title: Trends in immediate breast reconstruction across insurance groups after enactment of breast cancer legislation.
abstract: BACKGROUND
  To improve access to breast reconstruction for mastectomy patients, the United States enacted the Women's Health and Cancer Rights Act in January of 1999. The objective of the current study was to evaluate the impact of this legislation on patients with different insurance plans.
  
  
  METHODS
  Women aged ≥18 years who underwent mastectomy for cancer were identified in the Nationwide Inpatient Sample database (2000-2009) and were classified according to their immediate breast reconstruction (IBR) status. Trends in rates of IBR were described for each insurance category. Multivariable logistic regression analysis with adjustment for age, race, estimated household income, and Elixhauser comorbidity index was performed to evaluate the relation between insurance status and IBR.
  
  
  RESULTS
  In total, 168,236 patients were identified who underwent a mastectomy during the study interval. Across the 10-year study period, rates of IBR increased 4.2-fold in Medicaid patients, 2.9-fold in Medicare patients, 2.6-fold in privately insured patients, and 2.1-fold in self-pay patients (P < .01). However, after adjustment for confounders, women without private insurance were less likely to undergo IBR compared with women who had private insurance (Medicaid: odds ratio [OR], 0.34; 95% confidence interval [CI], 0.32-0.37; Medicare: OR, 0.53; 95% CI, 0.49-0.58; self-pay: OR, 0.43; 95% CI, 0.37-0.50; other types of nonprivate insurance: OR, 0.64, 95% CI, 0.56-0.73).
  
  
  CONCLUSIONS
  After the enactment of policy designed to improve access to IBR, Medicaid and Medicare patients experienced the greatest relative increase in rates of IBR. Although policy changes had the most impact on traditionally underserved populations, disparities still exist. Future studies should endeavor to understand why such disparities have persisted.
authors.affiliation: Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. srachel@mail.med.upenn.edu
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Yang
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Newman
authors.forename: Ines C
authors.initials: IC
authors.lastname: Lin
authors.forename: Caroline E
authors.initials: CE
authors.lastname: Reinke
authors.forename: Giorgos C
authors.initials: GC
authors.lastname: Karakousis
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Czerniecki
authors.forename: Liza C
authors.initials: LC
authors.lastname: Wu
authors.forename: Rachel R
authors.initials: RR
authors.lastname: Kelz
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000191:economics* / Q000601:surgery*; D005260:Female; D006297:Health Services Accessibility / Q000191:economics* / Q000331:legislation & jurisprudence*; D054625:Healthcare Disparities; D006801:Humans; D019458:Insurance Coverage / Q000331:legislation & jurisprudence*; D007348:Insurance, Health / Q000331:legislation & jurisprudence*; D016015:Logistic Models; D016462:Mammaplasty / Q000191:economics*; D015411:Mastectomy, Modified Radical; D008484:Medicaid; D006278:Medicare; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D013997:Time Factors; D014481:United States