Clifford Charles Sheckter

All Publications

• Homelessness and Inpatient Burn Outcomes in the United States. Journal of burn care & research : official publication of the American Burn Association Kiwanuka, H., Maan, Z., Rochlin, D., Curtin, C., Karanas, Y., Sheckter, C. C. 2019

  Abstract

  INTRODUCTION: Burn injuries are common in the homeless population. Little is known regarding whether homeless patients experience different outcomes when admitted for burns. We aim to 1) characterize the admitted homeless burn population, and 2) investigate differences in inpatient outcomes between the homeless and non-homeless populations.METHODS: A retrospective cohort study was performed utilizing the Nationwide Inpatient Sample. Adult patients with complete data for burn characteristics were extracted. Variables included demographic, burn, and facility characteristics. Homelessness was identified with International Classification of Disease 9th edition codes. Outcomes were modeled with regression analysis and included length of stay, total operations, charges, disposition, and patient safety indicators.RESULTS: 43,872 encounters were included of which 0.76% were homeless. Homeless encounters were more likely to be male (p<0.001) and Medicaid-insured (p<0.001). Flame and frostbite injuries were more likely (p<0.001), and the mean %TBSA was smaller (15.0 versus 16.8, p<0.001). After adjustment, homeless patients had greater lengths of stay (11.5 vs. 9.6, p=0.046), greater charges ($73,597 vs. $66,909, p=0.030), fewer operations (p=0.016), and three times higher likelihood leaving against medical advice (p=0.002). There was no difference in patient safety indicators or mortality.CONCLUSION: Homeless burn admissions represent a unique cohort that carries a higher comorbidity burden and experiences longer lengths of stay with greater difficulty in disposition. Ironically, these patients accumulate more charges with limited means to pay. Even though no differences were observed in patient safety indicators or mortality, further research is needed to understand how the challenges within this population affect their recovery.

  View details for DOI 10.1093/jbcr/irz045

  View details for PubMedID 30938433

• Applying a value-based care framework to post-mastectomy reconstruction. Breast cancer research and treatment Sheckter, C. C., Matros, E., Lee, G. K., Selber, J. C., Offodile, A. C. 2019

  Abstract

  PURPOSE: Reconstructive breast surgeons, like all procedural care providers, face a transition from volume reimbursement (i.e., per unit of service) to value-based care. Value can be defined as the relationship between outcomes and costs, or more specifically healthcare outcomes per unit cost. Although the definition of a meaningful outcome for a particular treatment can vary, some weighted average of survival, function, complications, process measures, and patient-reported outcomes (PROs) comprise the numerator, while the total cost of a complete care cycle is the denominator. We aim to construct a value-based care framework for reconstructive surgery using post-mastectomy reconstruction as an organizing element.METHODS: A preexisting value framework was applied to breast reconstruction using expert opinion and literature review. Domains and associated realization strategies were constructed based on established health economic principles.RESULTS: Seven domains were identified including: implementing an inclusive and transparent process for stakeholder engagement, practicing clear and explicit treatment goals, anchoring care delivery to the patient perspective, maximizing value across the entire continuum of care, optimizing operation efficiency, and scaling best practices with implementation science.CONCLUSIONS: In the near future, reconstructive plastic surgeons may be asked to solve clinical problems for fixed reimbursement (i.e. bundled payments). Considering breast reconstruction through a value lens provides surgeons with an opportunity to adapt and thrive in an evolving healthcare landscape. Lastly, we hope this document helps promote value assessment within the specialty.

  View details for DOI 10.1007/s10549-019-05212-0

  View details for PubMedID 30937659

• Reply; Reply: "The Influence of Physician Payments on the Method of Breast Reconstruction: a National Claims Analysis". Plastic and reconstructive surgery Sheckter, C. C., Matros, E. 2019

  View details for DOI 10.1097/PRS.0000000000005660

  View details for PubMedID 30907795

• Five Years Experience With Meek Grafting in the Management of Extensive Burns in an Adult Burn Center PLASTIC SURGERY Houschyar, K., Tapking, C., Nietzschmann, I., Rein, S., Weissenberg, K., Chelliah, M., Duscher, D., Maan, Z., Philipps, H., Sheckter, C., Reichelt, B., Branski, L., Siemers, F. 2019; 27 (1): 44–48

  Abstract

  In extensive burn injuries with lack of donor sites for skin grafting, the Meek technique of skin expansion can be an efficient and effective method in covering extensive wounds. The aim of this retrospective study was to present our experience with the Meek technique of grafting.We performed a retrospective analysis of patients from our burn center who underwent Meek grafting between 2012 and 2016. Demographics, burn details, clinical course, operative management, and outcomes were collected and analyzed from patient records and operative notes. Outcome measures, including graft take rate, complications and need for further surgery, were recorded.Twelve patients had Meek grafting. The average age was 38 years (range: 15-66). The average percent total body surface area burned was 54.3% (range: 31%-77%). Eighty-three percent of grafted areas healed well, and no regrafting was necessary. In the remaining 17%, infection and hematoma were the leading cause of graft failure.Meek grafting constitutes a rapid and efficient surgical approach for the skin coverage of extensive full-thickness burn injuries with limited autograft donor sites.

  View details for DOI 10.1177/2292550318800331

  View details for Web of Science ID 000460036100008

  View details for PubMedID 30854361

  View details for PubMedCentralID PMC6399769

• Resident Sensitive Processes of Care: the Impact of Surgical Residents on Inpatient Testing. Journal of the American College of Surgeons Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A., Hawn, M. 2019

  Abstract

  INTRODUCTION: Healthcare value is a national priority, and there are substantial efforts to reduce overuse of low-value testing. Residency training programs and teaching hospitals have been implicated in excessive testing. We evaluated the impact of surgery residents on the frequency of inpatient testing and investigated potential inter-resident variation.METHODS: Inpatient laboratory and imaging orders placed on general surgery services were extracted from an academic institution from 2014-2016 and linked to National Surgical Quality Improvement Program data. Using negative binomial mixed effects regression with unstructured covariance, we evaluated the frequency of testing orders compared to median utilization, accounting for case, patient, and attending-level variables.RESULTS: 111,055 laboratory and 7,360 imaging orders were linked with 2,357 patients. Multivariable analysis demonstrated multiple significant predictors of increased testing including: postoperative complications, medical comorbidities, length of stay, relative value units, attending surgeon, and resident surgeon (95% confidence intervals >1, p<0.05). Compared to the median resident physician, 47 residents (37.9%) placed significantly more laboratory orders, and 2 residents (1.6%) placed significantly more imaging orders (95% confidence interval >1, p<0.05). Resident identification explained 3.5% of the total variation in laboratory ordering and 4.9% in imaging orders.CONCLUSIONS: Individual surgical residents had a significant association with the frequency of inpatient testing after adjusting for attending, case, and patient-level variables. There was greater resident variation in laboratory testing compared to imaging, yet surgical residents had small contributions to the total variation in both laboratory and imaging testing. Our models provide a means of identifying high utilizers and could be used to educate residents on their ordering patterns.

  View details for DOI 10.1016/j.jamcollsurg.2018.12.037

  View details for PubMedID 30660819

• The impact of skin allograft on inpatient outcomes in the treatment of major burns 20-50% total body surface area - A propensity score matched analysis using the nationwide inpatient sample. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Li, A., Pridgen, B., Trickey, A. W., Karanas, Y., Curtin, C. 2018

  Abstract

  BACKGROUND: Human cadaveric skin (allograft) is used in treating major burns both as temporizing wound coverage and a means of testing wound bed viability following burn excision. There is limited information on outcomes, and clinicians disagree on indications for application in intermediate-sized burns. This study aims to improve understanding of allograft use in 20-50% total body surface burns by assessing current utilization and evaluating inpatient outcomes.METHODS: Discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality assessed 3557 major burn patients (>second degree depth and 20-50% TBSA) undergoing operative treatment. Outcomes were evaluated with propensity score matching. The primary outcome was mortality with secondary outcomes including complications, length of stay, total burn operations, and charges.RESULTS: After matching, 771 allografted patients were paired with 1774 controls. Covariate mean standard differences were all <11% after matching. The average treatment effect (ATE) of allograft on inpatient mortality was an increase of 2.8% (95% CI 0.2-5.3%, p=0.041). Allograft ATEs were all significantly higher for secondary outcomes: composite complication index increased 0.13 (95% CI 0.07-0.20, p<0.001), length of stay 8.4days (95% CI 6.1-1.9 days, p<0.001), total burn operations 1.6 (95% CI 1.4-1.9, p<0.001), and total charges $139,476 [$100,716-178,236, p<0.001).CONCLUSIONS: Allograft use in major burns 20-50% TBSA was associated with a significant increase in inpatient mortality. There was a notable correlation with increased inpatient complications, longer length of stay, more burn operations, and greater total charges. Better studies are needed to justify the use of this costly and limited resource in the intermediate sized major burn population.

  View details for DOI 10.1016/j.burns.2018.08.005

  View details for PubMedID 30527451

• National trends in contralateral prophylactic mastectomy in women with locally advanced breast cancer. Journal of surgical oncology Panchal, H., Pilewskie, M. L., Sheckter, C. C., Albornoz, C. R., Razdan, S. N., Disa, J. J., Cordeiro, P. G., Mehrara, B. J., Matros, E. 2018

  Abstract

  BACKGROUND AND OBJECTIVES: Women with unilateral early-stage breast cancer are increasingly choosing contralateral prophylactic mastectomy (CPM) despite the absence of survival benefits and increased risk of surgical complications. Data are lacking on whether this trend extends to women with clinically locally advanced nonmetastatic (cT4M0) cancer. This study aims to estimate national CPM trends in women with unilateral cT4M0 breast cancer.METHODS: Women aged≥18 years, who underwent mastectomy during 2004 to 2014 for unilateral cT4M0 breast cancer were identified using the National Cancer Database and grouped as all locally advanced (T4), chest wall invasion, skin nodule/ulceration, or both (T4abc), and inflammatory (T4d) cancer. Poisson regression for trends and logistic modeling for predictors of CPM were performed.RESULTS: Of 23 943 women, 41% had T4abc disease and 35% T4d. Cumulative CPM rates were 15%, 23%, and 18%, for the T4abc, T4d, and all T4 groups, respectively. Trend analysis revealed a significant upsurge in CPM demonstrating 12% annual growth for T4abc tumors, 8% for T4d and 9% for all T4 (all P<0.001).CONCLUSIONS: Increasing numbers of women with unilateral cT4M0 breast cancer are undergoing CPM. This rising trend warrants further research to understand stakeholders' preferences in surgical decision-making for women with locally advanced breast cancer.

  View details for DOI 10.1002/jso.25315

  View details for PubMedID 30480805

• Single Stage Repair of #30 Facial Cleft with Bone Morphogenic Protein PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Sheckter, C. C., Mittermiller, P., Hung, K., Maan, Z., Rochlin, D., Menard, R. M. 2018; 6 (11)

  View details for DOI 10.1097/GOX.0000000000001937

  View details for Web of Science ID 000453901600007

• Regional Variation and Trends in the Timing of Lower Extremity Reconstruction: A 10-Year Review of the Nationwide Inpatient Sample PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Pridgen, B., Li, A., Curtin, C., Momeni, A. 2018; 142 (5): 1337–47

  View details for DOI 10.1097/PRS.0000000000004885

  View details for Web of Science ID 000448330200080

• Resident Sensitive Processes of Care: The Impact of Individual Surgical Residents on Laboratory Testing Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A. M., Hawn, M. T. ELSEVIER SCIENCE INC. 2018: S228–S229

  View details for DOI 10.1016/j.jamcollsurg.2018.07.499

  View details for Web of Science ID 000447760600450

• Systems Delivery Innovation for Alzheimer Disease. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry Bott, N. T., Sheckter, C. C., Yang, D., Peters, S., Brady, B., Plowman, S., Borson, S., Leff, B., Kaplan, R. M., Platchek, T., Milstein, A. 2018

  Abstract

  OBJECTIVE: The authors describe a comprehensive care model for Alzheimer disease (AD) that improves value within 1-3 years after implementation by leveraging targeted outpatient chronic care management, cognitively protective acute care, and timely caregiver support.METHODS: Using current best evidence, expert opinion, and macroeconomic modeling, the authors designed a comprehensive care model for AD that improves the quality of care while reducing total per capita healthcare spending by more than 15%. Cost savings were measured as reduced spending by payers. Cost estimates were derived from medical literature and national databases, including both public and private U.S. payers. All estimates reflect the value in 2015 dollars using a consumer price index inflation calculator. Outcome estimates were determined at year 2, accounting for implementation and steady-state intervention costs.RESULTS: After accounting for implementation and recurring operating costs of approximately $9.5 billion, estimated net cost savings of between $13 and $41 billion can be accomplished concurrently with improvements in quality and experience of coordinated chronic care ($0.01-$6.8 billion), cognitively protective acute care ($8.7-$26.6 billion), timely caregiver support ($4.3-$7.5 billion), and caregiver efficiency ($4.1-$7.2 billion).CONCLUSION: A high-value care model for AD may improve the experience of patients with AD while significantly lowering costs.

  View details for DOI 10.1016/j.jagp.2018.09.015

  View details for PubMedID 30477913

• Increasing ambulatory treatment of pediatric minor burns-The emerging paradigm for burn care in children. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Kiwanuka, H., Maan, Z., Pirrotta, E., Curtin, C., Wang, N. E. 2018

  Abstract

  INTRODUCTION: Innovations in topical burn treatment along with a drive toward value-based care are steering burn care to the outpatient setting. Little is known regarding what characteristics predict outpatient treatment of pediatric minor burns and whether there is a temporal trend toward this treatment paradigm.METHODS: A retrospective cohort study was performed using California's Office of Statewide Health Planning and Development linked emergency department and inpatient database (2005-2013). All patients under 18years of age with a primary burn diagnosis were extracted. Using patient and facility level variables, we used regression modeling to evaluate predictors of outpatient burn treatment and temporal trends.RESULTS: There were 16,480 pediatric minor burn encounters during the period. 56.4% were male, 85.3% had <10% total body surface area (TBSA), 76.3% were scald or contact, and 77.3% were at deepest depth 2nd degree. Multiple variables predicted an increased likelihood of discharge home including older age(p<0.001), smaller TBSA(p<0.001), and superficial/partial thickness burns(<0.001). Children of Hispanic and Black race were less likely to be discharged home compared to White and Asian peers(p=<0.001). On Poisson modeling, the incidence rate ratio over the 9-year period for home discharge was 1.004 (95% CI 1.001-1.008, p=0.032).CONCLUSION: Older patients and those with more superficial burns were more likely to be treated as outpatients. Black and non-white Hispanic race was associated with inpatient admission. There is a growing trend toward ambulatory treatment of minor burns in the pediatric population. Further research is needed to assess whether outpatient treatment of pediatric minor burns results in greater readmissions.

  View details for DOI 10.1016/j.burns.2018.08.031

  View details for PubMedID 30236815

• Trends in Physician Payments for Breast Reconstruction (vol 141, pg 493e, 2018) PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Yi, D., Panchal, H. J., Rubin, D., Razdan, S. N., Pusic, A. L., McCarthy, C. M., Cordeiro, P. G., Disa, J. J., Mehrara, B., Matros, E. 2018; 142 (3): 833

  View details for DOI 10.1097/PRS.0000000000004972

  View details for Web of Science ID 000442857300074

• Breast Reconstruction Following Breast Cancer Treatment-2018. JAMA Lee, G. K., Sheckter, C. C. 2018

  View details for DOI 10.1001/jama.2018.12190

  View details for PubMedID 30178060

• Trends and inpatient outcomes for palliative care services in major burn patients: A 10-year analysis of the nationwide inpatient sample. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Hung, K., Rochlin, D., Maan, Z., Karanas, Y., Curtin, C. 2018

  Abstract

  INTRODUCTION: Despite advances in critical care and the surgical management of major burns, highly moribund patients are unlikely to survive. Little is known regarding the utilization and effects of palliative care services in this population.METHODS: All major burn hospitalizations were identified within the Nationwide Inpatient Sample. Patients were characterized by burn, demographic, facility, and diseases factors. Palliative care services were identified with International Classification Disease 9th edition code V6.67. Temporal trends were assessed with Poisson modeling. Inpatient mortality and death without surgical intervention were assessed with logistic regression. Outcomes were stratified by modified Baux scores.RESULTS: 7424 major burns were included; 1.9% received palliative care services. Patients receiving palliation had a mean age of 63.6 years (SD 19.6), mean total body surface area of 62.2% (SD 24.9%), and mean modified Baux score of 127.1 (SD 26.7). Adjusting for covariates, the incidence rate ratio was 1.42 over the 10-year period (95% CI, 1.31-1.54, p<0.001). Independent predictors of palliative consultations included older age, larger burns, deeper burns, and higher Elixhauser comorbidity score. Among patients with modified Baux scores between 100-153, those receiving palliative care services were significantly more likely to die without surgery, OR 3.24 (95% CI 1.13-10.39, p=0.029), with no significant difference in mortality, OR 11.72 (95% CI 0.87-22.57, p=0.051) CONCLUSION AND RELEVANCE: Palliative care services were increasingly used during the study period. Palliative care services in highly moribund burn patients do not impact survival and may decrease the likelihood of surgical intervention in select patients.

  View details for DOI 10.1016/j.burns.2018.07.012

  View details for PubMedID 30115531

• The Influence of Physician Payments on the Method of Breast Reconstruction: a National Claims Analysis. Plastic and reconstructive surgery Sheckter, C. C., Panchal, H. J., Razdan, S. N., Rubin, D., Yi, D., Disa, J. J., Mehrara, B., Matros, E. 2018

  Abstract

  INTRODUCTION: Flap-based breast reconstruction demands greater operative labor and offers superior patient reported outcomes compared to implants. However, implants continue to outpace flaps, with some suggesting inadequate remuneration as one barrier. This study aims to characterize market variation in the ratio of implants to flaps and assess correlation with physician payments.METHODS: Using the Blue Health Intelligence database from 2009-2013, patients were identified who received tissue expander (i.e. implant) or free-flap breast reconstruction. The ratio of implants/flaps and physician payments was assessed using quadratic modeling. Matched bootstrapped samples from the early and late periods generated probability distributions, approximating the odds of surgeons switching reconstructive method.RESULTS: 21,259 episodes of breast reconstruction occurred within 122 U.S. markets. The distribution of implant/flap ratio varied by market, ranging from 5 percentile at 1.63 to 95 percentile at 43.7 (median 6.19). Modeling the implant/flap ratio vs. implant payment showed a more elastic quadratic equation (f(x)=0.955x + 2.766x) compared to the function for flap/implant ratio vs. flap payment (f(x)=-0.061x + 0.734x). Probability modeling demonstrated that switching the reconstructive method from implants to flaps with 0.75 probability required a $1,610 payment increase, while switching from flaps to implants at the same certainty occurred at a loss of $960.CONCLUSION: There was a correlation between the ratio of flaps/implants and physician reimbursement by market. Switching from implants to flaps required large surgeon payment increases. Despite a revenue value unit schedule over twice as high for flaps, current flap reimbursements do not appear commensurate with physician effort.

  View details for DOI 10.1097/PRS.0000000000004727

  View details for PubMedID 29979366

• Overuse of Air Ambulance Services at a Regional Burn Center. Journal of burn care & research : official publication of the American Burn Association Chattopadhyay, A., Sheckter, C. C., Long, C., Karanas, Y. 2018; 39 (4): 598–603

  Abstract

  Air ambulances rapidly transport burn patients to regional centers, expediting treatment. However, limited guidelines on transport introduce the risk for inappropriate triage and overuse. Given the additional costs of air vs ground transport, evaluation of transportation use is prudent. A retrospective review of all burn patients transported by helicopter to a single burn center from May 2013 to January 2016 was performed. Data gathered included patient demographics, transfer origin, burn characteristics, and inpatient hospital stay. The primary outcome was appropriate triage based on literature-derived severity criteria. Secondary outcomes included independent predictors of emergent treatments and the cost of overuse. Sixty-eight patients were examined, of which 66% met air ambulance criteria. Inappropriately triaged patients sustained smaller burns (% TBSA 4.8 vs 25.3, P < .001), had fewer flame burns (48 vs 82%, P = .007), had decreased lengths of stay (mean days 8.2 vs 21.2, P = .002), underwent fewer inpatient surgeries (mean 0.69 vs 2.57, P = .006), received no emergent procedures (0 vs 56%, P < .001), and suffered no deaths (0 vs 9%, P < .001). Independent predictors of emergent procedures included transport for airway concern (odds ratio = 45.29, confidence interval = 2.49-825.21, P = .010) and % TBSA (odds ratio = 1.13, confidence interval = 1.02-1.27, P = .019). If the 23 inappropriately triaged patients had been transported by ground, a cost savings of $106,370 could have been realized using 2016 California Medicare reimbursements (per-patient savings of $4624). While appropriate in most circumstances, the cost of air ambulances should be weighed in light of their utility, as a significant proportion of patients did not benefit from air transport.

  View details for DOI 10.1093/jbcr/irx028

  View details for PubMedID 29901800

• To Cut is to Cure The Surgeon's Role in Improving Value ANNALS OF SURGERY Jopling, J. K., Sheckter, C. C., James, B. C. 2018; 267 (5): 817–19

  View details for DOI 10.1097/SLA.0000000000002596

  View details for Web of Science ID 000430269000021

  View details for PubMedID 29189380

• Trends in Physician Payments for Breast Reconstruction PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Yi, D., Panchal, H. J., Razdan, S. N., Pusic, A. L., McCarthy, C. M., Cordeiro, P. G., Disa, J. J., Mehrara, B., Matros, E. 2018; 141 (4): 493E–499E

  Abstract

  Prosthetic breast reconstruction rates have risen in the United States, whereas autologous techniques have stagnated. Meanwhile, single-institution data demonstrate that physician payments for prosthetic reconstruction are rising, while payments for autologous techniques are unchanged. This study aims to assess payment trends and variation for tissue expander and free flap breast reconstruction.The Blue Health Intelligence database was queried from 2009 to 2013, identifying women with claims for breast reconstruction. Trends in the incidence of surgery and physician reimbursement were characterized by method and year using regression models.There were 21,259 episodes of breast reconstruction, with a significant rise in tissue expander cases (incidence rate ratio, 1.09; p < 0.001) and an unchanged incidence of free flap cases (incidence rate ratio, 1.02; p = 0.222). Bilateral tissue expander cases reimbursed 1.32 times more than unilateral tissue expanders, whereas bilateral free flaps reimbursed 1.61 times more than unilateral variants. The total growth in adjusted tissue expander mean payments was 6.5 percent (from $2232 to $2378) compared with -1.8 percent (from $3858 to $3788) for free flaps. Linear modeling showed significant increases for tissue expander reimbursements only. Surgeon payments varied more for free flaps (the 25th to 75th percentile interquartile range was $2243 for free flaps versus $987 for tissue expanders).The incidence of tissue expander cases and reimbursements rose over a period where the incidence of free flap cases and reimbursements plateaued. Reasons for stagnation in free flaps are unclear; however, the opportunity cost of performing this procedure may incentivize the alternative technique. Greater payment variation in autologous reconstruction suggests the opportunity for negotiation with payers.

  View details for DOI 10.1097/PRS.0000000000004205

  View details for Web of Science ID 000428668900003

  View details for PubMedID 29595721

  View details for PubMedCentralID PMC5880309

• Assessing value in breast reconstruction: A systematic review of cost-effectiveness studies JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Sheckter, C. C., Matros, E., Momeni, A. 2018; 71 (3): 353–65

  Abstract

  Breast reconstruction is one of the most common procedures performed by plastic surgeons and is achieved through various choices in both technology and method. Cost-effectiveness analyses are increasingly important in assessing differences in value between treatment options, which is relevant in a world of confined resources. A thorough evaluation of the cost-effectiveness literature can assist surgeons and health systems evaluate high-value care models.A systematic review of PubMed, Web of Science, and the Cost-Effectiveness Analysis Registry was conducted. Two reviewers independently evaluated all publications up until August 17, 2017.After removal of duplicates, 1996 records were screened, from which 53 studies underwent full text review. All the 13 studies included for final analysis mention an incremental cost-effectiveness ratio. Five studies evaluated the cost-effectiveness of technologies including acellular dermal matrix (ADM) in staged prosthetic reconstruction, ADM in direct-to-implant (DTI) reconstruction, preoperative computed tomography angiography in autologous reconstruction, indocyanine green dye angiography in evaluating anastomotic patency, and abdominal mesh reinforcement in abdominal tissue transfer. The remaining eight studies evaluated the cost-effectiveness of different reconstruction methods. Cost-effective strategies included free vs. pedicled abdominal tissue transfer, DTI vs. staged prosthetic reconstruction, and fascia-sparing variants of free abdominal tissue transfer.Current evidence demonstrates multiple cost-effective technologies and methods in accomplishing successful breast reconstruction. Plastic surgeons should be well informed of such economic models when engaging payers and policymakers in discussions regarding high-value breast reconstruction.

  View details for DOI 10.1016/j.bjps.2017.09.010

  View details for Web of Science ID 000424928300010

  View details for PubMedID 29196176

• Conceptual Considerations for Payment Bundling in Breast Reconstruction PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Razdan, S. N., Disa, J. J., Mehrara, B. J., Matros, E. 2018; 141 (2): 294–300

  Abstract

  Rising health care costs and quality demands have driven both the Centers for Medicare and Medicaid Services and the private sector to seek innovations in health system design by placing institutions at financial risk. Novel care models, such as bundled reimbursement, aim to boost value though quality improvement and cost reduction. The Center for Medicare and Medicaid Innovation is leading the charge in this area with multiple pilots and mandates, including Comprehensive Care for Joint Replacement. Other high-cost and high-volume procedures could be considered for bundling in the future, including breast reconstruction. In this article, conceptual considerations surrounding bundling of breast reconstruction are discussed.

  View details for DOI 10.1097/PRS.0000000000004019

  View details for Web of Science ID 000425474200035

  View details for PubMedID 29369980

• Efficacy and Safety of Titanium Miniplates for Patients Undergoing Septorhinoplasty JAMA FACIAL PLASTIC SURGERY Mittermiller, P. A., Sheckter, C. C., Most, S. P. 2018; 20 (1): 82–84

  View details for DOI 10.1001/jamafacial.2017.0964

  View details for Web of Science ID 000423037400015

  View details for PubMedID 29167868

  View details for PubMedCentralID PMC5833670

• Dementia Care, Women's Health, and Gender Equity: The Value of Well-Timed Caregiver Support. JAMA neurology Bott, N. T., Sheckter, C. C., Milstein, A. S. 2017

  View details for DOI 10.1001/jamaneurol.2017.0403

  View details for PubMedID 28492832

• Recovery of a Missile Embolus From the Right Ventricle. Annals of thoracic surgery Marshall, C. D., Ma, M. R., Park, J., Sheckter, C. C., Massoudi, R. A., Ligman, C. M., Jou, R. M., Ogden, W. D. 2017; 103 (1): e69-e71

  Abstract

  Missile embolism is a clinical entity in which a projectile object enters a blood vessel and is carried to a distant part of the body. We present a case of the discovery of an iliac vein to right ventricle missile embolus in a young man, with successful extraction through a right atriotomy. We provide a historical overview of the literature concerning missile embolism, and we argue that whereas acute embolized projectiles should be removed in almost all cases, it may be reasonable to simply observe an asymptomatic chronic missile embolus.

  View details for DOI 10.1016/j.athoracsur.2016.06.107

  View details for PubMedID 28007279

• Individualized Acute Medical Care for Cognitively Impaired Individuals: A Call Always to Pause Before Hospitalization. Journal of the American Geriatrics Society Sheckter, C. C., Bott, N. T., Milstein, A., Leff, B. 2017

  View details for DOI 10.1111/jgs.15105

  View details for PubMedID 28960237

• Preoperative paravertebral blocks for the management of acute pain following mastectomy: a cost-effectiveness analysis. Breast cancer research and treatment Offodile, A. C., Sheckter, C. C., Tucker, A., Watzker, A., Ottino, K., Zammert, M., Padula, W. V. 2017

  Abstract

  Preoperative paravertebral blocks (PPVBs) are routinely used for treating post-mastectomy pain, yet uncertainties remain about the cost-effectiveness of this modality. We aim to evaluate the cost-effectiveness of PPVBs at common willingness-to-pay (WTP) thresholds.A decision analytic model compared two strategies: general anesthesia (GA) alone versus GA with multilevel PPVB. For the GA plus PPVB limb, patients were subjected to successful block placement versus varying severity of complications based on literature-derived probabilities. The need for rescue pain medication was the terminal node for all postoperative scenarios. Patient-reported pain scores sourced from published meta-analyses measured treatment effectiveness. Costing was derived from wholesale acquisition costs, the Medicare fee schedule, and publicly available hospital charge masters. Charges were converted to costs and adjusted for 2016 US dollars. A commercial payer perspective was adopted. Incremental cost-effectiveness ratios (ICERs) were evaluated against WTP thresholds of $500 and $50,000 for postoperative pain control.The ICER for preoperative paravertebral blocks was $154.49 per point reduction in pain score. 15% variation in inpatient costs resulted in ICER values ranging from $124.40-$180.66 per pain point score reduction. Altering the probability of block success by 5% generated ICER values of $144.71-$163.81 per pain score reduction. Probabilistic sensitivity analysis yielded cost-effective trials 69.43% of the time at $500 WTP thresholds.Over a broad range of probabilities, PPVB in mastectomy reduces postoperative pain at an acceptable incremental cost compared to GA. Commercial payers should be persuaded to reimburse this technique based on convincing evidence of cost-effectiveness.

  View details for DOI 10.1007/s10549-017-4371-9

  View details for PubMedID 28677010

• Reconstruction following abdominoperineal resection (APR): Indications and complications from a single institution experience JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Sheckter, C. C., Shakir, A., Vo, H., Tsai, J., Nazerali, R., Lee, G. K. 2016; 69 (11): 1506-1512

  Abstract

  Abdominoperineal resection (APR) is the surgical treatment of low-lying rectal cancers and other pelvic malignancies. Plastic surgery offers a means to close these complicated defects through obliterating dead space, providing tension-free closure, and introducing vascularized tissue into a radiated field. The indications for reconstructive surgery and choice of reconstruction are debatable. This study aims to identify when and which reconstruction is preferred.A retrospective comparative analysis was performed on all patients undergoing APR at Stanford Hospital between 2007 and 2013. Data points included demographics, disease, operative positioning, and postoperative complications. Univariate analysis and multivariate logistic regression analysis were performed to identify markers of flap reconstruction and complications.A total of 178 APRs were performed, of which 51 underwent flap reconstruction. The odds ratio of all complications between flap and primary closure was not significant at 1.36 (0.69-2.66). Independent predictors for flap reconstruction included prone positioning, anal squamous cell carcinoma (SCC), prior smoking, and neoadjuvant chemoradiation therapy. Univariate predictors of flap reconstruction included female gender and combined vaginectomy. Independent predictors of complications included current and prior smoking. Muscle flap closure had lower recipient site complications than V-to-Y advancement closure (20% vs. 50%, p = 0.039).Flap reconstruction following APR is associated with prone positioning, neoadjuvant chemoradiation, female gender, prior smoking, and anal SCC resections. Pedicled muscle flaps had a significantly lower rate of recipient site complications than V-to-Y advancement flaps and therefore should be the flap reconstruction of choice. The vertical rectus abdominis myocutaneous flap was superior to the gracilis flap in terms of the overall reduction of complications.

  View details for DOI 10.1016/j.bjps.2016.06.024

  View details for Web of Science ID 000388293400012

  View details for PubMedID 27538340

• Vermilion Only Cross-lip Flap for Treating Whistle Deformity in Secondary Bilateral Cleft Lip Repair. Plastic and reconstructive surgery. Global open Sheckter, C. C., Menard, R. M. 2016; 4 (10)

  Abstract

  Bilateral cleft lip repairs can result in various secondary deformities. One more commonly seen deformity, the whistle deformity, is characterized by a reduced or absent tubercle, orbicularis muscle diastasis, and abnormalities of the philtrum with notched appearance of cupid's bow. Various techniques have been described to address these problems. One common procedure is the lip-switch flap originally described by Abbe in 1898, which has been modified by various surgeons. In these procedures, lower lip vermilion, mucosa, orbicularis, and lip skin are transposed to the upper lip on a pedicle that is later divided. In all these variations of the lip-switch procedure, the transposed tissue involves the entire lower lip skin-leaving large, unsightly, and unnecessary scars. It also brings abnormal tissue into the philtrum further distorting the upper lip. A modified cross-lip flap that is limited to the taking only mucosa, vermilion, and orbicularis is feasible and provides an optimal reconstruction without compromising additional tissue.

  View details for PubMedID 27826484

  View details for PubMedCentralID PMC5096539

• Burns resulting from spontaneous combustion of electronic cigarettes: a case series. Burns & trauma Sheckter, C., Chattopadhyay, A., Paro, J., Karanas, Y. 2016; 4: 35-?

  Abstract

  Electronic cigarette (e-cigarette) sales have grown rapidly in recent years, coinciding with a public perception that they are a safer alternative to traditional cigarettes. However, there have been numerous media reports of fires associated with e-cigarette spontaneous combustion.Three severe burns caused by spontaneous combustion of e-cigarettes within a 6-month period were treated at the Santa Clara Valley Medical Center Burn Unit. Patients sustained partial and full-thickness burns. Two required hospitalization and surgical treatment.E-cigarettes are dangerous devices and have the potential to cause significant burns. Consumers and the general public should be made aware of these life-threatening devices.

  View details for PubMedID 27995151

  View details for PubMedCentralID PMC5151131

• Cost-Effectiveness Comparison Between Topical Silver Sulfadiazine and Enclosed Silver Dressing for Partial-Thickness Burn Treatment JOURNAL OF BURN CARE & RESEARCH Sheckter, C. C., Van Vliet, M. M., Krishnan, N. M., Garner, W. L. 2014; 35 (4): 284-290

  Abstract

  The standard treatment of partial-thickness burns includes topical silver products such as silver sulfadiazine (SSD) cream and enclosed dressings including silver-impregnated foam (Mepilex Ag; Molnlycke Health Care, Gothenburg, Sweden) and silver-laden sheets (Aquacel Ag; ConvaTec, Skillman, NJ). The current state of health care is limited by resources, with an emphasis on evidence-based outcomes and cost-effective treatments. This study includes a decision analysis with an incremental cost-utility ratio comparing enclosed silver dressings with SSD in partial-thickness burn patients with TBSA less than 20%. A comprehensive literature review was conducted to identify clinically relevant health states in partial-thickness burn patients. These health states include successful healing, infection, and noninfected delayed healing requiring either surgery or conservative management. The probabilities of these health states were combined with Medicare CPT reimbursement codes (cost) and patient-derived utilities to fit into the decision model. Utilities were obtained using a visual analog scale during patient interviews. Expected cost and quality-adjusted life years (QALYs) were calculated using the roll-back method. The incremental cost-utility ratio for enclosed silver dressing relative to SSD was $40,167.99/QALY. One-way sensitivity analysis of complication rates confirmed robustness of the model. Assuming a maximum willingness to pay $50,000/QALY, the complication rate for SSD must be 22% or higher for enclosed silver dressing to be cost effective. By varying complication rates for SSD and enclosed silver dressings, the two-way sensitivity analysis demonstrated the cost effectiveness of using enclosed silver dressing at the majority of complication rates for both treatment modalities. Enclosed silver dressings are a cost-effective means of treating partial thickness burns.

  View details for DOI 10.1097/BCR.0b013e3182a36916

  View details for Web of Science ID 000338847800020

  View details for PubMedID 24121806

• Simulation of plastic surgery and microvascular procedures using perfused fresh human cadavers JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Carey, J. N., Rommer, E., Sheckter, C., Minneti, M., Talving, P., Wong, A. K., Garner, W., Urata, M. M. 2014; 67 (2): E42-E48

  Abstract

  Surgical simulation models are often limited by their lack of fidelity, which hinders their essential purpose, making a better surgeon. Fresh cadaveric tissue is a superior model of simulation owing to its approximation of live tissue. One major unresolved difference between dead and live tissue is perfusion. Here, we propose a means of enhancing the fidelity of cadaveric simulation through the development of a perfused cadaveric model whereby simulation is further able to approach life-like surgery and teach one of the more technically demanding skills of plastic surgery: microsurgery.Fresh tissue human cadavers were procured according to university protocol. Perfusion was performed via cannulation of large vessels, and arterial and venous pressure was maintained by centrifugal circulation. Skin perfusion was evaluated with incisions in the perfused regions and was evaluated using indocyanine green angiography. Surgical simulations were selected to broadly evaluate applicability to plastic surgical education.Surgical simulation of 38 procedures ranging in complexity from skin excisions to microsurgical cases was performed with high priority given to the accurate simulation of clinical procedures. Flap dissections included perforator flaps, muscle flaps, and fasciocutaneous flaps. Effective perfusion was noted with ICG angiography and notable bleeding vessels. Microsurgical flap transfer was successfully performed.We report the establishment of a high fidelity surgical simulation using a perfused fresh tissue model in a realistic environment akin to the operating room. We anticipate utilization of this model prior to entering the operating room will enhance surgical ability and offer a valuable resource in plastic surgical education.

  View details for DOI 10.1016/j.bjps.2013.09.026

  View details for Web of Science ID 000330121900002

  View details for PubMedID 24094541

• Intra-abdominal pedicled rectus abdominis muscle flap for treatment of high-output enterocutaneous fistulae: Case reports and review of literature JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Carey, J. N., Sheckter, C. C., Watt, A. J., Lee, G. K. 2013; 66 (8): 1145-1148

  Abstract

  Despite advances in nutritional supplementation, sepsis management, percutaneous drainage and surgical technique, enterocutaneous fistulae remain a considerable source of morbidity and mortality. Use of adjunctive modalities including negative pressure wound therapy and fibrin glue have been shown to improve the rapidity of fistula closure; however, the overall rate of closure remains poor. The challenge of managing chronic, high-output proximal enterocutaneous fistulae can be successfully achieved with appropriate medical management and intra-abdominal placement of pedicled rectus abdominis muscle flaps. We report two cases of recalcitrant high output enterocutaneous fistulae that were treated successfully with pedicled intra-abdominal rectus muscle flaps. Indications for pedicled intra-abdominal rectus muscle flaps include persistent patency despite a reasonable trial of non-operative intervention, failure of traditional operative interventions (serosal patch, Graham patch), and persistent electrolyte and nutritional abnormalities in the setting of a high-output fistula.

  View details for DOI 10.1016/j.bjps.2012.12.008

  View details for Web of Science ID 000321441300026

  View details for PubMedID 23317765

• Incorporation of Fresh Tissue Surgical Simulation into Plastic Surgery Education: Maximizing Extraclinical Surgical Experience JOURNAL OF SURGICAL EDUCATION Sheckter, C. C., Kane, J. T., Minneti, M., Garner, W., Sullivan, M., Talving, P., Sherman, R., Urata, M., Carey, J. N. 2013; 70 (4): 466-474

  Abstract

  As interest in surgical simulation grows, plastic surgical educators are pressed to provide realistic surgical experience outside of the operating suite. Simulation models of plastic surgery procedures have been developed, but they are incomparable to the dissection of fresh tissue. We evolved a fresh tissue dissection (FTD) and simulation program with emphasis on surgical technique and simulation of clinical surgery. We hypothesized that resident confidence could be improved by adding FTD to our resident curriculum.Over a 5-year period, FTD was incorporated into the curriculum. Participants included clinical medical students, postgraduate year 1 to 7 residents, and attending surgeons. Participants performed dissections and procedures with structured emphasis on anatomical detail, surgical technique, and rehearsal of operative sequence. Resident confidence was evaluated using retrospective pretest and posttest analysis with a 5-point scale, ranging from 1 (least confident) to 5 (most confident). Confidence was evaluated according to postgraduate year level, anatomical region, and procedure.A total of 103 dissection days occurred, and a total of 192 dissections were reported, representing 73 different procedures. Overall, resident predissection confidence was 1.90±1.02 and postdissection confidence was 4.20±0.94 (p<0.001). The average increase in confidence correlated with training year, such that senior residents had greater gains. When compared by anatomical region, confidence was lowest for the head and neck region. When compared by procedure, confidence was lowest for rhinoplasty and face-lift, and highest for radial forearm and latissimus flaps.A high-volume FTD experience was successfully incorporated into the residency program over 5 years. Training with FTD improves resident confidence, and this effect increases with seniority of training. Although initial data demonstrate that resident confidence is improved with FTD, additional evaluation is needed to establish objective evidence that patient outcomes and surgical quality can be improved with FTD.

  View details for DOI 10.1016/j.jsurg.2013.02.008

  View details for Web of Science ID 000320211000006

  View details for PubMedID 23725934

• Scalp Erosion in Ankyloblepharon-Ectodermal Defect-Cleft Lip and/or Palate (AEC Syndrome): Treatment With Acellular Dermal Matrix JOURNAL OF CRANIOFACIAL SURGERY Sheckter, C., Rommer, E., Francis, C., Block, V., Chen, J., Rizvi, M., Urata, M. M., Hammoudeh, J. 2013; 24 (1): E28-E30

  Abstract

  Ankyloblepharon-ectodermal defect-cleft lip and/or palate (AEC syndrome, also known as Hay-Wells syndrome) is an autosomal dominant disease caused by mutation in the p63 gene that is primarily characterized by facial clefting, presence of ankyloblepharon, ectodermal dysplasia, and scalp erosion. Scalp erosion is perhaps the most debilitating manifestation of AEC due to its problematic treatment that is fraught with failure given the underlying pathology of the p63 mutation causing dysfunctional wound healing. Management is often targeted in a stepwise fashion, beginning with daily baths, light debridement, and emollients and progressing to extensive skin excision. Skin grafting has limited success and, inevitably, infections requiring aggressive debridement and antibiotic therapy result from dysfunctional healing. The use of acellular dermal matrix for treatment of scalp erosion is a novel approach attempted in a patient with severe scalp disease. Here we report her case and the failure of treatment, along with possible explanations and suggestions for future therapy.

  View details for DOI 10.1097/SCS.0b013e3182688c32

  View details for Web of Science ID 000314853300014

  View details for PubMedID 23348327

• Multifocal Lipoblastoma of the Face JOURNAL OF CRANIOFACIAL SURGERY Sheckter, C. C., Francis, C. S., Block, V., Lypka, M., Rizvi, M., Urata, M. M. 2012; 23 (6): E585-E587

  Abstract

  Lipoblastoma is a rare benign neoplasm found exclusively in the pediatric population that can occur anywhere in the body, most commonly seen in the extremities but also found in the face. We report an 8-month-old female subject who presented with multifocal soft tissue masses of the face. The diagnosis of lipoblastoma was made in 2 separate locations after surgical resection. Subsequent surgery was performed at the cheek site in an attempt to remove further mass, resulting in discovery of 2 other discrete tumors found to be lipoblastomas. Although the literature reports recurrence rates ranging from 14% to 27%, to our knowledge, aside from a case of Proteus syndrome, there are no known reports of multiple lipoblastomas in the literature. Presentation of the case, review of pertinent literature, and consideration of congenital infiltrative lipomatosis of the face follow.

  View details for DOI 10.1097/SCS.0b013e31826bf012

  View details for Web of Science ID 000311889300023

  View details for PubMedID 23172486