Trends in immediate breast reconstruction across insurance groups after enactment of breast cancer legislation
Rachel L. Yang BA,
Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
Corresponding author: Rachel L. Yang, BA, Department of Surgery, Hospital of the University of Pennsylvania, 4 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104; Fax: (215) 615-5881; email@example.com
The Nationwide Inpatient Sample (NIS) database is part of a family of databases developed under the Healthcare Cost and Utilization Project (HCUP), which is sponsored by the Agency for Healthcare Research and Quality. NIS has provided data to this entity in an effort to further their mission of informing decision-making at the national, state, and community levels by allowing researchers and policymakers to identify, track, and analyze national trends in health care utilization, access, charges, quality, and outcomes.
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This analysis was not prepared by NIS. This analysis was prepared by the authors. NIS, its agents, and its staff bear no responsibility or liability for the results of the analysis, which are solely the opinion of this entity.
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To improve access to breast reconstruction for mastectomy patients, the United States enacted the Women's Health and Cancer Rights Act in January of 1999. The objective of the current study was to evaluate the impact of this legislation on patients with different insurance plans.
Women aged ≥18 years who underwent mastectomy for cancer were identified in the Nationwide Inpatient Sample database (2000-2009) and were classified according to their immediate breast reconstruction (IBR) status. Trends in rates of IBR were described for each insurance category. Multivariable logistic regression analysis with adjustment for age, race, estimated household income, and Elixhauser comorbidity index was performed to evaluate the relation between insurance status and IBR.
In total, 168,236 patients were identified who underwent a mastectomy during the study interval. Across the 10-year study period, rates of IBR increased 4.2-fold in Medicaid patients, 2.9-fold in Medicare patients, 2.6-fold in privately insured patients, and 2.1-fold in self-pay patients (P < .01). However, after adjustment for confounders, women without private insurance were less likely to undergo IBR compared with women who had private insurance (Medicaid: odds ratio [OR], 0.34; 95% confidence interval [CI], 0.32-0.37; Medicare: OR, 0.53; 95% CI, 0.49-0.58; self-pay: OR, 0.43; 95% CI, 0.37-0.50; other types of nonprivate insurance: OR, 0.64, 95% CI, 0.56-0.73).
In the United States alone, there were 207,090 new cases of breast cancer diagnosed in 2010. Breast cancer remains the most common cancer affecting women in the United States, and the incidence continues to increase. Uninsured patients are more likely to present with larger tumors and more advanced disease than women who have health care insurance.
Many women undergo mastectomy for large or multicentric tumors, personal preference, fear of disease recurrence, desire to avoid radiation, or risk reduction after diagnosis of a genetic mutation associated with breast cancer. For mastectomy patients, breast reconstruction offers more than just cosmetic benefits. Studies have demonstrated that women who undergo breast reconstruction experience improved quality of life compared with those who do not undergo reconstruction.[3, 4] In addition, immediate breast reconstruction has proven to be safe and does not affect risk of local disease recurrence.[5, 6] Despite these known benefits, the use of immediate breast reconstruction remains low.
Barriers to breast reconstruction after mastectomy exist. Patients may not be informed of the option for reconstruction, they may not be referred to a plastic surgeon, or they may believe their insurance company will not cover a “cosmetic” procedure. The Women's Health and Cancer Rights Act (WHCRA), which mandated insurance coverage of all breast reconstruction after mastectomy, was signed into law on October 21, 1998 and took effect on January 1, 1999. The law required health plans to cover all breast and nipple reconstruction as well as contralateral breast operations for symmetry.
It is well documented that disparities exist in cancer-related care based on patient insurance status, including decreased access to cancer screening, poor survival,[11-13] and inferior postoperative outcomes. Although an increasing volume of literature suggests that breast cancer patients with suboptimal health insurance have poor outcomes and inferior access to care, there has been limited evaluation of insurance-based disparities in breast reconstruction. Because the aforementioned policy enactment aimed to improve access to breast reconstruction, it is of interest to evaluate the diffusion of policy into clinical practice.
We sought to describe the trends in mastectomy and immediate breast reconstruction after legislative changes by insurance status. Furthermore, we examined the likelihood of undergoing immediate breast reconstruction by insurance status with adjustment for potential confounders.
MATERIALS AND METHODS
After receiving approval from the Institutional Review Board at the University of Pennsylvania, we performed a retrospective cohort study of breast cancer patients who underwent an inpatient mastectomy and were enrolled in the Nationwide Inpatient Sample (NIS) between 2000 and 2009. We excluded patients younger than 18 years old and men. The NIS database is part of a family of databases developed under the Healthcare Cost and Utilization Project (HCUP), which is sponsored by the Agency for Healthcare Research and Quality. NIS data are used to inform decision-making at the national, state, and community levels by allowing researchers and policymakers to identify, track, and analyze national trends in health care use, access, charges, quality, and outcomes. The most recent NIS data contain all discharge data from 1051 hospitals located in 45 states, approximating a 20% stratified sample of US community hospitals. The NIS database includes information for all patients, regardless of payer type, including those with Medicare, Medicaid, private insurance, and people who are uninsured.
Patients were included in the study if they were women who 1) had a diagnosis of breast cancer as determined by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) diagnosis codes for breast cancer 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.7, 174.8, 174.9, or 233.0; 2) had undergone a mastectomy during the incident admission as defined by ICD-9 procedure codes 85.4, 85.41, 85.42, 85.43, 85.44, 85.45, 85.46, 85.47, 85.48, or 85.23; 3) were aged ≥18 years.
The primary outcome of interest was immediate breast reconstruction. Patients were classified as undergoing immediate breast reconstruction based on the presence of ICD-9 procedure codes during the incident admission indicating transverse rectus abdominis myocutaneous free or pedicled flap, latissimus dorsi myocutaneous pedicled flap, deep inferior epigastric perforator free flap, gluteal artery perforator free flap, implant-based reconstruction, or other method of breast reconstruction (ICD-9 code 85.33, 85.35, 85.50, 85.51, 85.52, 85.53, 85.54, 85.72, 85.73, 85.74, 85.75, 85.6, 85.79, 85.8, 85.84, 85.85, 85.89, 85.93, 85.95, or 85.96). In the absence of 1 of these codes, patients were classified as not receiving immediate breast reconstruction.
All data elements were defined by the HCUP “Description of Data Elements, Nationwide Inpatient Sample” document. Insurance status was obtained from the NIS database and was categorized as private insurance, Medicaid, Medicare, self-pay, and other nonprivate insurance plans. Patients classified as “no-pay” or who had missing insurance status were not included in the analyses. Patients with multiple types of health coverage were excluded from the analyses to allow for an uncomplicated comparison of the insurance groups.
Year of mastectomy and race were obtained directly from the NIS database as categorical variables. Age was obtained directly from the NIS database and was organized into a categorical variable (ages <40 years, 40-49 years, 50-59 years, 60-69 years, and >69 years). Race was defined as white, black, Hispanic, Asian or Pacific Islander, and other. Native Americans were combined into the “other” category because of small sample sizes. Patients were classified with zero, 1 or 2, or >2 comorbidities using the Elixhauser Comorbidity Index. The index is a widely applied tool that has demonstrated both reliability and validity and uses 30 categories of comorbid illness that are identified using ICD-9 diagnosis codes. Estimated household income quartile, as determined by median household income for the patient's zip code, was recorded directly from the NIS database and stratified by quartile. All analyses were performed with and without the inclusion of patients who had supplemental insurance, and no significant differences were observed in the results. Therefore, the results reported reflect analyses that were performed after excluding the patients who had supplemental insurance.
Descriptive statistical analyses were performed for the entire study period. The number of mastectomies performed and rates of immediate breast reconstruction were calculated by year. Univariate analysis was performed to investigate the association between patient characteristics, including insurance status, and immediate breast reconstruction, using the Fisher exact test or the chi-square test, as appropriate. Multivariable logistic regression analysis was performed to evaluate the relation between insurance status and immediate breast reconstruction with adjustment for potential confounders, including patient age, race, and estimated household income.
Rates of immediate breast reconstruction were plotted by year for each insurance group. A line of best fit was developed for each insurance group over the 10-year study period. Linear regression was used to determine whether there was a significant linear change in rates of immediate breast reconstruction over time. Because age—the dominant eligibility criteria for Medicare—is inversely associated with the likelihood of breast reconstruction, a subset analysis was performed on patients aged >64 years using the methodology described above.
Data management was performed using SAS statistical software (version 9.2; SAS Institute Inc., Cary, NC), and statistical analyses were performed using Stata/SE (version 11.1; StataCorp LP, College Station, Tex). P values < .05 were considered significant for all statistical analyses.
During the 10-year study interval (2000-2009), 168,236 women underwent a mastectomy, and 35,217 patients (20.9%) underwent immediate breast reconstruction. Of all mastectomy patients, 58.8% had private insurance, 8.2% had Medicaid, 28.1% had Medicare, 2.4% were self-pay, and 2.5% had another type of insurance. The Medicaid group had the greatest percentage of patients aged <40 years and the greatest percentage of patients who were nonwhite. The Medicare group had the greatest percentage of patients with >2 comorbid illnesses, and the private insurance group had the greatest percentage of patients with an estimated income in the top quartile (Table 1).
Table 1. Characteristics of Patients Undergoing Mastectomy, by Insurance Group
In 2000, 12.9% of all mastectomy patients underwent immediate breast reconstruction; whereas, in 2009, 36.3% of all mastectomy patients underwent immediate breast reconstruction. Over the 10-year period, 34.6% of privately insured patients underwent immediate reconstruction, whereas only 23% of those who were self-pay, 12.9% of Medicaid patients, and 6.7% of Medicare patients (P < .01) underwent immediate reconstruction (Table 2). Rates of immediate breast reconstruction were highest among white patients, younger patients, those with fewer comorbid illnesses, and those with an estimated household income in the top quartile (P < .01) (Table 2).
Table 2. Mastectomy and Immediate Breast Reconstruction by Patient Characteristics
Significance was determined using the chi-square test.
Age at surgery, y
Estimated household income
All insurance groups saw a rise in rates of immediate breast reconstruction over the study interval. From 2000 to 2009, rates of immediate breast reconstruction increased 4.2-fold in Medicaid patients, 2.9-fold in Medicare patients, 2.6-fold in privately insured patients, and 2.1-fold in self-pay patients (Table 3). When a line of best fit was applied to each insurance group to identify a linear relation between rates of immediate breast reconstruction and year, we observed that all insurance groups had a significant positive slope except for the self-pay category (Fig. 1).
Table 3. Mastectomy and Immediate Breast Reconstruction by Insurance Status and Year
No. of Mastectomies (% IBR)
Abbreviations: IBR, immediate breast reconstruction.
In univariate analysis, patients without private insurance were less likely to undergo immediate breast reconstruction compared with privately insured patients (Table 4). Multivariable logistic regression analysis with adjustment for age, race, comorbid illnesses, and estimated household income revealed that Medicaid patients, Medicare patients, self-pay patients, and those with other types of insurance all remained less likely to undergo immediate breast reconstruction compared with privately insured patients. Medicare patients were approximately 50% as likely to undergo immediate reconstruction compared with privately insured patients, whereas Medicaid patients and were approximately 33% as likely to undergo immediate reconstruction compared with privately insured patients (Table 4).
Table 4. Likelihood of Immediate Breast Reconstruction by Insurance Group
Unadjusted ORs were determined by logistic regression of insurance status as a predictor of immediate breast reconstruction.
Adjusted ORs were determined by logistic regression of insurance status as a predictor of immediate breast reconstruction with adjustment for age, race, Elixhauser comorbidity index, and estimated household income.
Despite overall lower receipt of immediate reconstruction in patients aged >64 years, the trends in reconstruction in older Americans were similar to those observed in the overall study cohort. In 2000, the rate of reconstruction in older adults was 3.6%, and it was 11.9% in 2009. Rates of reconstruction differed by insurance status in the subset analysis of patients aged >64 years (private insurance, 10.5% [n = 500 of 3813]; Medicaid, 2.2% [n = 15 of 672]; Medicare, 5.9% [n = 1657 of 28,263]; self-pay, 5.1% [n = 11 of 217]; other types of insurance, 5.8% [n = 15 of 258]; P < .01). After adjusting for confounders, patients aged >64 years who had Medicare still were significantly less likely to undergo immediate breast reconstruction compared with patients who had private insurance (odds ratio, 0.68; 95% confidence interval, 0.58-0.80).
By using a nationwide cohort of breast cancer patients undergoing mastectomy, we were able to describe trends in immediate breast reconstruction based on patient insurance status after the enactment of policies aimed to improve access to breast reconstruction. Rates of immediate breast reconstruction increased across the study period for privately insured patients, Medicaid patients, Medicare patients, and patients with other types of nonprivate insurance. The relative increase in rates of immediate breast reconstruction was greatest among patients who had Medicaid and Medicare, providing evidence that policy changes had the most impact on traditionally underserved populations. However, despite these dramatic increases in rates of immediate breast reconstruction for patients with Medicare and Medicaid, all patients who had nonprivate insurance still were less likely to undergo immediate reconstruction compared with privately insured patients, even after adjustment for multiple confounders.
The dramatic rise in rates of immediate breast reconstruction for Medicaid and Medicare patients during the period after this policy change may have been the result of increased awareness among enrolled patients and their providers regarding new federal policies affecting insurance coverage. Patients are undeniably more apt to elect to undergo an operation if they are aware that their insurance plan will cover the procedure. The gradual rise in rates of breast reconstruction that occurred across several years after policy enactment suggests that time is required for the diffusion of legislative knowledge into clinical practice. The dramatic rise in rates of immediate breast reconstruction for Medicare and Medicaid patients in the period after passage of the WHCRA suggests that the legislation effectively diffused into underserved communities.
Although the policy change had the greatest effect on use of immediate breast reconstruction for Medicare and Medicaid patients, patients with private insurance still were more likely to undergo immediate reconstruction. This argues for the existence of persistent disparities in access to breast cancer care based on insurance status. In agreement with our findings, other studies also have reported that Medicaid and Medicare patients are less likely to undergo breast reconstruction compared with privately insured patients.[18-23] In addition, a recent study using the NIS reported that patients with nonprivate insurance were less likely to undergo autologous breast reconstruction than implant reconstruction. To the best of our knowledge, our finding that Medicare patients have a decreased likelihood of undergoing immediate breast reconstruction compared with privately insured patients aged >64 years has not previously been reported. Our study expands on the current literature describing changes in the receipt of immediate breast reconstruction after legislative changes, but with a unique focus on insurance status.
There are several mechanisms that may explain the persistent lower likelihood that patients with nonprivate health insurance will undergo immediate breast reconstruction. First, Medicaid patients more often receive their treatment in Medicaid health centers, where time for patient education regarding reconstruction may be limited. Second, physicians may be less likely to refer these patients to a plastic surgeon. A study of referral patterns in breast reconstruction revealed that breast surgeons are more likely to refer privately insured patients to a plastic surgeon. Furthermore, it has been demonstrated that older patients are less likely to be referred for reconstruction, which may contribute to the lower likelihood of immediate breast reconstruction among Medicare patients.
The current study has several limitations. In our study, we were able to evaluate only inpatient mastectomies and, thus, could not consider the potential influence of outpatient operations. It is possible that the patterns of undergoing immediate breast reconstruction based on payer type may differ in the outpatient setting and, thus, may influence our findings if we were to consider all mastectomies. A recent study reported that >20% of mastectomies are performed in the outpatient setting, and the overwhelming majority of those patients do not undergo reconstruction. Thus, our study may overestimate the overall rates of immediate breast reconstruction in the United States. Despite this limitation, our reported rates of reconstruction are in line with other published studies that have examined rates of reconstruction across nationally representative samples.[18-20]
Another limitation of our study is that we were unable to evaluate delayed breast reconstruction, because the NIS database only allows for evaluation of the single admission linked to each mastectomy performed. It is possible that patients with nonprivate health insurance more often undergo delayed reconstruction, given the known correlation between insurance status and tumor stage and the role of delayed reconstruction in patients who require postoperative radiation. If we had examined both immediate and delayed reconstruction, then patients with nonprivate insurance may not have had the same disparities in the receipt of breast reconstruction compared with privately insured patients.
Because of the limitations of the NIS database, we were not able to adjust for disease stage. Historically, women with later stage tumors have been less likely to undergo breast reconstruction, possibly because of the undesired effects of postmastectomy radiation or the fear of postponing chemotherapy. Therefore, it is possible that disease stage had a confounding effect on our results, because it has been demonstrated that patients with nonprivate insurance present with later stage cancers. We suggest that policy changes affecting coverage of breast reconstruction best explain the increased use of this procedure among patients with nonprivate insurance. Alternatively, it is conceivable that the trends we identified reflect a shift toward earlier stage disease among women with nonprivate insurance resulting from improved access to screening.[29, 30] Either argument supports the implementation of policies to diminish disparities in cancer care that have historically led to poor outcomes for vulnerable populations.
In conclusion, we observed a significant rise in rates of immediate breast reconstruction after the enactment of policy aimed at reducing disparities in access to breast reconstruction. The magnitude of increased immediate breast reconstruction use differed by insurance status. The greatest relative increase in the use of immediate breast reconstruction was observed in Medicare and Medicaid patients, suggesting that the new legislation had the most impact on underserved populations. However, despite these changes, privately insured patients still were more likely to undergo immediate breast reconstruction compared with all other insurance groups. Future studies are needed to determine why patients with different health plans do not have equal rates of immediate breast reconstruction despite the enactment of policies mandating universal coverage of this valuable operation.