Regional Market Competition and the Use of Immediate Breast Reconstruction After Mastectomy

Abstract

Synopsis Background Prior work has shown that the competitiveness of the market in which hospitals operate is associated with use of surgical procedures. We examined the association between regional market competition and use of breast reconstruction in women with breast cancer and ductal carcinoma in-situ undergoing mastectomy. Methods Women who underwent mastectomy from 2010–2011 recorded in the National Inpatient Sample were selected. The competitive market environment for each hospital in which patients were treated was estimated using the Herfindahl-Hirschman Index (HHI). Multivariable models were developed to examine the association between regional market competition and breast reconstruction while adjusting for other clinical, demographic and structural variables. Results Among 22,011 women, immediate breast reconstruction was performed in 9902 (45.0%). The rate of immediate breast reconstruction was 34.5% in hospitals in non-competitive markets, 49.0% in moderately competitive markets, and 56.4% in highly competitive markets (P<0.0001). In a multivariable model, compared to women in non-competitive markets, women in moderately competitive markets were 24% (RR=1.24; 95% CI, 1.10–1.41) more likely to undergo immediate breast reconstruction while those in competitive markets were 25% (RR=1.25; 95% CI, 1.11–1.41). more likely to have reconstruction. Later year of treatment, higher census tract income level, and residence in an urban area were associated with an increased likelihood of reconstruction (P<0.05 for all). In contrast, older age, non-white race, and non-commercial insurance were associated with a lower likelihood of reconstruction (P<0.05 for all). Conclusion Patients who undergo mastectomy in hospitals in competitive markets are more likely to undergo immediate breast reconstruction.

Commercial Price Variation for Breast Reconstruction in the Era of Price Transparency

“…Existing studies using HHI as a measure of market concentration in breast reconstruction have shown that HHI is associated with an increased odds of immediate breast reconstruction and of breast reconstruction with a free flap. 58,59 In terms of the association with commercial rates, Cerullo et al 60 found that for privately insured patients who undergo breast reconstruction, increasing market concentration (ie, increasing HHI) was associated with decreasing costs and procedural markup (ie, pro- portional difference between charges and average procedural costs). 60 This study was limited, however, by using Healthcare Cost and Utilization Project data based on cost-to-charge ratios, which have questionable accuracy.…”

“…Higher prices in more concentrated markets may ultimately be passed down to patients in the form of higher premiums and deductibles. Existing studies using HHI as a measure of market concentration in breast reconstruction have shown that HHI is associated with an increased odds of immediate breast reconstruction and of breast reconstruction with a free flap . In terms of the association with commercial rates, Cerullo et al found that for privately insured patients who undergo breast reconstruction, increasing market concentration (ie, increasing HHI) was associated with decreasing costs and procedural markup (ie, proportional difference between charges and average procedural costs) .…”

Use of Flap Salvage for Lower Extremity Chronic Wounds Occurs Most Often in Competitive Hospital Markets

“…Operating in a competitive market often leads to hospitals investing in more high-technology services and equipment, particularly surgical fields. 19 – 22 Wright et al 19 found the effect of market competition on access to postmastectomy breast reconstruction to be independent of other clinical and demographic factors. Although only one-third of women in noncompetitive environments received postmastectomy breast reconstruction, over 50% of women were in receipt in competitive environments.…”

“… 16 Furthermore, there is a growing body of the literature suggesting that market forces significantly impact the adoption and delivery of advance surgical care. 19 – 22 …”

Impact of patient choice and hospital competition on patient outcomes after rectal cancer surgery: A national population‐based study

“… 3 Another study demonstrated that women with breast cancer were more likely to receive immediate reconstruction after mastectomy if they were treated in the most competitive hospitals. 4 However, there remains a lack of empirical evidence across different tumor types and treatment modalities.…”