Influence of race, insurance status, and geographic access to plastic surgeons on immediate breast reconstruction rates

Background: This study evaluates the rates of immediate breast reconstruction (IBR) among racial and insurance status subgroups, in the setting of a changing plastic surgeon workforce. Methods: Using state level inpatient and ambulatory surgery data, we identified discharges for adult women who underwent mastectomy for breast cancer. This information was supplemented with plastic surgeon workforce data and aggregated to the health service area-level (HSA). Hierarchical linear models were used to risk standardized IBR rates for 8 race-payer subgroups. Results: The final cohort included 65,246 women treated across 67 HSAs. The plastic surgeon density per 100,000 population directly related to the IBR rate. While all subgroups saw a modest increase in IBR rates, Caucasian women with private insurance realized the largest absolute increase (46%) while African-American and Asian women with public insurance saw the smallest increase (6%). Conclusion: Significant disparities persist in the provision of IBR according to the form of insurance a patient possesses. Of heightened concern is the novel finding that even within privately insured patients, women of color have significantly lower IBR rates compared to Caucasian women.