Regional Disparities Remain in Breast Reconstruction for Patients With Breast Cancer

Regional variations in the utilization, complication rate, and cost of breast reconstruction for patients with breast cancer exist; however, there does not seem to be regional variation in implicit bias that is associated with these differences, according to a study published in JAMA Network Open.

The researchers sought to understand if differences in breast reconstruction rates for White patients and patients from other racial and ethnic groups were a result of implicit racial bias by region. They used data from the National Inpatient Sample from 2009 to 2019.

While there is evidence that breast reconstruction improves quality of life after breast cancer, the procedure is underutilized following mastectomy, the authors explained. “Understanding drivers of disparities, such as biases among physicians, may serve as the basis for more equitable care,” they wrote.

General structural issues in the US health care system are known to result in disparities in access to care, but implicit racial bias by region did not correlate with these differences, the study found. Image credit: Vasyl - stock.adobe.com

The study used data from the National Inpatient Sample (NIS) from 2009 to 2019 on 52,115 adult female patients with a diagnosis of or a genetic predisposition for breast cancer. To measure implicit bias, they used the Implicit Association Test (IAT) data from Project Implicit to quantify implicit bias. The researchers linked the 2 databases to evaluate if implicit bias was association with any regional variations identified in breast reconstruction utilization rates.

The analysis included 38,487 White patients and 13,628 patients belonging to minoritized racial and ethnic groups. The majority had private insurance (76%), although White patients were more likely to be privately insured than minoritized racial and ethnic groups (79% vs 69%). The majority of patients received implant-based reconstruction (72%).

The White-to-minoritized racial and ethnic group utilization ratio for breast reconstruction was 1.03 for all regions. The ratio was highest for the East South Central Division (2.17) and lowest for the West South Central Division (0.75).

While there were differences in the complication ratio by region, with the ratio highest for the East South Central Division (1.73) and lowest for the West South Central Division (0.73), “Spearman rank correlation between the [weighted average] IAT score and breast reconstruction complication rate ratio for all divisions was 0.1 (P  =  .81), indicating annual complication rates did not correlate with changes in IAT at the division level,” the authors noted.

In an unadjusted analysis, White patients had lower mean cost of care compared with patients from minoritized racial and ethnic groups ($24,934 vs $25,256). However, cost was higher for White patients in the New England Division. Again, Spearman rank correlation indicated no correlation with IAT changes at the division level.

Among the limitations listed by the authors is the accuracy of the data in the database and the lack of information on potential confounding factors for the implicit bias data. In addition, more detailed categorization of the patients beyond just White or minoritized race and ethnicity could better help guide policy, they noted.

According to the authors, the overall findings show “implicit racial bias by region did not correlate with differences in breast reconstruction utilization or complication rates between White patients and patients from minoritized racial and ethnic groups.”

Due to general structural issues in the US health care system that result in disparities in access to care, policies targeting physicians may not be enough to combat these disparities, they wrote.

“Despite evidence that some of these disparities are decreasing, efforts to reduce the observed inequities should remain a national priority,” the authors concluded. “Efforts from individual institutions and national surgical organizations are needed to provide culturally competent, evidence-based care to individuals of all racial and ethnic backgrounds.”

Reference

Nasser JS, Fahmy JN, Song Y, Wang L, Chung KC. Regional implicit racial bias and rates of breast reconstruction, complications, and cost among US patients with breast cancer. JAMA Network Open. doi:10.1001/jamanetworkopen.2023.25487