasingly being evaluated using standardized metrics" to determine reimbursement, and toward making each surgeon's and hospital's complication rates publicly available.
But the difference in complication rates has never been formally measured and thus is not accounted for, they said. They wrote that their results "may be applicable to surgeons who perform other elective procedures in the obese population."
"Despite anecdotal evidence (of higher complication rates in obese patients) the increased risk of complications in obese patients is not accounted for in these metrics, largely because the difference in complication rates has not been formally measured."
"With the government and other insurers penalizing doctors whose patients get infections or are readmitted to the hospital, and with obese patients more likely to have those problems, policymakers need to make sure they aren't giving physicians financial incentives to discriminate on the basis of weight," Makary said in a Johns Hopkins press statement.
These surgeries usually take longer, and are more taxing; the operating fields are deeper, healing is slower, and opportunity for infection greater. All these factors that are not accounted for in the formula for reporting quality measures, Makary said. "Payments are based on the complexity of the procedure, and are not adjusted for the complexity of the patient."
The researchers wrote that the "marked increase in surgical complications rates related to obesity also presents an excellent opportunity for improving public health by informing patients of these quantitative risks of obesity during their preoperative evaluation a time when the risks are of direct relevance to them."
Surgery in the this population is growing, not only because more residents in the United States are obese, (34%), but also because of the increase in diabetes and other complications related to obesity that may necessitate surgery, from amputations to cardiovascular procedures.