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Translating Access To Outcomes: Socioeconomic Disparities May Affect Completion Of Breast Reconstruction
Yash Kadakia, BA1, Julie L. Cooper, BS1, Avinash Jayaraman, BA1, Connie Ma, BS1, Ricardo Garza, BS1, Austin Hembd, MD1, Sami U. Khan, MD2, Sumeet S. Teotia, MD1, Nicholas T. Haddock, MD1.
1University of Texas Southwestern Medical Center, Dallas, TX, USA, 2Stony Brook University, Stony Brook, NY, USA.

PURPOSE: Socioeconomic status (SES) has been shown to impact the likelihood of undergoing breast reconstruction following mastectomy. However, the effect of SES on the completion of breast reconstruction in a diverse patient population remains unexplored.
METHODS: Retrospective cohort analysis was performed on all patients of two senior surgeons at a single institution who underwent primary breast reconstruction following a mastectomy recorded from January 2007 to December 2017 (n=949). Patients were divided based on SES, as determined by the median household income of their residential zip code: (1) Low SES (<$67,640, n=501), and (2) High SES (>=$67,640, n=448). The threshold for grouping ($67,640) was four times the 2019 poverty level set by the Department of Health and Human Services for a household of two. The primary endpoint was percent completion of reconstruction, as defined by nipple reconstruction and/or areolar tattoo. Patients were further stratified by type of reconstruction and race. Student's t tests for independent sample means, two proportion z tests, and chi-squared tests were performed using Microsoft Excel.
RESULTS: There were no significant differences between the two groups in age, BMI, or incidence of diabetes. However, there was a lower incidence of hypertension in patients of high SES (28% vs. 37%, p=0.0032).
Overall, higher SES was associated with a significantly higher likelihood of completing breast reconstruction (57% vs. 51%, p=0.047), especially delayed breast reconstruction (61% vs. 50%, p=0.0088). Stratification by race revealed that high SES significantly correlated with increased overall completion only in Caucasians (60% vs. 49%, p=0.0074). However, high SES was associated with increased completion of delayed reconstruction across Caucasians (61% vs. 47%, p=0.0035), African Americans (p=0.58), Hispanics (p=0.68), and Asians (p=0.73).
Among only patients of low SES (Group 1), immediate reconstruction was more likely than delayed reconstruction to be completed (58% vs. 50%, p=0.081). Stratified by race, this trend was seen in Caucasians (58% vs. 47%, p=0.081), African Americans (66% vs. 54%, p=0.20), and Asians (78% vs. 33%, p=0.16).
CONCLUSION: Despite growing access to breast reconstruction, disparities in outcomes still exist between patients of different SES, most prominently in Caucasians. Our data suggest that compared to immediate reconstruction, delayed reconstruction may be associated with lower rates of completion in patients from lower socioeconomic backgrounds. Proper counseling and a greater consideration of immediate reconstruction in this patient population may increase completion rates, better allocate scarce healthcare resources, and improve patient satisfaction with the reconstructive process.


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