Commentary: The Impact of Breast Reduction Practice Variation in Hamilton,Ontario: A Cost Analysis

Breast reduction surgery is one of the most common procedures performed by plastic surgeons and accounts for a significant cost to the healthcare system. The article “The Impact of Breast Reduction Practice Variation in Hamilton, Ontario: A Cost Analysis ¹ ” is by an accomplished group of authors with a combined experience in breast surgery and clinical epidemiology. The authors surveyed 7 surgeons performing breast reduction surgery in a local community. Their goals were to look for variations in the management of the breast reduction patient and to assess the cost implications of these practice variations to the healthcare system and to patients.

Among the 7 surgeons, variations were seen in items such as drain use, frequency of appointments and use of out-of-hospital nursing care. The most impactful variation was based on surgical time. In fact, most cost differences between surgeons were almost entirely based on time in the operating room. Although specific data was not provided, the range for time in the operating room was between 2 and 3 h. This represents a 50% differential between the faster surgeons and the slower surgeons. Speed at the expense of outcomes or increased rates of complications is neither desirable nor cost-effective. Recognizing that all surgeons work at their own pace and that surgery should never feel rushed, there is always an opportunity to maximize surgical efficiency. Issues such as surgeon awareness of time costs, maximizing use of well-trained assistants, modifying surgical techniques, and prioritizing team-based processes for collaborative efficiency in the operating room should be visited on a regular basis.

A notable omission from the 30-question survey delivered to surgeons was exploring approaches to candidacy for publicly funded breast reduction surgery. Although objective measures, including breast measurements, volume estimates, body mass index, posture, and skin changes can be documented, subjective symptoms are impactful in determining a patient's candidacy for publicly funded surgery. Tremendous variation exists with approval rates and criteria for approval, based largely on jurisdiction. Five of the 7 surgeons self-reported that they only provide a publicly funded option. It would be interesting to know what impact that had on patient selection and specifically, what did these surgeons do when they felt that a patient did not meet the criteria for funded surgery? Was there a difference in approaches to approval and candidacy for surgery between surgeons who work solely within the public system and those who offer both public and private options? In an ever-evolving healthcare system with increasing financial pressures, medical providers are often left in the vulnerable position of supporting and advocating for what is best for our patients, with a balance against medical necessity and resulting associated costs.

The authors should be congratulated on an excellent article that brings attention to the need for cost containment with choices based on best evidence, while maintaining high levels of clinical care.