A. Miller1,2, E. Reiche3, A. Yang1, B. Starr1, M. Kaur1,4, J. Broyles1,3, D. Coon1,3 1Harvard Medical School, Boston, MA, USA 2Harvard Kennedy School, Cambridge, MA, USA 3Brigham And Women’s Hospital, Division Of Plastic And Reconstructive Surgery, Boston, MA, USA 4Brigham And Women’s Hospital, Value And Experience (PROVE) Center, Department Of Surgery, Boston, MA, USA
Introduction: Chest masculinization surgery (CMS) with nipple-areolar complex reconstruction (NAC) plays an integral role in chest reconstruction for many transgender and gender-diverse (TGD) people, reducing gender dysphoria and improving gender congruence. We examined access, delivery, and reimbursement of CMS with and without NAC.
Methods: Massachusetts All-Payer Claims Database was queried for TGD patients (International Classification of Diseases, Tenth Revision codes: F64, F64.0, F64.1, F64.2, F64.8, F64.9, F51.1, and Z87.890) who received mastectomy (CPT code: 19303). Subgroup analyses were performed between patients who did and did not undergo same-day NAC (Current Procedural Terminology code 19350). Professional fee reimbursements were adjusted for inflation.
Results: Between 2016 to 2020, 609 TGD patients underwent mastectomy with NAC and 232 had mastectomy alone. The incidence of mastectomy with NAC increased from 90 to 175 between 2016 to 2019, and the relative proportion of mastectomy with NAC among all gender-affirming mastectomies increased from 61.6% in 2016 to 84.5% during this time. Mastectomy with NAC volume almost halved from 2019 to 2020, likely due to the deferrals for elective surgery during the COVID-19 pandemic. Mastectomy without NAC volume was relatively unchanged between these two years.
With regards to income, 32.1% of mastectomy with NAC and 46.9% of mastectomy without NAC patients lived in ZIP codes with the lowest two quintiles of median household income, compared to 40.3% and 25.5% of these cohorts, respectively, who lived in ZIP codes with the highest two quintiles of median household income (p<0.001). Multivariable regression showed living in ZIP codes with higher median incomes was associated with higher odds of undergoing NAC (OR per $10,000 median income increase: 1.12, 95% CI: 1.07-1.19, p< 0.001), when controlling for age, insurance status, tobacco usage, obesity, and diabetes.
The majority of mastectomies with NAC and a minority of mastectomies without NAC were performed by surgeons near Boston. Median provider reimbursement was higher in patients with private insurance than with public insurance in mastectomy with NAC ($3312 vs. $1820) and without NAC ($2587 vs. $1086).
Conclusion: Our study highlights the increasing prevalence CMS with NAC, as well as potential socioeconomic disparities in access to these surgeries based on living in more wealthy regions. Additionally, most NAC surgeries were performed in Boston, while most non-NAC procedures were performed outside of Boston, suggesting geographic barriers to undergoing this procedure. Further research should explore US region-based disparities in access to NAC procedures.
