Andrew R Bauder1, Cary P Gross, Brigid K Killelea, Paris D Butler, Stephen J Kovach, Justin P Fox. 1. From the *Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA; †Robert Wood Johnson Foundation Clinical Scholars Program, Division of General Internal Medicine, Cancer Outcomes Policy and Effectiveness Research (COPPER) Center, Yale Comprehensive Cancer Center and Yale School of Medicine; Division of Chronic Disease Epidemiology, Yale School of Public Health; and ‡Department of Surgery, Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT.
Abstract
INTRODUCTION: Despite a national health care policy requiring payers to cover breast reconstruction, rates of postmastectomy reconstruction are low, particularly among minority populations. We conducted this study to determine if geographic access to a plastic surgeon impacts breast reconstruction rates. METHODS: Using 2010 inpatient and ambulatory surgery data from 10 states, we identified adult women who underwent mastectomy for breast cancer. Data were aggregated to the health service area (HSA) level and hierarchical generalized linear models were used to risk-standardize breast reconstruction rates (RSRR) across HSAs. The relationship between an HSA's RSRR and plastic surgeon density (surgeons/100,000 population) was quantified using correlation coefficients. RESULTS: The final cohort included 22,997 patients across 134 HSAs. There was substantial variation in plastic surgeon density (median, 1.4 surgeons/100,000; interquartile range, [0.0-2.6]/100,000) and the use of breast reconstruction (median RSRR, 43.0%; interquartile range, [29.9%-62.8%]) across HSAs. Higher plastic surgeon density was positively correlated with breast reconstruction rates (correlation coefficient = 0.66, P < 0.001) and inversely related to time between mastectomy and reconstruction (correlation coefficient = -0.19, P < 0.001). Non-white and publicly insured women were least likely to undergo breast reconstruction overall. Among privately insured patients, racial disparities were noted in high surgeon density areas (white = 79.0% vs. non-white = 63.3%; P < 0.001) but not in low surgeon density areas (34.4% vs 36.5%; P = 0.70). CONCLUSIONS: The lack of geographic access to a plastic surgeon serves as a barrier to breast reconstruction and may compound disparities in care associated with race and insurance status. Future efforts to improve equitable access should consider strategies to ensure access to appropriate clinical expertise.
INTRODUCTION: Despite a national health care policy requiring payers to cover breast reconstruction, rates of postmastectomy reconstruction are low, particularly among minority populations. We conducted this study to determine if geographic access to a plastic surgeon impacts breast reconstruction rates. METHODS: Using 2010 inpatient and ambulatory surgery data from 10 states, we identified adult women who underwent mastectomy for breast cancer. Data were aggregated to the health service area (HSA) level and hierarchical generalized linear models were used to risk-standardize breast reconstruction rates (RSRR) across HSAs. The relationship between an HSA's RSRR and plastic surgeon density (surgeons/100,000 population) was quantified using correlation coefficients. RESULTS: The final cohort included 22,997 patients across 134 HSAs. There was substantial variation in plastic surgeon density (median, 1.4 surgeons/100,000; interquartile range, [0.0-2.6]/100,000) and the use of breast reconstruction (median RSRR, 43.0%; interquartile range, [29.9%-62.8%]) across HSAs. Higher plastic surgeon density was positively correlated with breast reconstruction rates (correlation coefficient = 0.66, P < 0.001) and inversely related to time between mastectomy and reconstruction (correlation coefficient = -0.19, P < 0.001). Non-white and publicly insured women were least likely to undergo breast reconstruction overall. Among privately insured patients, racial disparities were noted in high surgeon density areas (white = 79.0% vs. non-white = 63.3%; P < 0.001) but not in low surgeon density areas (34.4% vs 36.5%; P = 0.70). CONCLUSIONS: The lack of geographic access to a plastic surgeon serves as a barrier to breast reconstruction and may compound disparities in care associated with race and insurance status. Future efforts to improve equitable access should consider strategies to ensure access to appropriate clinical expertise.
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