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Recruiting the Next Generation of Surgeon-Scientists in Plastic and Reconstructive Surgery: The Value of Research Fellowships.

prevalence of health services research studies, such as ours, that leverage administrative databases and their basis for public reporting of provider performance. Several studies have scrutinized the specificity with which these databases can appropriately identify complications.2–4 We believe that the underlying clinical context is critical to this issue. Surgical complications such as surgical-site infection, hematoma, and anastomotic revisions are not routinely considered to be comorbidities, so we presume that the concerns raised by the authors are largely centered on medical complications. For these, the clinical context is key and will inform the interpretation of both our study and the critique letter. In other words, the relevant question should be as follows: In this population of surgical patients (breast free flap recipients), is a myocardial infarction, stroke, or renal failure more likely to be a complication or a comorbidity? We estimate that patients with such comorbidity profiles are unlikely to be offered a free flap breast reconstruction because of the risk of adverse events in these patients. Furthermore, the medical comorbidities mentioned by the authors are already captured as inputs into the Charlson Comorbidity Index.5 The Charlson Comorbidity Index has been validated for use in administrative claims and replicated in many outcome studies involving acutely hospitalized patients.6,7 The process used by the National Inpatient Sample to map diagnosis codes to comorbidity indicators purposefully excludes or “drops” codes that are related to the principal diagnosis or that may be complications (prevent “double counting”).8 Lastly, by using propensity scores to create matched study groups according to sociodemographic characteristics and comorbidity burden (Charlson Comorbidity Index), we minimized the likelihood that safety-net hospital patients and non–safetynet hospital patients were systematically different. Overall, we do agree that one must be cautious in drawing conclusions about clinical comorbidities from administrative data. Equally important, drawing meaningful clinical conclusions rests with the underlying context. DOI: 10.1097/PRS.0000000000006133