Textbook Outcomes in DIEP Flap Breast Reconstruction: An International Delphi Study to Establish an Expert-Based Consensus

Abstract

Introduction: Composite measures, like textbook outcomes, may be superior to individual metrics when assessing hospital performance and the quality of care. This study utilized a Delphi process to establish an international, expert-based consensus that defines a textbook outcome in DIEP flap breast reconstruction. Materials and Methods: A two-round Delphi survey defined: 1) A textbook outcome, 2) Exclusion criteria for a study population, and 3) Expert opinion regarding textbook outcomes. An a priori threshold of ≥70% agreement established consensus among tested statements. Results: Out of 85 experts, 48 responded in the first round and 41 in the second. A textbook outcome was defined as one that meets the following within 90-days: 1) No intraoperative complications, 2) Operative duration≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, 3) No post-surgical complications requiring re-operation, 4) No surgical site infection requiring IV antibiotics, 5) No readmission, 6) No mortality, 7) No systemic complications, and 8) Length of stay ≤5 days. Exclusion criteria for medical and surgical characteristics (e.g., BMI>40, HgbA1c>7) and case-volume cut-offs for providers (≥21) and institutions (≥44) were defined. Most agreed that textbook outcomes should be defined for complex plastic surgery procedures (75%) and utilized to gauge hospital performance for microsurgical breast reconstruction (77%). Conclusion: This international Delphi study identified: 1) Key elements of a textbook outcome for DIEP flap breast reconstruction, 2) Exclusion criteria for future studies, and 3) Characterized expert opinions regarding the utility of textbook outcomes in serving as a quality metric for breast reconstruction care. Future, multi-institutional studies are needed to analyze the incidence and rates of achieving a textbook outcome after DIEP flap breast reconstruction, determine which characteristics may be associated with achieving this outcome, and evaluate how this novel composite measure may be used to assess outcomes across institutions and providers.