title: Geographic Variation Immediate and Delayed Breast Reconstruction Utilization in Ontario, Canada and Plastic Surgeon Availability: A Population-Based Observational Study.
abstract: BACKGROUND
  Utilization of breast reconstruction (BR) is low in many jurisdictions. We studied the geographical and surgical workforce factors that contribute to access and use of BR using a small area analysis approach with a geographical unit of analysis.
  
  
  METHODS
  We linked administrative data from Ontario Canada to calculate the age-standardized rates for immediate BR (IBR) (same time as mastectomy) between 2002 and 2011, and delayed BR (DBR) (within 3 years of mastectomy) for each county. The influence of plastic surgeon access on variation in county rates of BR was examined using Poisson random effects models.
  
  
  RESULTS
  12,663 women underwent mastectomy in Ontario; 2,948 had BR within 3 years (23.3%). Over 50% of the counties had no access to any plastic surgeon. County IBR rates ranged from 0 to 21.5%; plastic surgeon access explained 46% of geographic variation (p<0.0001). IBR rates in counties with very low, low, and moderate access to plastic surgeons were significantly less than counties with high access (relative rate [RR] 0.48 [95% confidence interval (CI) 0.35-0.66], RR 0.61 [CI 0.43-0.87] and RR 0.70 [CI 0.52-0.96], respectively) after adjusting for age and county socioeconomic characteristics. For DBR, while there was less geographic variation, very low access counties demonstrated reduced rates (RR 0.60 [CI 0.47-0.76]).
  
  
  CONCLUSIONS
  Geographic access to a plastic surgeon is a major determinant of BR. Targeted interventions for regions without high access to plastic surgeons may improve overall rates and reduce geographic disparities in care, particularly for IBR.
authors.affiliation: Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Canada, jennicaplatt@gmail.com.
authors.forename: Jennica
authors.initials: J
authors.lastname: Platt
authors.forename: Toni
authors.initials: T
authors.lastname: Zhong
authors.forename: Rahim
authors.initials: R
authors.lastname: Moineddin
authors.forename: Gillian L
authors.initials: GL
authors.lastname: Booth
authors.forename: Alexandra M
authors.initials: AM
authors.lastname: Easson
authors.forename: Kimberly
authors.initials: K
authors.lastname: Fernandes
authors.forename: Peter
authors.initials: P
authors.lastname: Gozdyra
authors.forename: Nancy N
authors.initials: NN
authors.lastname: Baxter
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000601:surgery; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D016462:Mammaplasty / Q000706:statistics & numerical data*; D008408:Mastectomy / Q000706:statistics & numerical data; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D066231:Surgeons / Q000600:supply & distribution*; D055815:Young Adult