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Assessing the Effect of New York State (NYS) Legislation on Autologous Tissue Based Post-Mastectomy Reconstruction Rates
Jessica C. Gooch, MD1, Brian O'Hea, MD1, Dana Telem, MD2, Jie Yang, PhD1, Jihye Park, MS1, Duc Bui, MD1, Sami Khan, MD1.
1Stony Brook University Medical Center, Stony Brook, NY, USA, 2University of Michigan, Ann Arbor, MI, USA.

Introduction: Underutilization of post-mastectomy breast reconstruction was highlighted in 2008-2009 by increased media attention. This preceded 2011 New York State (NYS) legislation mandating discussion of reconstructive options prior to mastectomy. Our study evaluates the potential impact of this policy on volume and method of immediate breast reconstruction in NYS.
Methods: The New York State SPARCS database was used to identify women undergoing mastectomy from 2005-2013 to determine incidence and timing of reconstruction. Demographic and socioeconomic characteristics were collected. Follow-up was at least 1 year. Log-linear Poisson regression models and multivariable logistic regression were used to compare periods before (2005-2010) and after (2011-2013) the legislative change.
Results: Of 45,591 SPARCS records, 20,181 women underwent immediate post mastectomy reconstruction. 15,761 (78.1%) underwent implant-based reconstruction while 4,420 (21.9%) underwent autologous reconstruction. Implants were chosen by 26% of patients in 2005, which increased to 36.4% by 2013. Flap-based reconstruction was chosen by 1% in 2005 and increased to 20.3% in 2013 [Figure 1].
Among women undergoing autologous breast reconstruction, all age groups up to the age of 75 (p<0.0005 for all groups) and all racial groups demonstrated a significant increase in reconstruction rates (p<0.0001 for white, p<0.0005 for black, p<0.0228 for Hispanic). Patients with either Medicare (p=0.0042) or Commercial (p<0.0001) insurance had significantly increased rates of autologous reconstruction with Medicare patients having the steepest increase in reconstructive rates (RR 1.45). Patients across all regions of the state had an increase in flap-based reconstruction with the steepest increases occurring upstate compared NYC, Long Island and the surrounding areas (RR 1.52 for upstate regions). Patients in all income brackets showed a significant increase in flap-based reconstructive rates (p=0.002 or less for all comparisons).
Medicare patients and those age 65-74 had a significantly increased odds of having implant-based reconstruction after 2011 when compared to pre-2011 (OR 1.1 vs. 1.4). Flap-based reconstruction utilization showed a sharp increase in the pre-2011 years especially between 2008-2009 with a slower rate of increase post-2011 (OR 1.98 vs. 1.17).
Conclusions:The largest increase in autologous breast reconstruction utilization in NYS occurred between 2008-2009 while implant based reconstruction rates leveled off after 2010. In general, younger patients with commercial insurance from higher median income brackets tended to have the greatest increase in utilization of either reconstructive method. Medicaid patients and those from lower income brackets showed a significantly increased trend in flap based reconstruction between 2009-2011. Although an increase in both flap and implant based reconstruction were observed, these changes appear to have occurred prior to the enactment of the NYS Reconstruction Act in 2011. Legislative changes likely are not the only factor that influences health care utilization and it may require a longer follow-up period post-legislation to establish the exact influence of legislation as an independent factor.
Figure 1: Increases in Flap and Implant based Reconstruction in New York State from 2005-2013.


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