title: Barriers to immediate breast reconstruction in the Canadian universal health care system.
abstract: OBJECTIVE
  To describe the population-based rates of immediate breast reconstruction (IBR) for all women undergoing mastectomy for treatment or prophylaxis of breast cancer in the past decade, and to evaluate geographic, institutional, and patient factors that influence use in the publically funded Canadian health care system.
  
  
  METHODS
  This population-based retrospective cohort study used administrative data that included 28,176 women who underwent mastectomy (25,141 mastectomy alone and 3,035 IBR) between April 1, 2002, and March 31, 2012, in Ontario, Canada. We evaluated factors associated with IBR by using a multivariable logistic regression model with the generalized estimating equation approach.
  
  
  RESULTS
  The population-based, age-adjusted IBR rate increased from 5.1 procedures to 8.7 in 100,000 adult women (43.7%; P < .001), and the increase was greatest for prophylactic mastectomy or therapeutic mastectomy for in situ breast cancer (78.6%; P < .001). Women who lived in neighborhoods with higher median income had significantly increased odds of IBR compared with mastectomy alone (odds ratio [OR], 1.71; 95% CI, 1.47 to 2.00), and immigrant women had significantly lower odds (OR, 0.59; 95% CI, 0.44 to 0.78). A patient had nearly twice the odds of receiving IBR when she was treated at a teaching hospital (OR, 1.84; 95% CI, 1.1 to 3.06) or at a hospital with two or more available plastic surgeons (OR, 2.01; 95% CI, 1.53 to 2.65). Patients who received IBR traveled significantly farther compared with those who received mastectomy alone (OR, 1.04; 95% CI, 1.02 to 1.05 for every 10 km increase).
  
  
  CONCLUSIONS
  IBR is available to select patients with favorable clinical and demographic characteristics who travel farther to undergo surgery at teaching hospitals with two or more available plastic surgeons.
authors.affiliation: Toni Zhong, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, and Jonathon C. Irish, University Health Network; Bret A. Beber, Women's College Hospital; Nancy N. Baxter, St Michael's Hospital; Toni Zhong, Jennica Platt, Brett A. Beber, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, Jonathon C. Irish, and Nancy N. Baxter, University of Toronto; Kimberly A. Fernandes, Refik Saskin, Rinku Sutradhar, and Nancy N. Baxter, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. toni.zhong@uhn.ca.
authors.forename: Toni
authors.initials: T
authors.lastname: Zhong
authors.affiliation: Toni Zhong, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, and Jonathon C. Irish, University Health Network; Bret A. Beber, Women's College Hospital; Nancy N. Baxter, St Michael's Hospital; Toni Zhong, Jennica Platt, Brett A. Beber, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, Jonathon C. Irish, and Nancy N. Baxter, University of Toronto; Kimberly A. Fernandes, Refik Saskin, Rinku Sutradhar, and Nancy N. Baxter, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Fernandes
authors.affiliation: Toni Zhong, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, and Jonathon C. Irish, University Health Network; Bret A. Beber, Women's College Hospital; Nancy N. Baxter, St Michael's Hospital; Toni Zhong, Jennica Platt, Brett A. Beber, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, Jonathon C. Irish, and Nancy N. Baxter, University of Toronto; Kimberly A. Fernandes, Refik Saskin, Rinku Sutradhar, and Nancy N. Baxter, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Refik
authors.initials: R
authors.lastname: Saskin
authors.affiliation: Toni Zhong, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, and Jonathon C. Irish, University Health Network; Bret A. Beber, Women's College Hospital; Nancy N. Baxter, St Michael's Hospital; Toni Zhong, Jennica Platt, Brett A. Beber, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, Jonathon C. Irish, and Nancy N. Baxter, University of Toronto; Kimberly A. Fernandes, Refik Saskin, Rinku Sutradhar, and Nancy N. Baxter, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Rinku
authors.initials: R
authors.lastname: Sutradhar
authors.affiliation: Toni Zhong, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, and Jonathon C. Irish, University Health Network; Bret A. Beber, Women's College Hospital; Nancy N. Baxter, St Michael's Hospital; Toni Zhong, Jennica Platt, Brett A. Beber, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, Jonathon C. Irish, and Nancy N. Baxter, University of Toronto; Kimberly A. Fernandes, Refik Saskin, Rinku Sutradhar, and Nancy N. Baxter, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Jennica
authors.initials: J
authors.lastname: Platt
authors.affiliation: Toni Zhong, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, and Jonathon C. Irish, University Health Network; Bret A. Beber, Women's College Hospital; Nancy N. Baxter, St Michael's Hospital; Toni Zhong, Jennica Platt, Brett A. Beber, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, Jonathon C. Irish, and Nancy N. Baxter, University of Toronto; Kimberly A. Fernandes, Refik Saskin, Rinku Sutradhar, and Nancy N. Baxter, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Brett A
authors.initials: BA
authors.lastname: Beber
authors.affiliation: Toni Zhong, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, and Jonathon C. Irish, University Health Network; Bret A. Beber, Women's College Hospital; Nancy N. Baxter, St Michael's Hospital; Toni Zhong, Jennica Platt, Brett A. Beber, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, Jonathon C. Irish, and Nancy N. Baxter, University of Toronto; Kimberly A. Fernandes, Refik Saskin, Rinku Sutradhar, and Nancy N. Baxter, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Christine B
authors.initials: CB
authors.lastname: Novak
authors.affiliation: Toni Zhong, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, and Jonathon C. Irish, University Health Network; Bret A. Beber, Women's College Hospital; Nancy N. Baxter, St Michael's Hospital; Toni Zhong, Jennica Platt, Brett A. Beber, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, Jonathon C. Irish, and Nancy N. Baxter, University of Toronto; Kimberly A. Fernandes, Refik Saskin, Rinku Sutradhar, and Nancy N. Baxter, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: David R
authors.initials: DR
authors.lastname: McCready
authors.affiliation: Toni Zhong, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, and Jonathon C. Irish, University Health Network; Bret A. Beber, Women's College Hospital; Nancy N. Baxter, St Michael's Hospital; Toni Zhong, Jennica Platt, Brett A. Beber, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, Jonathon C. Irish, and Nancy N. Baxter, University of Toronto; Kimberly A. Fernandes, Refik Saskin, Rinku Sutradhar, and Nancy N. Baxter, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Stefan O P
authors.initials: SO
authors.lastname: Hofer
authors.affiliation: Toni Zhong, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, and Jonathon C. Irish, University Health Network; Bret A. Beber, Women's College Hospital; Nancy N. Baxter, St Michael's Hospital; Toni Zhong, Jennica Platt, Brett A. Beber, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, Jonathon C. Irish, and Nancy N. Baxter, University of Toronto; Kimberly A. Fernandes, Refik Saskin, Rinku Sutradhar, and Nancy N. Baxter, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Irish
authors.affiliation: Toni Zhong, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, and Jonathon C. Irish, University Health Network; Bret A. Beber, Women's College Hospital; Nancy N. Baxter, St Michael's Hospital; Toni Zhong, Jennica Platt, Brett A. Beber, Christine B. Novak, David R. McCready, Stefan O.P. Hofer, Jonathon C. Irish, and Nancy N. Baxter, University of Toronto; Kimberly A. Fernandes, Refik Saskin, Rinku Sutradhar, and Nancy N. Baxter, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
authors.forename: Nancy N
authors.initials: NN
authors.lastname: Baxter
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000517:prevention & control* / Q000601:surgery*; D002278:Carcinoma in Situ / Q000601:surgery*; D005260:Female; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D007182:Income; D016015:Logistic Models; D016462:Mammaplasty / Q000379:methods; D008408:Mastectomy; D008875:Middle Aged; D016017:Odds Ratio; D009864:Ontario; D010820:Physicians / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D019472:Universal Health Insurance