External validation of the breast reconstruction risk assessment calculator
Introduction
The number of breast reconstructions performed annually in the United States continues to grow.1, 2, 3, 4, 5, 6 Reasons for this trend include the expanding use of bilateral mastectomies and increasing comfort among plastic surgeons with high-risk cases.1, 4 With this widening pool of patients, selection of operative technique among the myriad of options is becoming ever more challenging.7, 8, 9, 10 Given an individual patient's unique history and physical exam, a number of considerations must be weighed and effectively communicated throughout the shared decision-making process, including aesthetic goals, patient and physician preference, and, importantly, the risk of complications.
Among these complications, seroma, surgical site infection (SSI), and reconstructive failure can be particularly devastating for patients and thus play an important role in patient education.11 Although traditionally the surgical community has relied on coarse, population-derived measures of average risk to inform these conversations,12, 13, 14, 15 there is increasing evidence for the inaccuracy of extrapolating such figures to the individual patients within a heterogeneous population.16, 17, 18, 19
The Breast reconstruction Risk Assessment (BRA) Score risk calculator was developed to improve the understanding of an individual's surgical risk by considering her unique combination of preoperative variables.18, 19 Initially developed using cases from the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) dataset, the calculator has since then expanded to include additional plastic surgery specific data sources.18, 20 Available online, the BRA Score provides measures of individual risk for eight complications and four reconstructive modalities. As its user base grows internationally, the BRA Score must be held to the same rigorous standards of validity as other high-profile prognostic tools, such as the CHA2DS2-VASc Score.21, 22, 23
The models underlying the BRA Score were internally validated using bootstrapping methodologies at the time of their conception. However, external validation is critical to their clinical implementation in a generalized population.24, 25, 26 This is the first report to assess the reproducibility of BRA Score validation in an external cohort of patients. Specifically, we endeavored to externally validate the BRA Score models for SSI, seroma, and explantation in patients undergoing tissue expander/implant-based breast reconstruction by assessing their performance using a large sample of intra-institutional patients. For each model, we assess its discrimination, calibration, and accuracy of predictions and determine both areas of strength and potential weaknesses as we continue to develop and improve the risk calculator.
Section snippets
BRA score risk calculator
The BRA Score Risk Calculator was developed by the senior authors (NK, JYSK), and is available online at www.brascore.org.18, 19 Its back-end computations rely on a set of multivariate logistic regression models that translate preoperative patient traits into probabilities for developing various postoperative complications. The models for tissue expander/implant reconstruction were derived from two national databases: ACS NSQIP and the American Society of Plastic Surgeons Tracking Operations
Primary outcomes
The dataset consisted of 1743 tissue expander placements among 1152 patients in the 12-year period covered by this study. Exclusion of patients with any missing data for the necessary input variables resulted in 855 remaining patients (1333 reconstructed breasts) who were ultimately included for analysis. Median follow-up time was 14.0 months from the placement of the tissue expander.
Demographic data for these patients are displayed in Table 1. Patient age ranged from 22 to 82 years with a mean
Discussion
The advent of nationwide, multicenter patient registries has enabled a paradigm shift in the way that the surgical community approaches patient risk. With demographics, risk factors, and surgical outcomes available for tens of thousands of patients, researchers can develop high-powered, multivariable models predicting the risk of complications with great accuracy. These models provide the foundation for the concept of surgical risk calculators such as the BRA Score. Using data from three
Conclusion
In this external validation study, the BRA Score tissue expander/implant reconstruction models performed with generally good calibration, discrimination, and accuracy for 30-day outcomes. Some weaknesses in certain models were identified as targets for future improvement. Taken together, these analyses validate the clinical utility of the BRA score risk models in predicting acute events following two-stage prosthetic breast reconstruction.
Author contributions
JYSK, NK, and CSQ contributed substantially to project design.
NK, CSQ, and ASM contributed substantially to data analysis.
NK, CSQ, ASM, and MMV contributed substantially to data interpretation.
JYSK, NK, CSQ, ASM, MMV, RGD, and NAF contributed substantially to drafting of the manuscript and final approval of the version to be submitted.
Conflict of interest
The research presented here received no external funding.
Financial disclosures
JYSK receives research funding from the Musculoskeletal Transplant Foundation.
Ethical approval
This study also utilizes data from the National Surgical Quality Improvement Program (NSQIP) and the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) program, which are HIPAA-compliant, de-identified databases available to members of NSQIP and the American Society of Plastic Surgeons, respectively. Intra-institutional data were obtained following the approval by the Northwestern University Institutional Review Board (IRB). A statement from the IRB is available upon request.
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