Figure 2 shows the relationship between travel distance and immediate reconstruction rate by cancer program type. The mean distances traveled by patients who received care at community, comprehensive community, or academic programs were 21.1, 21.9, and 47.0 miles, respectively (p < 0.01). Similarly, reconstruction rates increased from 10.3 percent in community, to 19.9 percent in comprehensive community, and to 26.2 percent in academic programs (p < 0.01).
Table 3 shows travel distance by method of reconstruction. The mean distance traveled by patients who underwent autologous reconstruction was greater than the distance traveled by patients who underwent immediate implant-based reconstruction (p < 0.01). The mean travel distance for both types of procedures increased significantly at a rate of 2 percent per year.
Trends for mean travel distance to high-volume autologous centers are shown in Figure 3. Although the number of high-volume centers increased significantly from six to 28 in 1998 and 2011, respectively (p < 0.01), the mean distance traveled by patients receiving treatment at these centers also increased from 22.3 miles to 53 miles (p < 0.01). The average number of procedures performed by high-volume autologous centers did not change significantly over the study period (p = not significant) (data not shown).
Because unequal access is a major source of health outcome variation, it is a target of many initiatives within the Affordable Care Act.16 Geography affects not only people’s ability to obtain health care services but also the quality of those services.17 For example, high-volume centers are associated with lower complication rates but are often located in metropolitan centers, resulting in increased travel distance for patients residing in rural areas.15,18 Greater travel distance creates both direct (e.g., commute cost) and indirect (e.g., time, foregone wages) economic barriers, thereby restricting health care options for many patients.19 The premise of the current report was to use travel distance as a proxy for measuring the influence of geographic barriers on breast reconstruction rates and methods.
The greater distance traveled by women undergoing breast reconstruction, compared with mastectomy without reconstruction, suggests the presence of a geographic disparity (Table 2). Ideally, women should not have to travel farther to undergo breast reconstruction. Furthermore, a direct relationship was observed between travel distance and reconstruction rate. A woman who traveled 0 to 20 miles from her home zip code underwent reconstruction at a rate of 13.9 percent, whereas those who traveled 100 to 200 miles underwent reconstruction at a rate of 24.9 percent (Fig. 1). Similar findings have been observed in Canada, where universal health coverage is provided. Women who underwent postmastectomy breast reconstruction traveled farther from their residence to the hospital compared with those undergoing mastectomy alone.20 An undersupply of reconstructive surgeons was posited as an explanation; however, factors such as specific referral patterns and patient preference were also suggested. Within the United States, it has been shown that the number of plastic surgeons at an institution correlates with the likelihood for postmastectomy reconstruction.21 Considered together, these findings suggest that the Women’s Health and Cancer Rights Act and individual mandate for insurance coverage under the Affordable Care Act will be insufficient to eliminate all access issues to breast reconstruction. Training greater numbers of plastic surgeons who could diffuse into less saturated communities would be one method of addressing this issue.
A second important observation was that the distance traveled for breast reconstruction has increased over time, whereas it is unchanged for those who do not undergo reconstruction. Since 1998, the distance traveled by women who underwent breast reconstruction increased by 2 percent each year (p = 0.04) (Table 2). A variety of factors may contribute to this trend. Although the overall rate of breast reconstruction is increasing nationwide, plastic surgeons who perform these procedures may be saturated geographically, requiring patients to seek care at a greater distance. It is estimated that by 2020 there will be a significant shortage of plastic surgeons because of the growing U.S. population, a significant number of retiring surgeons, and a fixed number of training positions.22 Alternatively, the number of plastic surgeons performing breast reconstruction may be decreasing because of falling reimbursement rates, particularly for autologous breast reconstruction.23 Lastly, although microsurgical breast reconstruction was not specifically measured in this study, it creates a number of barriers that may negatively impact the ability to perform these procedures widely. Not only is specialized training necessary to perform microsurgery techniques, it is also commonly performed in urban academic centers where residents are available.11,24
The type of institution where a woman received care was observed to impact her rate of reconstruction, creating the observed geographic disparity. For example, women treated at academic centers needed to travel more than double the distance than those who received care at community or comprehensive community hospitals, but underwent reconstruction at the highest rates (Fig. 2) (p < 0.01). Although other studies have shown the association between academic centers and reconstruction rates, none has demonstrated travel distance as a factor.25 Academic centers provide subspecialty care, which may affect referral patterns, and also possess extra resources, including residents, skilled nursing staff, and financial incentives, which may promote reconstruction.11,21,23,24,26–28 Alternatively, women may choose academic centers because of their reputation, prestige, or research notoriety.
A secondary aim of the current study was to determine whether the distance traveled by patients to undergo autologous reconstruction was greater than that for implant reconstruction. When travel distance was dichotomized by method of reconstruction (Table 3), the average distance to undergo autologous reconstruction was greater than that for prosthetic techniques. Moreover, the distance traveled for autologous reconstruction was greater than for implants in 12 of the 14 years evaluated. Whereas autologous transfer used to be the most common method, implants are now the predominant method of breast reconstruction.12 Furthermore, with widespread adoption of perforator flaps, autologous reconstruction has become increasingly specialized, requiring advanced training and more resources, including but not limited to microscopes, flap monitoring devices, and specially trained nursing staff.24 The greater impact of these changes to the health care system has been a smaller number of hospitals providing this service, with the downstream effect of increased travel distance for the patient.4
Recent evidence of a market concentration of autologous reconstructions to high-volume centers led us to question whether this created an inadvertent barrier.12 Figure 3 demonstrates a simultaneous increase in the number of high-volume centers and the distance traveled for patients to reach them. Although the proliferation of high-volume centers could be interpreted in a positive light because of their association with favorable outcomes,18 reconstruction needs to be offered widely because of the prevalence of breast cancer.15 Thus, a shift to high-volume centers can create a bottleneck that limits access to care. The Centers for Medicare & Medicaid Services restricted coverage of Medicare patients undergoing bariatric surgery to Centers of Excellence in 2006, hoping to improve outcomes.29 Not only were outcomes unchanged,30 there was a decline in nonwhite Medicare patients undergoing weight-loss surgery.31 The policy was subsequently reversed in 2013.32
Although the study provides important insights, it has limitations. The National Cancer Database was chosen because it is the only database that contains information on the unique variable of travel distance. Although some of the absolute values reported in this study differ from previous large database studies, the long-term data trends are congruent (e.g., implant reconstructions have surpassed autologous reconstructions as the most common method of U.S. breast reconstruction).12 Moreover, the fidelity of national databases has been shown to correlate with individual centers.33 Unfortunately, the National Cancer Database does not allow for assessment of outcomes such as complications or patient satisfaction. This is important because greater travel distance could impact quality as well. Although in most cases greater travel distance can be interpreted as a geographic disparity, there may be instances when a woman chooses to seek care at a greater distance for a particular surgeon or academic medical center. Finally, the National Cancer Database differentiates reconstruction as tissue or prosthetic based, but does not report specific methods of autologous transfer. The investigation of microsurgery would likely show greater travel distance for these highly technical procedures.
Surgeons should be aware of an ongoing unmet need for breast reconstruction in the United States. Although greater patient awareness and insurance coverage have contributed to increased breast reconstruction rates in the United States, geographic barriers to access this service remain, particularly with regard to academic centers. Greater numbers of plastic surgeons, especially in community centers, would be one method of addressing this inequality.
The data used in the study are derived from a deidentified National Cancer Database file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology used, or the conclusions drawn from these data by the investigator.
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©2016American Society of Plastic Surgeons
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