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The impact of the sociodemographic variables in the breast reconstruction type:A United States population based study
Claudia R. Albornoz, Evan Matros, MD, Peter Bach, MD, Colleen McCarthy, MD, Andrea L. Pusic, MD, Babak J. Mehrara, MD, Joseph J. Disa, MD, Peter G. Cordeiro, MD.
Memorial Sloan Kettering Cancer Center, New York, NY, USA.

BACKGROUND:
With advances in surgical technique, microsurgical breast reconstruction has an increasing place in the reconstructive armamentarium. Yet despite its popularity, no information exists regarding national utilization of microsurgical breast reconstruction. Disparities in the likelihood to receive any breast reconstruction have been studied previously; however, little information exists regarding sociodemographic predictors of breast reconstruction type, including microsurgery.
The premise of this study is to assess current rates of microsurgical breast reconstruction performed in the US and to identify sociodemographic predictors of breast reconstruction type.
METHODS:
The Nationwide Inpatient Sample (NIS) is the largest all-payer inpatient care database in the United States representing a stratified 20% sample of all hospital discharges from non-federal facilities. Since specific ICD-9 procedure codes for microsurgical breast reconstruction (DIEP, free TRAM) only became available in 2008, the database was analyzed in a cross-sectional design for this year. Inclusion criteria were patients undergoing total mastectomy, subcutaneous mastectomy, and/or any breast reconstruction procedure. Breast reconstruction type was classified into three groups: microsurgical flap, pedicled flap, or implant based. Autologous reconstructions were defined as either pedicle or microsurgical flaps. The relationship between the variables and outcomes was determined using logistic regression. Statistical significance was set at p<0.05.
RESULTS:
The immediate reconstruction rate following all mastectomies performed in 2008 was 35.2% with the highest rate reported in the Northeast (42.7%). Predictors of immediate breast reconstruction include white race, bilateral mastectomy, subcutaneous mastectomy, higher income, teaching hospital, large hospitals and private insurance. Patients over 50 years old and those operated on in the West were less likely to receive immediate breast reconstruction. Approximately 1063 immediate microsurgical breast reconstructions were performed in the US in 2008, representing 4.6% of all immediate reconstructions. Half of these were either DIEP, SIEA or SGAP flaps while the remainder were microsurgical TRAMS. Pedicled flaps and implant based reconstructions were performed in 13.8% and 81.6% of cases respectively. Predictors of autologous versus implant based reconstruction include teaching hospitals, private insurance, and delayed timing. Implant based reconstructions were more likely than autologous in young patients, Whites, Asians and patients from the West. The only predictor of a microsurgical versus a pedicle autologous reconstruction was the presence of bilateral mastectomy.
CONCLUSIONS:
This study reports the highest immediate breast reconstructions rates in a population based study. Sociodemographic factors such as age, race, teaching hospital, insurance type and geographic region impact not only receipt of a breast reconstruction, but whether patients undergo an implant based versus autologous reconstruction. These factors do not influence the type of autologous reconstruction performed.


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