A. Mandelbaum1, M. Nakhla1, Y. Seo1, V. Dobaria1, M. L. DiNome1, P. Benharash1, M. K. Lee1 1University Of California – Los Angeles,Los Angeles, CA, USA
Introduction: Since 1998, the Women’s Health and Cancer Rights Act (WHCRA) has mandated insurance coverage of immediate breast reconstruction (IR) after mastectomy. Previous reports show disparities in the rates of IR. The objective of our study was to identify trends in utilization, resource use, and predictors of IR using a national cohort.
Methods: The National Inpatient Sample (NIS) database was used to identify all adult women (>/=18 years) undergoing mastectomies from 2005 to 2014. The NIS is the largest available all-payer database and provides accurate national estimates for inpatient hospitalizations in the United States. Patient comorbidities, type of operations, and complications were tabulated using International Classifications of Diseases 9 codes. IR was defined as any reconstruction during the same inpatient stay. Temporal trends were assessed using a chi squared and a Mann-Whitney test while independent predictors of IR were identified using multivariable logistic regression models.
Results: Of an estimated 729,560 patients undergoing mastectomy, 301,276 (41.3%) received IR. Rates of IR increased steadily from 28.2% in 2005 to 58.3% in 2014 (P<0.001). Inpatient hospitalizations for mastectomies, with or without IR, decreased by 31.1% over time. Both the rate of bilateral mastectomies (13.6% to 40.0%, P<0.001) and diagnoses of increased breast cancer risk (13.9% to 31.0%, P<0.001) increased significantly. Patients who had IR were on average younger (51.1 vs. 64.5 years, P<0.001), had lower burden of comorbidities, as measured by the Elixhauser index (1.7 vs. 2.6, P<0.001), and had fewer complications (4.3 vs. 6.3%, P<0.001). Compared to mastectomy alone, IR had a similar length of stay (2.5 vs. 2.1 days, P<0.001), but significantly higher hospitalization costs ($17631.3 vs. $8642.6, P<0.001). Average costs for mastectomy with IR increased significantly during the study period (P<0.001). Independent predictors of IR included age<65 (AOR=3.9, P<0.001), teaching and urban hospital designation (AOR=4.8, P<0.001), performance of bilateral mastectomies (AOR=3.8, P<0.001), lower comorbidity scores (AOR=2.2, P<0.001), private insurance (AOR=2.4, P<0.001), white race, top income quartile, and hospital region in the Northeast.
Conclusion: Mastectomy with IR is increasingly performed with resource utilization rising at a steady pace. Patients medical characteristics aside, our study points to persistent racial, socioeconomic, and hospital level disparities associated with the under-utilization of IR. Additional efforts are needed to ensure equitable access to IR.
