Introduction
Insurance type profoundly impacts healthcare access, yet limited studies exist exploring the relationship between insurance type and surgical outcomes in autologous breast surgery. This study aims to identify trends and associations between coverage type and outcomes in autologous breast reconstruction.
Methods
A retrospective cohort study was conducted through the Pearl Diver Mariner national all-payer claims database. The study included patients who received various types of reconstructive breast flaps, identified via CPT and ICD-10 procedural codes between 2012 and 2023. Patients were stratified based on insurance type. The primary outcome was surgical flap-related complications. Secondary outcomes included hospital length of stay (LOS), total cost, and 30-day readmission rate. Chi-squared tests and multivariate logistic regression were used for data analysis.
Results
This study included 39,886 patients, of which 5.4% had insurance coverage through Medicaid, 6.7% through Medicare, 88.1% commercial, 1.6% government, and 0.1% paid cash. Following DIEP reconstructions, patients with Medicaid coverage had significantly higher infection rates compared to all other insurance types (OR:2.005, p=0.004). Following LD flaps, patients who paid cash had significantly lower rates of dehiscence, while patients with Medicaid coverage (OR:0.72, p < 0.001) had higher rates of postoperative debridement, compared to those with commercial insurance. Regarding secondary outcomes, patients with Medicare and Medicaid experienced significantly longer LOS (Medicare, OR:1.72, p<0.001; Medicaid, OR:1.84, p<0.001) and higher total costs (Medicare, OR:1.28, p<0.001; Medicaid, OR:1.17, p<0.001) following DIEP flaps. Medicaid coverage was also associated with the highest rates of 30-day readmission (OR:2.43, p=0.048) following TRAM flaps compared to all other insurance types.
Conclusion
Insurance type is associated with significant differences in complication rates and postoperative metrics in autologous flap breast reconstruction. Notably, greater disparities were observed in patients with Medicaid and Medicare coverage. Given that insurance type can serve as a proxy for socioeconomic status, further investigation into the root causes of these variations is warranted to promote equitable access and health outcomes across groups undergoing breast surgery.
References
Celaya, M.O., Rees, J.R., Gibson, J.J. et al. Travel Distance and Season of Diagnosis Affect Treatment Choices for Women with Early-stage Breast Cancer in A Predominantly Rural Population (United States) . Cancer Causes Control 17, 851–856 (2006). https://doi.org/10.1007/s10552-006-0025-7
Schroen AT, Brenin DR, Kelly MD, Knaus WA, Slingluff CL Jr. Impact of patient distance to radiation therapy on mastectomy use in early-stage breast cancer patients. J Clin Oncol. 2005 Oct 1;23(28):7074-80. doi: 10.1200/JCO.2005.06.032. PMID: 16192590.
Boscoe FP, Johnson CJ, Henry KA, Goldberg DW, Shahabi K, Elkin EB, Ballas LK, Cockburn M. Geographic proximity to treatment for early stage breast cancer and likelihood of mastectomy. Breast. 2011 Aug;20(4):324-8. doi: 10.1016/j.breast.2011.02.020. Epub 2011 Mar 25. PMID: 21440439.
Albornoz CR, Cohen WA, Razdan SN, Mehrara BJ, McCarthy CM, Disa JJ, Dayan JH, Pusic AL, Cordeiro PG, Matros E. The Impact of Travel Distance on Breast Reconstruction in the United States. Plast Reconstr Surg. 2016 Jan;137(1):12-18. doi: 10.1097/PRS.0000000000001847. PMID: 26710002; PMCID: PMC4776632.