Plastic Surgery Research Council
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PSRC 60th Annual Meeting
Program and Abstracts

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Disparity in Rate of Immediate Breast Reconstruction at Safety Net Hospitals
Tiffany N.S. Ballard, MD, Lin Zhong, MPH, Adeyiza O. Momoh, MD, Kevin C. Chung, MD, MS, Jennifer F. Waljee, MD, MPH, MS.
University of Michigan, Ann Arbor, MI, USA.

PURPOSE:Safety net hospitals (SNHs) are defined as hospitals that provide a disproportionate amount of care to vulnerable populations. Considerable federal resources are directed to ensure that such hospitals provide high quality care, and previous studies demonstrate that they provide equivalent or superior care to at-risk patients compared with what such patients may otherwise receive. In this context, we sought to determine if the rate of immediate breast reconstruction was similar between SNHs and non-safety net hospitals (nSNHs).
METHODS:Women ages 21-64 with breast cancer or increased risk of breast cancer undergoing mastectomy and immediate breast reconstruction were identified in the National Inpatient Sample database by ICD-9 codes. Lumpectomies, partial mastectomies, and delayed reconstructions were excluded. SNHs were defined as hospitals with the highest quartile of disproportionate share hospital percentage (proportion of Medicaid plus self-pay patients). Adjusted odds ratios of undergoing autologous or implant-based reconstruction, compared to no reconstruction, were calculated using multinomial logistic regression.
RESULTS:Between 2005 and 2011, 67,478 mastectomies were performed, with 75% at nSNHs (n=50,513). Of the 28,193 total reconstructions performed at nSNHs, 16% (n=7,833) were autologous procedures, and another 4% (n=2,248) included a variety of procedures involving both an implant and a flap (Figure 1). There were 7,168 reconstructions at SNHs, with 12% (n=2,089, p<0.001) autologous and 4% (n=711) combination procedures.

Forty-four percent (n=22,320) of women at SNHs did not undergo reconstruction compared to 58% (n=9,797) at SNHs (p<0.001). Logistic regression controlling for age, race, primary payer, and chronic conditions revealed that patients at SNHs remained significantly less likely to undergo either autologous (OR 0.79, CI 0.74-0.84) or implant-based reconstruction (OR 0.82, CI 0.78-0.86) compared to those at nSNHs.
CONCLUSION:Even after accounting for sociodemographic factors, women treated at SNHs are less likely to receive immediate post-mastectomy breast reconstruction. Given the strong evidence supporting the long-term psychosocial benefits of reconstruction, it is critical to understand why reconstruction rates continue to lag at SNHs, despite federal efforts to ensure high quality care for vulnerable individuals.


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