Influence of health insurance, hospital factors and physician volume on receipt of immediate post-mastectomy reconstruction in women with invasive and non-invasive breast cancer

Abstract

For women with breast cancer who undergo mastectomy, immediate breast reconstruction (IR) offers a cosmetic and psychological advantage. We evaluated the association between demographic, hospital, surgeon and insurance factors and receipt of IR. We conducted a retrospective hospital-based analysis with the Perspective database. Women who underwent a mastectomy for invasive breast cancer (IBC) and ductal carcinoma in situ (DCIS) from 2000 to 2010 were included. Logistic regression analysis was used to determine factors predictive of IR. Analyses were stratified by age (<50 vs. ≥50) and IBC versus DCIS. Of the 108,992 women with IBC who underwent mastectomy, 30,859 (28.3 %) underwent IR, as compared to 6,501 (44.2 %) of the 14,710 women with DCIS who underwent mastectomy underwent IR. In a multivariable model for IBC, increasing age, black race, being married, rural location, and increased comorbidities were associated with decreased IR. Odds ratios (OR) of IR increased with commercial insurance (OR 3.38) and Medicare (OR 1.66) insurance (vs. self-pay), high surgeon-volume (OR 1.19), high hospital-volume (OR 2.24), and large hospital size (OR 1.20). The results were identical for DCIS, and by age category. The absolute difference between the proportion of patients who received IR with commercial insurance compared to other insurance, increased over time. Immediate in-hospital complication rates were higher for flap reconstruction compared to implant or no reconstruction (15.2, 4.0, and 6.1 %, respectively, P <.0001). IR has increased significantly over time; however, modifiable factors such as insurance status, hospital size, hospital location, and physician volume strongly predict IR. Public policy should ensure that access to reconstructive surgery is universally available.

Socio-demographic, clinical, and health-related factors associated with breast reconstruction – A nationwide cohort study

“…We also found no indication that marital status influenced the choice of reconstruction. This result is in line with the findings in a substantial number of other studies [2,5,6,26,38,41], although a higher rate of reconstruction among married women has been reported [30,42].…”

Adherence to colonoscopy at 1 year following resection of localized colon cancer: a retrospective cohort study

“…We have found previously that racial/ethnic disparities that favor Whites exist for a substantial number of treatments and interventions. [35][36][37][38] This was found in addition to the fact that lower SES patients were also less likely to undergo colonoscopy at 1 year; thus, both factors were associated with receipt of this procedure independently. Our studies have also found that being married versus being single is usually associated with increased compliance with the appropriate guidelines and receipt of the appropriate treatment or intervention, as in this study.…”

Patients opting for breast reconstruction following mastectomy: an analysis of uptake rates and benefit

“…Age less than 50 years was a constant and best predictor of having breast reconstruction. 20,21,24,25,[31][32][33][34] Some physicians fear offering breast reconstruction to older women, due to their coexisting morbidities and perceived increase in complications. However, breast reconstruction is a safe and feasible option in older patients.…”

“…20 Other studies have shown that women with commercial insurance had a threefoldhigher likelihood of undergoing immediate reconstruction compared to those without insurance. 34 A Southern California study found that patients with private insurance were ten times more likely to undergo reconstruction than patients with Medi-Cal insurance. 24 In contrast, patients who are considered financially indigent and who receive their care at a university-based public hospital are more likely to have breast reconstruction.…”