A retrospective cohort study on payor type and the effect on revisions in breast reconstruction

Background: Patients who are insured by Medicare and Medicaid are less likely to undergo breast reconstruction than their privately insured counterparts. Whether insurance type also affects subsequent revisions remains unknown. This study explores the relationship among payor type, revision procedures, and the completion of breast reconstruction. Methods: A retrospective cohort study was created including patients who underwent breast reconstruction at the authors' institution from 1996 to 2016. Data collected included age, cancer stage, race, laterality, initial breast reconstruction type, total number of procedures, number of trips to the operating room, and subsequent revisions. Analysis of covariance and logistic regression were used to estimate the controlled mean number of revisions and probability of completion of reconstruction as a function of insurance type. Results: A total of 3113 patients were included: 2271 (72.9 percent) with private insurance, 450 (14.5 percent) with Medicare, and 392 (12.6 percent) with Medicaid. On controlled analysis, there was no difference in total number of procedures, number of revisions, or number of trips to the operating room among the three insurance types. There was no difference in the proportion of patients undergoing symmetry procedures or nipple-areola reconstruction. Conclusions: To the authors' knowledge, this is the first study to evaluate discrepancies in number of procedures, revisions, and the proportion of patients completing breast reconstruction among insurance types. When controlling for other factors, the authors report no differences in care based solely on payor type. Instead, patient and surgeon variables may be responsible for the differences observed, and should be targeted in future research to improve equity.