The Northeastern Society of Plastic Surgeons

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Comparing Care For Out-of-State Versus In-State Patients Undergoing Autologous Free Flap Breast Reconstruction
Tobias J. Bos, BSc, Allison Haley, BS, Gurjot S. Walia, BS, Brian H. Cho, MD, Nicholas A. Calotta, BA, Charalampos Siotos, MD, Michele Manahan, MD, Gedge D. Rosson, MD, Justin M. Sacks, MD MBA FACS.
Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Health care disparities based on socioeconomic status (SES), race and primary payer have been shown to exist across medical specialties, including breast reconstruction. Additionally, the impact of treatment location has demonstrated large variations in breast reconstruction rates nationwide. In the state of Maryland there is a Medicare waiver. All patients regardless of payer type (individual, Medicare, Medicaid, Tricare or private) are charged the same for the same procedure. Maryland hospitals are given a global revenue budget by the state that cannot be exceeded. Out-of-state patients do not count against the global revenue cap and therefore an incentive can be created to treat these out-of-state patients. The purpose of this study is to determine whether out-of-state patients undergoing autologous free flap breast reconstruction receive equal care compared to in-state patients. Our hypothesis is that all patients are treated the same regardless of geographical origin.
Methods: Using an IRB approved database, we performed standardized retrospective chart review on patients who underwent autologous free flap breast reconstruction at our institution from January 2013 to March 2014, insuring ample follow up. Information regarding patient demographics, type of reconstruction, time-to-surgery, timing of reconstruction, additional surgeries, fat grafting procedures, and nipple reconstruction were collected and managed using REDCap electronic data capture tools hosted at Johns Hopkins University. Statistical analysis was performed using Stata; p values <0.05 were considered significant.
Results: Of the 114 patients whom we identified as undergoing autologous free flap breast reconstruction, 64 (56%) patients were in-state and 50 (44%) traveled from out-of-state. Both in-state and out-of-state patients were primarily Caucasian; 51.6% (n=33) vs. 74% (n=37), respectively. There was a significantly higher African American representation in the in-state group (p=.004); 39% (n=25) vs. 10% (n=5). No significant differences for other demographics (i.e. age, BMI, SES or insurer-type) were found, see table 1. The majority of patients undergoing breast reconstruction at our institution also had their mastectomy here (68%, n=78) versus breast reconstruction alone (32%, n=36), with no difference between patient groups (p=.69). Additionally no significant differences were found for: time to flap-surgery from first consultation; timing of reconstruction (immediate, staged or delayed); any additional surgery (p=.82); number of revisions (p=.8); fat grafting status (p=.09); or nipple reconstruction (p=.10), see table 2.​
Conclusion: A significant portion of patients undergoing autologous free flap breast reconstruction at our institution are from out-of-state. The results from this study suggest that out-of-state patients receive comparable breast reconstruction care compared to that of in-state patients. In changing health care economic landscapes it is critical to put patient care first and foremost. Access to care and disparities in care remain important issues that warrant continued investigation and attention.

Table 1 - Demographics
Median* or N (%)
Median* or N (%)
P Value
Age at flap surgery48.50 (42.75 - 54.00)49.00 (43.00 - 54.00)>0.05
BMI30.24 (27.24 - 34.32)28.36 (25.64 - 32.36)>0.05
SES [median household income by zipcode]$77,986 (58,203 - 100,352)$51,581 (51,581 - 81,144)>0.05
Private payer41 (64%)37 (74%)0.12
Caucasian33 (51.6%)37 (74%)
African American25 (39%)5 (10%)
Asian4 (6.3%)3 (6%)
Other2 (3.1%)5 (10%)
* Median 0.5 IQR (0.25 - 0.75)

Table 2 - Surgical Variables
Median* or N (%)
Median* or N (%)
P Value
Breast Reconstruction and Mastectomy at Johns Hopkins45 (70.3%)33 (66%)0.69
Timing of reconstruction0.99
Immediate (flap at mastectomy)15 (20.8%)11 (20.4%)
Staged (tissue expander)37 (51.4%)28 (51.8%)
Delayed20 (27.8%)15 (27.8%)
Time to flap surgery7.88 months (4.25-13.88)6.09 months (3.99-11.25)>0.05
Any additional surgery 49 (76.6%)40 (80%)0.82
Fat grafting 28 (43.75%)30 (60%)0.09
Nipple reconstruction+9 (15.8%)14 (29.8%)0.10
Number of Revisions0.50
0 Revisions18 (28.1%)11 (22%)
1 Revision26 (40.6%)18 (36%)
2 Revisions16 (25%)13 (26%)
3 Revisions3 (4.7%)7 (14%)
>3 Revisions1 (1.6%)1 (2%)
*Median 0.5 IQR (0.25 - 0.75), +Corrected for nipple sparing mastectomies

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