Macromastia and Reduction Mammaplasty: Analysis of Outpatient Cost of Care and Opioid Consumption at 5 Years Postoperatively

Abstract

Background

Macromastia is associated with increased opioid consumption, which could potentially be the initial exposure for patients with an opioid use disorder amid an escalating opioid crisis in the United States.

Objectives

The purpose of this study was to evaluate outpatient cost of care and opioid consumption in patients with macromastia and compare those who underwent reduction mammaplasty vs those who did not have surgery.

Methods

PearlDiver, a database encompassing a national cohort of private payers with 153 million unique patients, was queried. The study cohort included patients diagnosed with macromastia who did or did not undergo reduction mammaplasty utilizing both ICD-9 and ICD-10 and CPT codes. Outpatient cost of care and morphine milligram equivalents (MME) were calculated up to 5 years postoperatively for both cohorts.

Results

At 1 to 3 years postoperatively, there was no statistically significant difference in outpatient cost of care between cohorts. At every follow-up thereafter, outpatient cost of care was higher among macromastia patients who did not undergo reduction mammaplasty, with cohort differences of US$240.68 and US$349.90 at 4 years and 5 years, respectively (P < .05). MME consumption was greater in patients who underwent reduction mammaplasty up to 30 days postoperatively (P < .01). Beyond that, there was no significant difference in MME consumption between cohorts. However, patients who did not undergo surgery had opioid consumption levels above 50 MME/day until 3 years after diagnosis of macromastia.

Conclusions

Patients with macromastia who undergo reduction mammaplasty have lower outpatient care costs than patients who do not undergo reduction mammaplasty, with safer long-term opioid consumption in alignment with current Centers for Disease Control and Prevention guidelines.

See the Commentary on this article here.

Reduction mammaplasty is a frequently performed plastic surgery procedure; over 100,000 such procedures are completed annually in the United States.¹ It is the standard of care for treatment of symptomatic macromastia, a condition in which large breasts can cause pain, headaches, intertriginous infections, shoulder grooving, poor posture, sleep disturbances, and poor psychosocial well-being, among others.^2–6 Reduction mammaplasty serves to improve symptoms with the goal of re-creating symmetric breasts that are natural-looking with aesthetic features and limited scars. It is well supported in the literature that an overwhelming majority of patients postoperatively report resolution of symptoms related to their large breasts and describe improved confidence and self-assurance.^7–12

Despite consistent numbers of patients with macromastia desiring reduction mammaplasty, insurance companies are often unwilling to pay for the operation. The most common reason for denial of coverage for reduction mammaplasty is perceived cosmetic indication.¹³ Insurers are also requiring a greater range of symptoms and higher levels of disability to meet medical necessity benchmarks for financial coverage.

Treatment of macromastia by reduction mammaplasty results in improvement of symptoms such as back and shoulder pain.^3,5,14 Resolution of pain and other macromastia-related symptoms may play a role in reducing the use of opioids.^5,14,15 Macromastia patients undergoing surgery have increased preoperative pain medication consumption, including narcotic analgesics, when compared with other breast hypertrophy and normal patients.^14,16 At the same time, however, the perioperative period serves as the source of initial exposure for many patients with an opioid use disorder.¹⁷ Reduction in opioid consumption is essential to combat the escalating opioid crisis in the United States. With more than 2 million Americans addicted to prescription opioids and deaths from opioid overdose quadrupling since 2000, it is essential to fight this crisis in every possible way.^18–21 Any findings that prove reduction mammaplasty results in reduced opioid consumption in macromastia patients may influence the decisions of hospital leadership and insurance companies as these relate to the importance of reimbursement for this surgery and would provide incentivization to fight the opioid crisis. To date, there are no published studies reporting whether reduction mammaplasty reduces narcotic consumption in patients with macromastia. Additionally, there are no studies describing the specific long-term costs associated with a diagnosis of macromastia and how reduction mammaplasty affects these. Thus, it is essential to better understand patterns in narcotic consumption among patients with macromastia amid the ongoing opioid epidemic in the United States.^18,22–24

This study queried the PearlDiver (PearlDiver Inc., Colorado Springs, CO) database to compare 5-year outpatient costs of care for patients with macromastia who did not undergo reduction mammaplasty vs those who did, as well as to compare long-term morphine milligram equivalents (MME) consumption between these 2 cohorts.

METHODS

Database

The PearlDiver patient record database was utilized for this IRB-exempt retrospective chart review. PearlDiver is a commercially available online database encompassing 153 million unique patients from both the Humana Claims dataset and Medicare Standard Analytic File between January 1st, 2010 and March 30th, 2020. Services that do not provide their data to PearlDiver, or patients who do not have insurance coverage, were not included in the database. PearlDiver tracks patients across all episodes of care in which their insurance was utilized. The database utilizes International Classification of Disease (ICD) codes ICD-9 and ICD-10, or current procedural terminology (CPT) codes, to associate all billable encounters. Compared with other commonly queried insurance databases, PearlDiver provides a large sample size covering many regions of the country and includes patients from various types of practices. There were no study-specific considerations in the choice of PearlDiver rather than other databases.

Patient Cohorts

The study cohort included patients who underwent bilateral reduction mammaplasty (ICD-9: P8532; CPT: 19318) following a diagnosis of macromastia (ICD-9: D6111; ICD-10: D-N62). Unilateral reduction mammaplasty procedures were not included as they may have been performed for reasons other than macromastia. This cohort was then filtered to exclude all male patients to avoid contamination with coding accounting for gynecomastia surgeries or males with breast reduction after massive weight loss. Patient demographics included age, and social history included tobacco use, alcohol abuse, and drug abuse. Comorbid conditions identified are reported in Table 1.

Analysis

To mitigate selection bias and demographic differences, patients diagnosed with macromastia who underwent reduction mammaplasty were matched with macromastia patients who did not undergo reduction mammaplasty, based on age, obesity, and Charlson Comorbidity Index (CCI). The CCI is a validated, weighted index to measure burden of disease. Patients with a higher CCI have more comorbidities, higher disease burden, and subsequent lower rates of survival.²⁵ MME consumption was obtained at 30 days, 1 year, 3 years, and 5 years postoperatively in both the reduction mammaplasty cohort and the macromastia cohort who did not undergo reduction mammaplasty. Outpatient cost of care was calculated and compared at each consecutive year through 5 years. Financial data were derived from the index diagnosis of macromastia and reduction mammaplasty. Descriptive statistics were computed as means and standard deviations. Comparative statistics across the cohorts were calculated with t tests. Statistical analysis was conducted in R (R Core Team, Vienna, 2014) and an unadjusted α level of 0.05 for significance was used for all tests.

RESULTS

Between January 1st, 2010 and March 30th, 2020, a total of 559,235 patients were diagnosed with macromastia; of these, 105,184 patients underwent reduction mammaplasty following an initial diagnosis of macromastia. Overall, the mean [standard deviation] age of patients who underwent reduction mammaplasty was 42.85 [14.47] years (range, 18-80 years). The average CCI was 1.11 [1.50]. Tobacco use was reported by 28,916 (27.49%) patients. Obesity was the most common comorbid condition (55.72%, n = 58,603), followed by depression (49.19%, n = 51,736) and hypertension (47.28%, n = 49,731). A total of 406,723 patients with macromastia did not undergo reduction mammaplasty. The mean age of patients within this cohort was 52.87 [20.82] years (range, 18-83), with an average CCI of 1.12 [1.77]. Tobacco use was reported by 108,872 (26.77%) patients. Hypertension (48.17%, n = 195,930) was the most common comorbidity, followed by obesity (44.69%%, n = 181,775) and depression (42.74%, n = 173,818). Patient demographics and other characteristics comparing the 2 patient populations (ie, macromastia patients with and without reduction mammaplasty) are shown in Table 1.

At 1 to 3 years postoperatively, there was no statistically significant difference in outpatient cost of care between cohorts. However, at every successive follow-up thereafter, outpatient cost of care was higher among macromastia patients who did not undergo reduction mammaplasty. These differences in outpatient cost of care between the 2 cohorts amounted to US$240.68 and US$349.90 at 4 and 5 years, respectively (P < .05) (Table 2).

Initially, MME consumption was greater in macromastia patients who underwent reduction mammaplasty than in those who did not (Table 3). At 0 through 30 days postoperatively, there was a statistically significant difference in average MME consumption between the 2 cohorts, with macromastia patients who underwent surgery having higher MME consumption. However, at every successive follow-up thereafter, there was no statistically significant difference in MME consumption. Average MME consumption in patients with macromastia who underwent reduction mammaplasty at 0 to 30 days was 58.09 MME compared with 53.85 MME for those who did not undergo reduction mammaplasty (P < .01). At 30 days through 5 years postoperatively, average MME consumption for those who did not undergo reduction mammaplasty was higher (range, 45.73-53.73 MME) than for patients who underwent surgery (range, 41.78-49.84 MME) (Figure 1). However, differences in MME consumption between the 2 cohorts were not significant at these time points.

DISCUSSION

This is one of the largest published studies evaluating patients with macromastia who did or did not undergo reduction mammaplasty and compared outpatient costs of care and opioid consumption. The results demonstrated that patients with macromastia who underwent reduction mammaplasty had lower outpatient care costs, with a decreased trend in chronic opioid consumption. Notably, patients who underwent reduction mammaplasty had a decreased trend in chronic opioid consumption, which aligns with current Centers for Disease Control and Prevention (CDC) guideline recommendations for reducing opioid overdose.²⁶ These results are demonstrated up to 5 years postoperatively through longitudinal tracking among this large database. Large comprehensive data sets not only allow researchers to longitudinally identify variances in treatment and outcomes, but also to analyze associated costs and medication consumption. To date, to the best of your knowledge, this is the only study to have explored long-term consumption of opioids related to macromastia diagnosis. Additionally, this is the first study in the United States comparing specific healthcare costs associated with macromastia patients who underwent reduction mammaplasty with those who did not. As the insurance reimbursement landscape continues to evolve, it is essential to provide strong evidence to decision-makers about the role of reduction mammaplasty in addressing a debilitating condition amid an increasingly burdensome opioid epidemic.^18,22–24

Our study demonstrated a statistically significant decrease in outpatient cost of care beyond 4 years postoperatively for macromastia patients who underwent reduction mammaplasty compared with those who did not. The differences in outpatient cost of care between the 2 cohorts increased with each subsequent year from US$240.68 to US$349.90 at 4 and 5 years, respectively, suggesting less long-term outpatient utilization by these patients. At 1 to 3 years postoperatively, there was no statistically significant difference in outpatient cost of care between cohorts. This initial similarity in cost could be related to complications related to the index operation and outpatient management of these issues. Published complication rates for reduction mammaplasty vary between 4% and 54%.^27–31 Interestingly, several studies have reported associations between mass of resection and complication rates,^{28,30,32–34} with specific reports that increases in mass resections correspond with downtrends in nipple sensitivity.³² Although we do not report resection masses here, such associations could better elucidate postoperative outcomes and outpatient healthcare utilization. More notable, however, is the increasing difference in outpatient cost of care beyond 4 years postoperatively between the 2 cohorts. This difference in outpatient cost of care remains significant many years beyond the expected period of routine postoperative expenses. This may suggest that macromastia patients who do not undergo surgery may be seeking alternative interventions for their macromastia-related symptoms. Such treatments may include physical therapy visits and encounters with primary care doctors or other specialists, such as spine surgeons.¹⁵ These alternative interventions seem to impose a considerable cost in the outpatient setting, which perhaps will become a burden for the healthcare system in the long run.

Although the most effective and only causal treatment of macromastia is reduction mammaplasty, this type of surgery is often regarded as cosmetic by insurance companies who instead favor conservative therapies.^15,16,35 The most common requirements of healthcare insurance providers for coverage of reduction mammaplasty are discordant with current clinical evidence.^36,37 Insurance companies, therefore, often recommend conservative treatments with subsequent approval of surgical costs depending on previous implementation of such treatments. Several studies have demonstrated that nonoperative measures for the treatment of macromastia, such as weight reduction and exercise,¹⁶ fail to reduce breast size and that physiotherapy, special brassieres, and medications do not lead to long-lasting reduction of symptoms.^5,16,38 All these treatments create further costs. Moreover, we have shown that deferring causal treatment of macromastia promotes concerning levels of opioid consumption.

At 0 through 30 days postoperatively, MME consumption among patients who underwent reduction mammaplasty was significantly higher than among those who did not. This initial increase in opioid consumption can likely be attributed to the need for acute postoperative pain control or even control of pain related to complications following the procedure such as wound dehiscence requiring frequent dressing changes. Although there was no significant difference in MME consumption at every successive follow-up beyond 30 days postoperatively, macromastia patients who did not undergo surgery sustained opioid consumption levels above 50 MME/day for up to 3 years postoperatively. Alternatively, the long-term downtrend in consumption of opioids in patients who underwent reduction mammaplasty aligns with the current CDC guideline recommendations for reducing opioid overdose. The 2022 CDC clinical evidence review reported that opioid-related overdose is dose dependent, with higher dosages associated with increased overdose risk.^26,39 When compared with prescribed opioid doses of <20 MME/day, the risk of overdose among patients prescribed opioids for chronic nonmalignant pain increases by factors of 1.9-4.6 for doses of 50 to <100 MME/day.^40,41 Most experts have agreed that increasing dosages to ≥50 MME/day increases risk of overdose with no added benefit in pain control or function.²⁶ Because there are no reports in the published literature indicating any conservative therapy that leads to permanent relief of macromastia symptoms, the risk of overdose associated with such treatments should be mitigated with a causal treatment such as reduction mammaplasty.

In 2011, the American Society of Plastic Surgeons commissioned a panel of experts to establish recommendations for insurance coverage for reduction mammaplasty.³⁸ Pain, including back, shoulder, and neck pain, is one of the most common symptoms listed as a recommended criterion for insurance coverage of reduction mammaplasty.³⁸ Although several studies have reported reduction in pain after reduction mammaplasty,^3,5,14 the literature is scant regarding reduction and resolution in specific macromastia-related symptoms, such as back pain. A recently published systematic review of 8 articles covering 1008 patients demonstrated a statistically significant improvement in back pain following reduction mammaplasty.⁴² Given that back pain is often exacerbated by or caused by macromastia when present, it is reasonable to postulate that reduction mammaplasty may improve back pain. Although the authors of the review admitted that heterogeneity was high, all studies showed some improvement in back pain. This was the first study to correlate reduction mammaplasty and back pain as its only primary outcome. It could be further suggested that improved back pain would subsequently result in less opioid consumption, and therefore in fewer outpatient visits with providers.

Although there was no statistical difference in opioid consumption after 30 days postoperatively, there was a notable long-term reduction in MME among reduction mammaplasty patients. This reduction in opioid use aligns with the growing trend of strategies to stem the opioid epidemic in the United States. Opioid pain medication use presents serious risks, including opioid use disorder and overdose.^17,26 The White House declared a national Public Health Emergency in 2017 due to the rising number of opioid-related deaths in the United States.¹⁸ From 1999 to 2014, 165,000 people died from opioid pain medication–related overdose in the United States, with a marked increase in death rate in the past decade.^23,26 Given that the perioperative period serves as the source of initial exposure for many patients with an opioid use disorder,¹⁷ an increasing number of studies have focused on quantifying the need for postoperative analgesics for a variety of surgical procedures including reduction mammaplasty.^43–46 Although perioperative multimodal analgesia models result in shorter length of hospital stay and opioid-sparing benefits, these care pathways have no impact on postdischarge opioid prescribing patterns.^17,47,48 To date, this is the first study to report on whether reduction mammaplasty reduces long-term narcotic consumption in patients with macromastia. More so than ever, emergent methods for reducing overall opioid consumption, such as a surgical procedure itself, should be fully realized by insurance companies and hospital stakeholders amid a nationwide opioid epidemic.

To account for patient homogeneity between the cohorts, macromastia patients who underwent reduction mammaplasty were matched with macromastia patients who did not undergo reduction mammaplasty, based on age, obesity, and CCI. The burden of comorbidities was quantified with the CCI, which contains 19 categories of comorbidity and assigns a weighted value to each comorbidity based on its risk of 1-year mortality. This classification of comorbidity provides a valid method of estimating risk of death from comorbid disease.²⁵

As with all studies that utilize large insurance databases, this study has several limitations that must be taken into consideration when interpreting the results.^49–51 Power of analysis is dependent on the accuracy and quality of the coded data, which may be prone to errors and skew outcomes. Additionally, these data are only representative of patients in the United States with Medicare or private insurance, which may not be generalizable to other populations. However, our large sample size seems to cover different regions of the country and includes patients from various types of practices. We also did not account for patients undergoing multiple procedures at the time of their breast reduction (ie, breast reduction and abdominoplasty). The number of patients who fall into this cohort is likely small and with minimal, if any, impact on our results given our very large sample size and long-term follow-up. Additionally, we could not identify the reason for which macromastia patients who did not undergo surgery were later seen by a provider. PearlDiver tracks insurance utilization across all episodes of care. These patients, however, were likely seen in the outpatient setting for management of macromastia-related symptoms as well as other comorbid conditions. Database studies also do not allow us to identify the reason for which patients did or did not undergo surgery. Future studies should address these considerations to better inform results. Similarly, it is important to consider that macromastia patients will likely carry the diagnosis in their medical record regardless of disease severity. However, we minimized the effect of confounding variables by matching cohorts and analyzing time frames specific to the diagnosis of macromastia and reduction mammaplasty surgery. Lastly, additional surgery and surgeon-specific preferences, such as reduction technique used, resected breast weight, perioperative antibiotic use, and use of wetting solution or drains, are not accounted for. Such factors may have varying impacts on outcomes and complications, but most likely have minimal effect many years postoperatively.

CONCLUSIONS

This study has demonstrated that patients with macromastia who undergo reduction mammaplasty have lower outpatient care costs than patients who do not undergo surgery, with a decreased trend in chronic opioid consumption. This provides further evidence for insurance companies and hospital stakeholders to support each patient with macromastia pursuing surgery and emphasizes that reduction mammaplasty is not simply a cosmetic procedure, but rather a medically necessary operation for treatment of a debilitating condition. Furthermore, given the long-term downtrend in opioid consumption in patients who underwent reduction mammaplasty, there is further indication to provide financial coverage for reduction mammaplasty to help combat the opioid epidemic affecting the United States.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes