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National Disparities In Post-Mastectomy Breast Reconstruction: A Comparative Demographics And Cost Analysis
Yida Cai, BA, Lesley Summerville, BS, ScM, Samuel Boas, BS, Arvin Smith, BS, Cristin Coquillard, MD, Anand Kumar, MD.
Case Western Reserve University School of Medicine, Cleveland, OH, USA.

PURPOSE: There is significant cost variation across all forms of post-mastectomy breast reconstruction. Research into the source of this cost variation will help reduce overall health care expenditures. Our study compares trends in hospital charges relating to free flap breast reconstruction when compared to the implant based alternative. METHODS: The Healthcare Cost and Utilization Project National Inpatient Sample database was analyzed from January 2009 to December 2014. All female patients who were diagnosed with breast cancer or at a high risk for breast cancer who underwent either autologous free flap breast reconstruction or mastectomy with immediate one or two stage implant based breast reconstruction were included. Variables of interest included demographic data, hospital characteristics, hospitalization data and total hospital charges. All charges were inflated to May 2019 value with the consumer price index. Univariate and generalized linear models were used compare differences in cost and demographics between patients receiving different procedures. RESULTS: 659,220 female patients were diagnosed with breast cancer or had a high risk of breast cancer during hospitalization between January 2009 and December 2014. Of these patients, 44,175 (6.7%) received implant-based breast reconstruction and 20,050 (3.0%) received autologous free flap breast reconstruction. Patients who received free flap were significantly younger than patients who received implant (50.31 vs 50.79, p = 0.01). There were also significantly more minorities receiving free flap (p < 0.001). A significantly larger proportion of free flap procedures were performed in larger, teaching hospitals and in the south (p < 0.001). Regression analysis showed that the proportion of patients who received implant procedures did not significantly change between 2009 and 2014 (p = 0.113), while patients who received free flap procedures increased significantly (p = 0.02). Implant procedures were associated with significantly less charges than free flap (mean = $98,468.15 vs $64,632.54, p < 0.001), however both procedures are associated with increasing charges despite decreasing length of stay. CONCLUSION: Although implant based breast reconstruction remains to most performed form of post-mastectomy breast reconstruction, autologous free flap reconstruction is growing in popularity within the patient population. In addition to the increased demand for post-mastectomy breast reconstruction, increases in hospital charges were found to be associated with all procedures, despite significant differences in patient demographics, hospital location and region. Further studies will be done to better identify factors influencing access and cost to different types of breast reconstruction following mastectomy.


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