Differences in the Reporting of Racial and Socioeconomic Disparities among Three Large National Databases for Breast Reconstruction

Kamali, Parisa M.D.; Zettervall, Sara L. M.D., M.P.H.; Wu, Winona B.Sc.; Ibrahim, Ahmed M. S. M.D., Ph.D.; Medin, Caroline B.Sc.; Rakhorst, Hinne A. M.D., Ph.D.; Schermerhorn, Marc L. M.D.; Lee, Bernard T. M.D., M.P.H., M.B.A.; Lin, Samuel J. M.D., M.B.A.

Plastic & Reconstructive Surgery: April 2017 - Volume 139 - Issue 4 - p 795–807
doi: 10.1097/PRS.0000000000003207
Breast: Original Articles
Press Release
Video Discussion

Background: Research derived from large-volume databases plays an increasing role in the development of clinical guidelines and health policy. In breast cancer research, the Surveillance, Epidemiology and End Results, National Surgical Quality Improvement Program, and Nationwide Inpatient Sample databases are widely used. This study aims to compare the trends in immediate breast reconstruction and identify the drawbacks and benefits of each database.

Methods: Patients with invasive breast cancer and ductal carcinoma in situ were identified from each database (2005–2012). Trends of immediate breast reconstruction over time were evaluated. Patient demographics and comorbidities were compared. Subgroup analysis of immediate breast reconstruction use per race was conducted.

Results: Within the three databases, 1.2 million patients were studied. Immediate breast reconstruction in invasive breast cancer patients increased significantly over time in all databases. A similar significant upward trend was seen in ductal carcinoma in situ patients. Significant differences in immediate breast reconstruction rates were seen among races; and the disparity differed among the three databases. Rates of comorbidities were similar among the three databases.

Conclusions: There has been a significant increase in immediate breast reconstruction; however, the extent of the reporting of overall immediate breast reconstruction rates and of racial disparities differs significantly among databases. The Nationwide Inpatient Sample and the National Surgical Quality Improvement Program report similar findings, with the Surveillance, Epidemiology and End Results database reporting results significantly lower in several categories. These findings suggest that use of the Surveillance, Epidemiology and End Results database may not be universally generalizable to the entire U.S. population.

Video Discussion By Amy Alderman, M.D., is Available Online for this Article.

Boston, Mass.; Washington, D.C.; New Orleans, La.; and Enschede, The Netherlands

From the Divisions of Plastic and Reconstructive Surgery and Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School; George Washington University Medical Center; the Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center; and the Division of Plastic, Reconstructive and Hand Surgery, Medisch Spectrum Twente.

Received for publication May 18, 2016; accepted September 7, 2016.

Disclosure: Dr. Schermerhorn receives consulting fees from Endologix. None of the other authors has a conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www.PRSJournal.com).

A Video Discussion by Amy Alderman, M.D., accompanies this article. Go to PRSJournal.com and click on “Video Discussions” in the “Videos” tab to watch.

Samuel J. Lin, M.D., M.B.A., 110 Francis Street, Suite 5A, Boston, Mass. 02215, sjlin@bidmc.harvard.edu

Article Outline

In breast cancer research, the most often used large national databases in breast cancer research are the Surveillance, Epidemiology and End Results1 program, an epidemiologic surveillance system based on population-based tumor registries; the American College of Surgeon National Surgical Quality Improvement Program,2 a prospectively collected clinical database aiming to measure and improve the quality of surgical care across surgical specialties; and the Nationwide Inpatient Sample database,3 the largest administrative database within in the United States. All three databases have previously been used to study trends in surgical treatment of breast cancer and postmastectomy breast reconstruction.4–39 These databases collectively offer unique opportunities to study patterns of care, variation in practice, and outcomes following surgical intervention.40,41 In recent years, research derived from these large databases has played an increasing role in the development of clinical guidelines and health policy.42 After the implementation of the Women’s Health and Cancer Rights Act in 1998, mandating health care payer coverage for postmastectomy reconstructive surgery, a growing body of research used these large national databases and reported increased use of breast reconstruction but emphasized the geographic and racial disparities.5,9,12,17,23,25,29,30,32,37–39,43,44 As a result, the Breast Cancer Patient Education Act of 2015 was introduced with the goal of increasing awareness regarding the availability and coverage of breast reconstruction, especially for racial and ethnic minority groups.45

With the increased use of these national databases for research, clinical guidelines, and health policy, an understanding of the background, similarities, and fundamental differences among the Nationwide Inpatient Sample; the National Surgical Quality Improvement Program; and the Surveillance, Epidemiology and End Results program databases is necessary. Despite the robust data coming out of each database, few articles have evaluated the differences among these databases with regard to use of immediate breast reconstruction. Given this gap in knowledge, this study aims to (1) compare the trends in breast reconstruction from these databases and to evaluate whether similar trends are seen and (2) to identify the drawbacks and benefit of each database.

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PATIENTS AND METHODS

Databases

The Surveillance, Epidemiology and End Results database is an epidemiologic surveillance system that was developed in 1973.1 The Surveillance, Epidemiology and End Results database is a population-based tumor registry designed to track cancer incidence, cancer-directed surgery, radiation therapy provided for the first course of treatment, and survival in 18 cancer registries across 15 states (Fig. 1, above). The Nationwide Inpatient Sample database is an administrative database maintained by the Agency for Healthcare Research & Quality, with data available from 1988 to 2013.3 The Nationwide Inpatient Sample serves as the largest administrative database within the United States, representing a 20 percent stratified sample of U.S. hospitals, and includes approximately 8 million annual admissions up to 2011, and all patients in the following years. Data in the Nationwide Inpatient Sample are collected from inpatient hospital stays from 47 states and are weighted to produce national estimates (Fig. 1, center). The National Surgical Quality Improvement Program was created by the American College of Surgeons and has become a nationally validated registry.2 First developed in 2005, the National Surgical Quality Improvement Program provides a prospective, peer-controlled, database of patient demographics, comorbid conditions, operative variables, and 30-day postoperative surgical outcomes–based clinical data for patients older than 15 years. In 2014, the database included data from 708 hospitals in 49 states (Fig. 1, below). National Cancer Institute–Designated Cancer Centers and Comprehensive Cancer Centers are included in each map to reflect the distribution of large-volume cancer centers with data included in each state represented (Fig. 1).46

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Patient Selection

All databases include International Classification of Diseases, Ninth Revision, diagnosis codes, which were used to identify patients with diagnoses of ductal carcinoma in situ (International Classification of Diseases, Ninth Revision, diagnosis code 233.0) or invasive breast cancer (International Classification of Diseases, Ninth Revision, diagnosis codes 174.0 to 174.9). The surgical procedure coding system available in each database (Nationwide Inpatient Sample, International Classification of Diseases, Ninth Revision, procedure coding; National Surgical Quality Improvement Program, Current Procedural Terminology coding; Surveillance, Epidemiology and End Results, Surveillance, Epidemiology and End Results Program Coding and Staging) was then used to identify patients undergoing subcutaneous, simple, radical, or extended radical mastectomy.47–49 (See Table, Supplemental Digital Content 1, which shows International Classification of Diseases, Ninth Revision, breast cancer and carcinoma in situ coding, http://links.lww.com/PRS/C87. See Table, Supplemental Digital Content 2, which shows International Classification of Diseases, Ninth Revision, Current Procedural Terminology and Procedure mastectomy codes, http://links.lww.com/PRS/C88.) In both the Nationwide Inpatient Sample and the National Surgical Quality Improvement Program databases, immediate breast reconstruction is defined as placement of tissue expander or permanent implant, autologous flap reconstruction, or combined (autologous and implant-based) reconstruction concurrent with mastectomy. (See Table, Supplemental Digital Content 3, which shows International Classification of Diseases, Ninth Revision, Current Procedural Terminology, and Procedure immediate breast reconstruction codes, http://links.lww.com/PRS/C89.) In the Surveillance, Epidemiology and End Results database, immediate breast reconstruction is defined as any type of breast reconstruction concurrent with or within 4 months of mastectomy (See Table, Supplemental Digital Content 3, http://links.lww.com/PRS/C89). Patients younger than 18 years or without documented age, male patients, those undergoing outpatient procedures, and those without International Classification of Diseases, Ninth Revision, or Procedure codes were excluded. Postmastectomy immediate reconstruction rates and trend over time were evaluated separately for invasive breast cancer and ductal carcinoma in situ patients.

To allow for uniform comparison among databases, demographic and comorbidity data were evaluated for the years 2005 to 2012. Moreover, to illustrate immediate breast reconstruction use after implementation of the Women’s Health and Cancer Rights Act of 1998, the trend over time is demonstrated from 1998 to 2012 for both the Surveillance, Epidemiology and End Results and the Nationwide Inpatient Sample databases and from 2005 to 2014 for the National Surgical Quality Improvement Program database. Subgroup analysis included stratification per race and a direct state-to-state comparison. Comparison between states was only possible in the Surveillance, Epidemiology and End Results and Nationwide Inpatient Sample databases. We therefore compared rates of immediate breast reconstruction of the state of California for the Surveillance, Epidemiology and End Results and the Nationwide Inpatient Sample. The state of California was chosen because of its highly diverse population. In the Surveillance, Epidemiology and End Results database, the state of California included four cancer registries: Greater California (excluding San Francisco, Los Angeles, and San Jose-Monterey), San Francisco-Oakland standard metropolitan statistical area, San Jose-Monterey, and the Los Angeles cancer registry. In the Nationwide Inpatient Sample, data from the state of California were provided by hospital identification number.

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Variables

Patient comorbidities were identified. Age and race were the only variables that were available in all three databases. Age was divided into categories (younger than 39, 40 to 49, 50 to 59, 60 to 69, and older than 70 years). Race was classified into similar categories as census population data (white, black, Hispanic, Asian or Pacific Islander, and other). Diabetes mellitus, hypertension, chronic obstructive pulmonary disease, and obesity were available in both the Nationwide Inpatient Sample and the National Surgical Quality Improvement Program databases.

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Statistical Analysis

Descriptive statistics were reported as proportions and compared using the Pearson chi-square test. Trends were analyzed using the Cochran-Armitage test for trend. All statistical analyses were performed using IBM SPSS Version 22.0 (IBM Corp., Armonk, N.Y.) and significance was set at p < 0.05.

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RESULTS

Invasive Breast Cancer

Between 2005 and 2012, a total of 607,867 patients diagnosed with invasive breast cancer were identified in the Nationwide Inpatient Sample database. Among these patients who underwent mastectomy, 32.7 percent (n = 151,660) opted for immediate reconstruction. When divided into type of reconstruction, 78.6 percent (n = 119,152) underwent implant-based, 13.7 percent (n = 20,764) underwent autologous flap, and 7.7 percent (n = 11,744) underwent combined type breast reconstruction (Table 1). Immediate breast reconstruction increased significantly over time from 11.5 percent in 1998 to 47.0 percent 2012 (p < 0.001) (Fig. 2, above).

The National Surgical Quality Improvement Program database included 38,567 breast cancer patients, of whom 40.7 percent (n = 13,372) underwent immediate breast reconstruction. Among all patients undergoing reconstruction, 77.2 percent (n = 10,324) underwent implant-based breast reconstruction, 17.8 percent (n = 2376) underwent autologous breast reconstruction, and 5.0 percent (n = 672) underwent combined breast reconstruction (Table 1). Immediate breast reconstruction also increased significantly over time in the National Surgical Quality Improvement Program database, from 30.3 percent in 2005 to 54.4 percent in 2014 (p < 0.001) (Fig. 2, above).

The Surveillance, Epidemiology and End Results database included 439,564 breast cancer patients, of whom 18.8 percent (n = 34,384) underwent immediate reconstruction. In total, 45.3 percent (n = 15,587) underwent implant-based breast reconstruction, 41.2 percent (n = 14,151) underwent autologous reconstruction, and 13.5 percent (n = 4646) underwent a combined type of reconstruction (Table 1). Immediate breast reconstruction increased significantly from 8.3 percent in 1998 to 24.9 percent in 2012 (p < 0.001) (Fig. 2, above).

When demographics and comorbidities were evaluated, the average age differed among databases (Nationwide Inpatient Sample, 60.5 ± 14.5 years; National Surgical Quality Improvement Program, 56.7 ± 13.4 years; Surveillance, Epidemiology and End Results, 61.4 ± 14.9 years). Patients older than 70 years constituted 28.5 percent of patients in the Nationwide Inpatient Sample database; 21.3 percent in the National Surgical Quality Improvement Program database; and 29.3 percent in the Surveillance, Epidemiology and End Results database. In the National Surgical Quality Improvement Program, the most common age was 50 to 59 years (Nationwide Inpatient Sample, 23.6 percent; National Surgical Quality Improvement Program, 26.2 percent; Surveillance, Epidemiology and End Results, 24.2 percent). When comparing comorbidities between the Nationwide Inpatient Sample and the National Surgical Quality Improvement Program, significant differences were found in hypertension (41.0 percent and 39.8 percent, respectively; p < 0.001), diabetes mellitus (14.4 percent and 10.8 percent, respectively; p < 0.001), and chronic obstructive pulmonary disease (5.0 percent and 2.6 percent, respectively; p < 0.001) (Table 1).

Figure 3 (above) demonstrates the significantly different rates of immediate breast reconstruction in breast cancer patients stratified per race within the Nationwide Inpatient Sample; National Surgical Quality Improvement Program; and Surveillance, Epidemiology and End Results databases (p < 0.001). The highest rate of immediate breast reconstruction was seen among whites: 35.7 percent in the Nationwide Inpatient Sample; 43.1 percent in the National Surgical Quality Improvement Program; and 20.6 percent in the Surveillance, Epidemiology and End Results database (p < 0.001). The lowest rates of immediate breast reconstruction were found among blacks: 27.3 percent in the Nationwide Inpatient Sample; 30.7 percent in the National Surgical Quality Improvement Program; and 15.5 percent in the Surveillance, Epidemiology and End Results database (p < 0.001). In the Hispanic population, the rates were 30.8 percent in the Nationwide Inpatient Sample; 40.3 percent in the National Surgical Quality Improvement Program; and 12.9 percent in the Surveillance, Epidemiology and End Results database (p < 0.001). Finally, within the Asian/Pacific Islander population, immediate breast reconstruction was used in 30.5 percent in the Nationwide Inpatient Sample; 32.1 percent in the National Surgical Quality Improvement Program; and 14.0 percent in the Surveillance, Epidemiology and End Results database (p < 0.001).

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Ductal Carcinoma In Situ Patients

The Nationwide Inpatient Sample included 86,733 patients diagnosed with ductal carcinoma in situ, of which 51.4 percent opted for immediate breast reconstruction. Implant-based breast reconstruction accounted for 77.0 percent (n = 31,836), autologous breast reconstruction accounted for 15.4 percent (n = 6350), and combined type of breast reconstruction accounted for 7.7 percent (n = 3172) (Table 1). Over time, immediate breast reconstruction increased significantly, from 23.2 percent to 66.4 percent between 1998 and 2012, respectively (p < 0.001) (Fig. 2, below).

The National Surgical Quality Improvement Program included 7173 patients diagnosed with ductal carcinoma in situ; 54.1 percent (n = 3445) of the patients treated with mastectomy underwent immediate reconstruction. Among all patients undergoing reconstruction, 75.4 percent (n = 2597) underwent implant-based breast reconstruction, 19.9 percent (n = 687) underwent autologous breast reconstruction, and 4.7 percent (n = 116) underwent combined breast reconstruction (Table 2). Immediate breast reconstruction rates increased significantly, from 53.6 in 2005 to 62.6 percent in 2014 (p < 0.001) (Fig. 2, below).

The lowest rate of immediate breast reconstruction was seen in the Surveillance, Epidemiology and End Results database. Of the 108,482 patients diagnosed with ductal carcinoma in situ who underwent mastectomy, 31.7 percent (n = 10,690) opted for immediate breast reconstruction. A total of 46.0 percent (n = 4922) underwent implant-based breast reconstruction, 39.9 percent (n = 4265) underwent autologous reconstruction, and 14.1 percent (n = 1503) underwent a combined type of reconstruction. Over time, immediate reconstruction increased significantly from 18.1 percent in 1998 to 36.6 percent in 2012 (p < 0.001) (Fig. 2, below).

The mean age was similar among databases (Nationwide Inpatient Sample, 57.7 ± 13.0 years; National Surgical Quality Improvement Program, 56.7 ± 12.3 years; and Surveillance, Epidemiology and End Results, 59.2 ± 13.5 years), and the majority of women were aged 50 to 59 years (Nationwide Inpatient Sample, 26.3 percent; National Surgical Quality Improvement Program, 29.4 percent; and Surveillance, Epidemiology and End Results, 28.5 percent). Rates of comorbidities within the Nationwide Inpatient Sample and National Surgical Quality Improvement Program were significantly different for hypertension (36.8 percent versus 35.4 percent; p < 0.001), diabetes (11.7 percent versus 9.6 percent; p < 0.001), and chronic obstructive pulmonary disease (3.0 percent versus 2.0 percent; p < 0.001) (Table 2).

There were significant differences in use of immediate breast reconstruction by ductal carcinoma in situ patients stratified per race (p < 0.001). White patients opted for immediate breast reconstruction in 54.9 percent in the Nationwide Inpatient Sample; 58.2 percent in the National Surgical Quality Improvement Program; and 34.0 percent in the Surveillance, Epidemiology and End Results population (p < 0.001). Black patients underwent immediate breast reconstruction less frequently (Nationwide Inpatient Sample, 43.2 percent; National Surgical Quality Improvement Program, 42.1 percent; and Surveillance, Epidemiology and End Results, 27.9 percent) (p < 0.001). Hispanic patients underwent immediate breast reconstruction at rates of 51.3 percent in the Nationwide Inpatient Sample; 59.0 percent in the National Surgical Quality Improvement Program; and 27.1 percent in the Surveillance, Epidemiology and End Results database (p < 0.001). Finally, immediate breast reconstruction use in the Asian/Pacific Islander population was as follows: Nationwide Inpatient Sample, 47.9 percent; National Surgical Quality Improvement Program, 41.5 percent; and Surveillance, Epidemiology and End Results, 22.6 percent (p < 0.001).

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Comparison by State: California

Within the Surveillance, Epidemiology and End Results cohort, a total of 196,100 patients diagnosed with either invasive breast cancer or ductal carcinoma in situ were treated in California, reflecting 35.8 percent of the total Surveillance, Epidemiology and End Results cohort. Of these, 81.4 percent (n = 159,673) were diagnosed with invasive breast cancer and 18.6 percent (n = 36,427) were diagnosed with ductal carcinoma in situ. Of the postmastectomy cohort, 15.9 percent (n = 10,493) of invasive breast cancer patients and 28.2 percent (n = 3176) of ductal carcinoma in situ patients underwent immediate breast reconstruction. In the Nationwide Inpatient Sample, the state of California reported 78,714 patients, reflecting 11.3 percent of the complete Nationwide Inpatient Sample cohort. Of these, 86.4 percent (n = 67,971) consisted of patients diagnosed with breast cancer and 13.6 percent (n = 10,743) consisted of patients diagnosed with ductal carcinoma in situ. Of patients undergoing mastectomy, 31.6 percent (n = 15,999) of invasive breast cancer patients and 52.5 percent (n = 5044) of ductal carcinoma in situ patients underwent immediate breast reconstruction.

Figure 4 demonstrates the rates of immediate breast reconstruction use stratified per race. For invasive breast cancer patients, immediate breast reconstruction use differed significantly among white (Nationwide Inpatient Sample, 35.0 percent; Surveillance, Epidemiology and End Results, 18.2 percent; p < 0.001), black (Nationwide Inpatient Sample, 25.8 percent; Surveillance, Epidemiology and End Results, 11.9 percent; p < 0.001), Hispanic (Nationwide Inpatient Sample, 25.1 percent; Surveillance, Epidemiology and End Results, 10.8 percent; p < 0.001), and Asian/Pacific Islander populations (Nationwide Inpatient Sample, 28.6 percent; Surveillance, Epidemiology and End Results, 13.2 percent; p < 0.001). Significant differences among races were also seen in the ductal carcinoma in situ population in whites (Nationwide Inpatient Sample, 57.1 percent; Surveillance, Epidemiology and End Results, 23.5 percent; p < 0.001), blacks (Nationwide Inpatient Sample, 46.0 percent; Surveillance, Epidemiology and End Results, 24.4 percent; p < 0.001), Hispanics (Nationwide Inpatient Sample, 38.9 percent; Surveillance, Epidemiology and End Results, 24.4 percent) (p < 0.001) and Asian/Pacific Islanders (Nationwide Inpatient Sample, 50.3 percent; Surveillance, Epidemiology and End Results, 21.3 percent; p < 0.001).

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DISCUSSION

In this study, we present a nationwide comparison of immediate breast reconstruction as reported by three large national databases: the Nationwide Inpatient Sample; the National Surgical Quality Improvement Program; and the Surveillance, Epidemiology and End Results program. This study found that, despite large numbers of patients undergoing breast reconstruction in all databases, the reported frequency differed significantly for both invasive breast cancer patients and ductal carcinoma in situ among databases. In both disease cohorts, a significant upward trend over time was seen in the use of immediate breast reconstruction in the National Surgical Quality Improvement Program; Nationwide Inpatient Sample; and Surveillance, Epidemiology and End Results databases (Fig. 2) (p < 0.001). In addition, after subgroup analysis, the extent of disparities in immediate reconstruction differed significantly among databases (Fig. 3).

The overall rate of immediate breast reconstruction following mastectomy in this study was 18.8 percent in invasive breast cancer patients within the Surveillance, Epidemiology and End Results population, which is supported by the work of Ashfaq et al.,13 Agarwal et al.,5 and Lang et al.,30 who reported 16 to 20 percent immediate breast reconstruction rates using the same database. In the Nationwide Inpatient Sample cohort, we found immediate breast reconstruction in 32.7 percent of invasive breast cancer patients and 51.4 percent of ductal carcinoma in situ patients, similar to previous reports.6,7,23,37 Our study also found an increase in immediate breast reconstruction after mastectomy (from 11.5 percent to 47.0 percent in invasive breast cancer patients and from 23.2 percent to 66.4 percent in ductal carcinoma in situ patients between 1998 and 2012, respectively), which supports other studies using the Nationwide Inpatient Sample database. Albornoz et al.6 demonstrated an increase in use of immediate breast reconstruction from 20.8 percent in 1998 to 37.8 percent in 2008 for patients diagnosed with breast cancer or increased risk of breast cancer. Other studies reflect similar rates of immediate breast reconstruction use after mastectomy ranging from 18.0 to 38.0 percent.7,34,37,39 Finally, we found immediate reconstruction rates of 40.7 percent among invasive breast cancer patients and 54.1 percent among ductal carcinoma in situ patients within the National Surgical Quality Improvement Program population. Recent reports by Kwok et al. and Butler et al. reported a significant increase in immediate breast reconstruction use, with rates similar to those found in our study (26.0 to 29.7 percent to 40.0 to 42.8 percent between 2005 and 2011/2012, respectively).17,29

Despite passage of the Women’s Health and Cancer Rights Act of 1998, many have noted women of color to be significantly less likely to receive breast reconstruction.5,7,9,10,12,17,26,27,30,32,38,39,44 As a result, the Breast Cancer Patient Education Act of 2015 was introduced in 2015, in the effort to raise awareness about the availability and coverage of breast reconstruction, especially for racial and ethnic minority groups.45 This bill referred to statistics provided by the American Cancer Society, multiple institutional studies, and in terms of one large database, only Surveillance, Epidemiology and End Results studies.45

Similar to previous studies, we found significant racial disparities in immediate breast reconstruction use. Our study, however, contributes new insight into and identifies significant interdatabase variability of racial disparities in immediate breast reconstruction. Our results showed that the rates of immediate breast reconstruction use differed among the different databases (Fig. 3). This persisted even following subgroup analysis of the state of California, where variability in racial disparities was seen with differences up to 50 percent (Fig. 4).

Major differences in type and nature of the databases exist (Table 2). Generally, large-volume databases can be broadly categorized as either administrative or clinically based databases. Administrative databases, such as the Healthcare Cost and Utilization Project (which includes the Nationwide Inpatient Sample, the Kids Inpatient Database, the State Inpatient Database, and the State Ambulatory Surgery Database), Medicare, and the University HealthSystem Consortium databases were originally not designed for clinical research, but rather to track billing for hospitals, providers, and procedures. Although providing a wealth of information, patient-level clinical information is not available in these administrative databases (stage of disease, tumor characteristics, preoperative performance status). Clinical databases, such as the National Surgical Quality Improvement Program; Surveillance, Epidemiology and End Results; and National Cancer Database, are developed with specific clinical goals in mind and therefore populated with defined patient information. In addition, the population within the database may be limited by specific restrictions, including age (Medicare) or diagnosis (cancer registries).

The National Surgical Quality Improvement Program; Nationwide Inpatient Sample; and the Surveillance, Epidemiology and End Results databases are used extensively as a nationwide representation of the U.S. population, but major variations exist in the states covered by the different databases (Fig. 1). Most importantly, it should be noted that the Nationwide Inpatient Sample and the National Surgical Quality Improvement Program reflect practice patterns in 47 or more states, whereas the Surveillance, Epidemiology and End Results database reflects the practice of only 17 states. Previous studies focused on cancer care found that treatment trends and outcomes varied according to volumes, teaching or academic medical centers, national cancer institute cancer center designation, and subspecialist providers.50 When our study evaluated nationwide and National Cancer Institute–Designated Cancer Center coverage of the National Surgical Quality Improvement Program; Nationwide Inpatient Sample; and Surveillance, Epidemiology and End Results databases, we found that the National Surgical Quality Improvement Program and the Nationwide Inpatient Sample cover the majority of states and National Cancer Institute cancer hospitals. The Surveillance, Epidemiology and End Results database, however, covers only 18 cancer registries in 15 states and lacks coverage in most states and of the major cancer centers throughout the Unites States. In addition, we showed that when comparing the databases in only one state, California, significant differences existed in immediate breast reconstruction use between the Nationwide Inpatient Sample and Surveillance, Epidemiology and End Results databases (Fig. 4).

Sampling of the type of hospital is another factor that may also affect the rates of immediate breast reconstruction, with academic centers more likely to perform autologous reconstruction and immediate reconstruction.7,23,25,51,52 Although the Surveillance, Epidemiology and End Results program samples the population based on race, income, and education, with the specific aim of increasing generalizability to the U.S. population, it lacks coverage of most major cancer centers throughout the United States, including most major academic medical centers (Figs. 1, above and 2). In the National Surgical Quality Improvement Program, academic institutions are represented more prominently, potentially explaining the high immediate breast reconstruction rates when compared to the Nationwide Inpatient Sample and Surveillance, Epidemiology and End Results databases. The Nationwide Inpatient Sample is a random sampling that may be the best representation, but remains only sampling through 2011.

There are important clinical implications to this research. Clinicians and researchers should have a basic understanding and should know the strengths and weaknesses of the databases to interpret the data. One database should therefore not uniformly be used for clinical guidelines and policies. This study has several notable limitations. First, all data are collected from national databases that are subject to missing data, coding errors, and poor long-term follow-up. In addition, this study is not able to assess long-term survival, as the National Surgical Quality Improvement Program does not capture postoperative events occurring beyond 30 days; the Nationwide Inpatient Sample includes only data from inpatient stay; and the Surveillance, Epidemiology and End Results database does not include data beyond 4 months. However, Tseng et al.53 revealed that only 8 percent of mastectomy patients pursued reconstruction in a delayed fashion, suggesting that the racial disparities in immediate breast reconstruction use revealed in this present study would be unlikely to significantly change if the delayed reconstruction patients were able to be captured. In addition, the lowest rate of immediate breast reconstruction occurred in the Surveillance, Epidemiology and End Results database, which interestingly also has the longest follow-up compared with the National Surgical Quality Improvement Program and the Nationwide Inpatient Sample. Finally, we are unable to account for patient preferences, which may vary across cultural groups; this is an important area for future research.

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CONCLUSIONS

Our study confirmed previous work suggesting that the use of immediate breast reconstruction has increased over time, and significant racial disparities exist. However, the reported rates of reconstruction are lowest and disparities are highest in the Surveillance, Epidemiology and End Results database. These findings suggest that use of the Surveillance, Epidemiology and End Results database may not be universally generalizable to the entire U.S. population, and should be considered when studies are used for wider policy making.

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