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Effect of Federal and State Policy Changes on Racial/Ethnic Variation in Immediate Postmastectomy Breast Reconstruction

Mahmoudi, Elham Ph.D., M.S.; Giladi, Aviram M. M.D., M.S.; Wu, Lizi Ph.D., M.A.; Chung, Kevin C. M.D., M.S.

Plastic and Reconstructive Surgery: May 2015 - Volume 135 - Issue 5 - p 1285–1294
doi: 10.1097/PRS.0000000000001149
Breast: Outcomes Article
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Background: Breast reconstruction after mastectomy has been shown to provide substantial clinical and psychosocial benefits for many patients; however, disparities in the use of immediate postmastectomy breast reconstruction persist. Using the unique dataset from the New York State Inpatient Database, the following developments were studied: (1) trends in immediate postmastectomy breast reconstruction between 1998 and 2006 among white, African American, and Hispanic women; (2) factors associated with its use; and (3) changes in racial/ethnic variation in immediate postmastectomy breast reconstruction before and after implementation of the New York State Medicaid expansion in 2001.

Methods: A step-in multivariable logistic regression model was used to assess the effect of race/ethnicity, age, mastectomy type, number of comorbidities, socioeconomic status, and insurance on the probability of undergoing immediate postmastectomy breast reconstruction. Then, adjusted immediate postmastectomy breast reconstruction rates for before and after Medicaid expansion were predicted, stratified by race/ethnicity.

Results: The probability of undergoing immediate postmastectomy breast reconstruction increased (p < 0.001); however, even with Medicaid expansion occurring during the 8 years studied, gaps in use between white and African American women and between white and Hispanic women increased by 6 percent (95% CI, 0.07 to 0.05) and 5 percent (95% CI, 0.07 to 0.04), respectively. Being younger, having greater income and education, and having private health insurance are associated with a greater probability of immediate postmastectomy breast reconstruction.

Conclusion: These findings indicate that expanding safety-net policies such as Medicaid without providing support such as consultation or health literacy education might not be effective in reducing disparities in health care.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Supplemental Digital Content is available in the text.

Ann Arbor, Mich.

From the Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, and the University of Michigan Health System.

Received for publication October 3, 2014; accepted November 7, 2014.

Disclosure: The authors have no conflicts of interest to declare.

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Kevin C. Chung, M.D., M.S., 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, Mich. 48109, kecchung@med.umich.edu

©2015American Society of Plastic Surgeons