Breast Reconstruction National Trends and Healthcare Implications

Abstract

Breast reconstruction improves quality-of-life of breast cancer patients. Different reconstructive options exist, yet commentary in the plastic surgery literature suggests that financial constraints are limiting access to autologous reconstruction (AR). This study follows national trends in breast reconstruction and identifies factors associated with reconstructive choices. Data were obtained from the Nationwide Inpatient Sample from 1998 to 2008. Patients were categorized as having either implant or ARs. Bivariate and multivariate regression analysis identified variables associated with receiving implants versus AR. Physician fee schedules were analyzed using national average Medicare physician reimbursement rates. From 1998 to 2008, 324,134 breast reconstructions were performed. Reconstructions increased 4% per year. The proportion of implant reconstructions increased 11% per year, whereasARs decreased 5% per year (p < 0.05). Our model showed that the odds of having implant-based versus AR were significantly associated with age, disease severity, payer type, hospital teaching status, and year of surgery. Year of surgery was the strongest predictor of implant reconstruction; patients receiving breast reconstructive surgery in 2009 were three times more likely to have implant breast reconstructive surgery compared with similar patients in 2002. Medicare reimbursement steadily declined for AR over a similar time frame. From 1998 to 2008, autologous breast reconstruction has significantly declined, parallel to a decrease in physician reimbursement. Our data found no significant change in patient characteristics supporting the lack of choice of AR. Further research is warranted to better understand this shift to implant reconstruction and to ensure future access of these complex reconstructive procedures.

Cost-Effectiveness Analysis of Implants versus Autologous Perforator Flaps Using the BREAST-Q

“…10 Furthermore, Medicare physician payments from 1998 to 2008 have declined by only 4 percent for implants, whereas they have decreased by 11 percent for autologous tissue transfers. 11 These effects are magnified by the adoption of lengthier microsurgical techniques, particularly in the setting of bilateral mastectomy defects. 12 The high proportion of U.S. gross domestic product spending on health care is one factor that motivated passage of the Affordable Care Act, with the aims of reducing cost and maximizing quality.…”

Rise in Microsurgical Free-Flap Breast Reconstruction in Academic Medical Practices

“…1,2,16 Although the present study confirms that implant-based reconstructions are still the preferred method for primary reconstruction in academic institutions, the trend toward their increasing use year to year has tapered. The most notable finding of the present study is the prominence of microsurgical reconstruction and revision reconstruction in academic settings (Fig.…”

“…1 Immediate reconstructions, mostly implant based, also increased by 5% yearly, with a near-doubling reported in a Surveillance, Epidemiology, End-Results database analysis. 2 Associated with this trend, a growing incidence of elective mastectomy and contralateral prophylactic surgery in lieu of breast conservation has been described in several large studies.…”

“…Primary implant reconstructions are generally less technically challenging, requiring less intraoperative time, with more favorable insurance reimbursement when compared to autologous reconstructions. 1 More rapid postoperative recovery and avoidance of donor site morbidity are also reasons that may help explain the greater number of practices offering only implant-based reconstruction versus the full spectrum of autologous reconstructions and microvascular free flaps. 5 However, breast implants have negative implications.…”

A Comparative Analysis of 2 National Breast Reconstruction Surveys

“…Also, a study 13 demonstrated that the number of IBR increased 11% per year from 1998 to 2008. During the same period, it was also noted that the number of autologous reconstructions decreased 5% per year.…”