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Nationwide cost variation for lower extremity flap reconstruction



With increased attention around a value-based healthcare system, continuous emphasis has been made on the evaluation of hospital volume and its association with cost and outcomes. The aim of this study was to analyze nationwide cost variation and outcomes in relation to hospital case volume and geographical location for lower extremity flap reconstruction.


A retrospective analysis of the National Inpatient Sample database was performed. Participants were patients who were admitted with the diagnosis of lower extremity trauma and underwent flap reconstruction, inclusive of pedicled and free flaps. The primary variable of interest was hospital cost. Additionally, we evaluated patient demographics, hospital characteristics, and outcomes of postoperative complications and length of stay.


A total of 1200 patients were extracted. Median hospital cost for each procedure was $67,845.09. High volume hospitals had significantly lower costs than medium and low volume hospitals (p = 0.011), with median cost being $56,498.77. On regression analysis, hospital volume was not independently associated with increased hospital costs; however, notable factors identified included surgical and systemic complications, as well as longer length of stay. Of note, high volume hospitals were also associated with significantly fewer surgical complications (p = 0.002) and shorter length of stay (p < 0.001). The Western region was also independently associated with increased hospital costs.


High hospital case volume appears to be indirectly associated with decreased hospital costs. The results of this study highlight the constant need to improve cost efficiency and reduce excess utilization costs while maintaining optimal patient outcomes.

Level of evidence: Level IV, risk/prognostic study.

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Corresponding author

Correspondence to Samuel J. Lin.

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Conflict of interest

Nargiz Seyidova, Austin D. Chen, Diana del Valle, David Chi, Ryan P. Cauley, Bernard T. Lee, and Samuel J. Lin declare that they have no conflict of interest.

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved for exempt status from the Institutional Review Board at the Beth Israel Deaconess Medical Center.

Informed consent

The NIS is a subset of the Healthcare Cost and Utilization Project (HCUP) sponsored by Agency of Healthcare Research and Quality. The NIS is a large publicly available all-payer inpatient healthcare database designed to produce US regional and national estimates of inpatient utilization, access, charges, quality, and outcomes. Developed through a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and Quality (AHRQ), HCUP data inform decision-making at the national, State, and community levels. Participant use file (PUF) of de-identified data was requested from the NIS central repository. Since all data in the NIS database are de-identified, the requirement for informed consent was waived.

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Nargiz Seyidova first author and Austin D. Chen second author

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Table S1

Table that demonstrates the International Classification of Diseases, Ninth Revision (ICD-9) codes (DOCX 55 kb)

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Seyidova, N., Chen, A.D., del Valle, D. et al. Nationwide cost variation for lower extremity flap reconstruction. Eur J Plast Surg 44, 475–482 (2021).

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  • Lower extremity
  • Reconstruction
  • Cost
  • National Inpatient Sample