New Advances in Identifying Improvements Following Breast Reduction
However, the algorithm for determining medical necessity is archaic, cumbersome, and prone to unnecessary ambiguity on the part of achieving prior authorization. Currently, the indication for macromastia reduction is to achieve symptomatic relief from neck and back discomfort. This metric is very difficult to quantify and is prone to speculation about malingering with poor correlation between patient report and physical findings.
Historically, the Schnur scale has been used to approximate the amount of tissue to be removed. However, it has been found that volumes even less than the Schnur scale can reliably confer reduced symptoms in patients. Breast-Q demonstrates a reproducible metric for evaluating patient satisfaction, physical, psychosocial, and sexual well-being.
Our hypothesis was that patients who were approved for breast reduction would also demonstrate improvement in the Disability of Arm, Shoulder and Hand (DASH) questionnaire (DASH questionnaire). If the patient’s functional improvement is validated by a well-respected functional capacity measurement in the DASH score, breast reduction surgery now becomes a measurable functional treatment which strongly correlates with improved patient well-being.
An algorithm which identifies significant Breast-Q and DASH scores in addition to Schnur scale measurements, pre-operative photographs, and physical exam measurements should provide a fast track pathway to insurance authorization for medically necessary breast reduction surgery. Here we propose such a clinical pathway for guidance on treatment.
Methods/Technique: We conducted a retrospective chart review of 350 patients who were operated on between 2005 and 2017. Patients were sent questionnaires asking them to evaluate their breast symptoms before surgery and at present, based on a breast Q questionnaire (scores were graded on a scale of 0 to 100, where higher numbers correlated to stronger satisfaction). Patients were selected based on surgery dates between 2005 and 2017 who were operated on by either the senior author, RBC or associate surgeon, RBN. They were simultaneously sent requests for information on their symptoms of disability of arm shoulder and hand (DASH score) before surgery and their current symptomatology (where higher scores correlated with greater symptomatology). Thirty-three patients responded having completed the questionnaire and signing consent to participate in the IRB study. Retrospective chart analysis to identify age and amount of tissue to be removed were also employed. Data obtained underwent statistical analysis with Paired T Test for BreastQ data and Wilcoxon Signed ranks for the DASH data.
Results/Complications: There were 33 respondents (n=33) with an average age of 34.5 years. Data analysis performed using paired T tests from the BreastQ data showed that there was a statically significant difference in pre-op and post-op psychosocial well-being 54.0 vs 81.5 (p<0.001), pre-op and post-op satisfaction with breasts 38.5 vs 80.3 (p<0.001), and pre-op and post-op physical well-being 60.8 vs 84.6 (p<0.001). The average post op satisfaction with nipples was 92.3 (SD=16.5). Statistical significance was also demonstrated for Wilcoxon ranks of the pre-op and post-op DASH scores for the 25th percentile 4.7 vs 0 (p<0.001), for the 50th percentile 22.3 vs 0 (p<0.001), and for the 75th percentile 40.4 vs 6.4 (p<0.001).
Conclusion: By introducing a highly credentialed functional impairment analysis (DASH score) as part of the authorization process, in conjunction with the well-established Breast-Q analysis, a simple algorithm flowchart can be employed by insurance companies and physicians to pre-certify patients for breast reduction who are most likely to see sexual, physical and psychosocial wellness benefits, as well as functional improvement. These pre-operative measurements screen out the patients who are cosmetic or who are unlikely to have wellness or functional improvement, and therefore would not be good candidates for surgery.
Statistically significant improvement in both Breast-Q and DASH scores following surgery shows strong correlation with improved sexual, physical, and psychosocial wellness and functional arm activity following breast reduction. These improvements directly translate to better health and well-being of patients. 