The Empire State Mandate: A Multi-Decade Multi-Institutional Analysis of The 2010 New York State Legislature's Impact on Post-Mastectomy Immediate Flap-Based Reconstruction
Paul A. Asadourian1, MEng; Yunchan Chen, BS2; Wooram Jung, MSc2; Marcos Lu Wang, BS2; Anna Koerner, BS1; Nancy Qin, BS1; Malini Chinta, MD2; Caronline Andy, BS2; Christine H. Rohde, MD, MPH1; David M. Otterburn, MD2
1Division of Plastic Surgery, Columbia University Irving Medical Center, New York, NY; 2Division of Plastic Surgery, Weill Cornell Medicine, New York, NY
Purpose: Despite the psycho-social benefits of immediate post-mastectomy breast reconstruction, national trends show that only 16-40% of patients undergo immediate breast reconstruction after total mastectomy. In 2010 New York State passed the Breast Cancer Provider Discussion Law with the aim of increasing awareness of post-mastectomy reconstructive options through provider-driven patient education. Given that analysis of immediate years following implementation suggested that the law increased access to care, we aimed to conduct a multi-institutional study of the long term effects of the bill.
Materials and Methods: Retrospective review identified demographic, socioeconomic, and clinical data for patients undergoing mastectomy with immediate reconstruction at Weill Cornell Medicine and Columbia University Irving Medical Center from 2002 to 2019. Primary outcome was receiving implant or flap-based reconstruction. Subgroup analysis was based on sociodemographic factors. Interrupted time series (ITS) modeling analyzed differences in reconstructive trends for sociodemographic factors before and after the 2011 implementation of the NYS law.
Results: 2217 patients were included in our cohort. 1462 (65.9%) and 755 (34.1%) patients underwent implant and flap-based reconstruction, respectively. ITS showed that with each year leading up to 2011 law implementation, patients were 9% less likely to receive flap-based reconstruction (p < 0.05). Following implementation, there was no significant difference in the odds of receiving flap-based reconstruction with passing each year. With each year following implementation, Black patients were 43% more likely to receive flap reconstruction than White patients (p <0.05). No difference was seen between Asian American or Pacific Islander vs. White patients, pre and post-implementation. Prior to 2011, the highest income quartile was 16% less likely to receive flap-based reconstruction with each passing year than the lowest income quartile (p < 0.05). No difference was seen following implementation. Pre and post-implementation, there was no difference between groups based on ethnicity or distance from hospital. However, when comparing Medicaid/Medicare and Private Insurance patients, the odds that Medicaid/Medicare patients were 15% more likely (p = 0.06) and 16% less likely (p = 0.06) to get flap-based reconstruction pre- and post-2011, respectively, approached significance.
Conclusions: Our data indicates the long-term efficacy of the NYS Breast Cancer Provider Discussion Law in increasing the flap-based reconstruction rate for minority groups. This finding underscores the importance of this bill and encourages its adoption into other states. However, our analysis also suggests that disparities in access to flap-based reconstruction based on insurance status continue to exist, indicating the need for further study.
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