National trends and regional variation in immediate breast reconstruction rates.
BACKGROUND
Previous studies have identified variation in immediate reconstruction (IR) rates following mastectomy for breast cancer across English regions during a period of service reorganization, a national audit and changing guidelines. This study analysed current variations in regional rates of IR in England.


METHODS
Patient-level data from Hospital Episode Statistics were used to define a cohort of women who underwent primary mastectomy for invasive or in situ breast carcinoma in English National Health Service (NHS) hospitals between April 2000 and March 2014. A time series of IR rates was calculated nationally and within regions in 28 cancer networks. Regional IR rates before and after the national audit were compared, using logistic regression to adjust for patient demographics, tumour type, co-morbidity and year of mastectomy.


RESULTS
Between 2000 and 2014, a total of 167 343 women had a mastectomy. The national IR rate was stable at around 10 per cent until 2005; it then increased to 23·3 per cent by 2013-2014. Preaudit (before January 2008), adjusted cancer network-level IR rates ranged from 4·3 to 22·6 per cent. Postaudit (after April 2009) adjusted IR rates ranged from 13·1 to 36·7 per cent, with 20 networks having IR rates between 15 and 24 per cent. The degree of change was not greatest amongst those that started with the lowest IR rates, with four networks with the largest absolute increase also starting with relatively high IR rates.


CONCLUSIONS
The national IR rate increased throughout the study period. Substantial regional variation remains, although considerable time has elapsed since a period of service reorganization, guideline revision and a national audit.
Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.|Regional Paediatric Burns and Plastic Surgery Service, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
R
R
Jeevan
Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.|Plastic Surgery Service, Guy's and St Thomas' NHS Foundation Trust, London, UK.
J C
JC
Mennie
Plastic Surgery Service, Guy's and St Thomas' NHS Foundation Trust, London, UK.
P N
PN
Mohanna
Plastic and Reconstructive Surgery Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
J M
JM
O'Donoghue
Department of Breast Surgery, Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Winchester, UK.
R M
RM
Rainsbury
Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.|Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
D A
DA
Cromwell
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000601:surgery*; D018270:Carcinoma, Ductal, Breast / Q000601:surgery*; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000601:surgery*; D004739:England; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data / Q000639:trends*; D006801:Humans; D016462:Mammaplasty / Q000379:methods / Q000706:statistics & numerical data / Q000639:trends*; D008408:Mastectomy; D008875:Middle Aged; D013222:State Medicine; D055815:Young Adult