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Direct-To-Implant Breast Reconstruction: A Nationwide Utilization and Charges Analysis
Pooja S. Yesantharao, MS1; Connor Arquette, MD2; Merisa L. Piper, MD3; Jennifer E. Cheesborough, MD2; Gordon K. Lee, MD2; Rahim S. Nazerali, MD MHS2 1. Department of Plastic & Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA 2. Division of Plastic & Reconstructive Surgery, Stanford University School of Medicine, Stanford, California, USA 3. Division of Plastic & Reconstructive Surgery, University of California, San Francisco, San Francisco, California, USA

Background: Direct-to-implant breast reconstruction has gained popularity in recent years, as a way to minimize the morbidity associated with breast reconstruction without sacrificing aesthetic and clinical outcomes. Besides the clinical benefits of a single-stage procedure, direct-to-implant techniques have also been demonstrated to reduce procedure lengths and operating charges, thereby enhancing global metrics of care. In an era of cost-conscious healthcare practices, therefore, it is important to investigate trends in utilization of direct-to-implant breast reconstruction, especially as clinical indications for this procedure expand and more patients gain access to breast reconstruction through policy reform measures such as the Affordable Care Act. The current study investigated direct-to-implant trends over the past decade on a nationwide basis. As a secondary aim, this study investigated resource utilization and global costs associated with direct-to-implant breast reconstruction in comparison to staged or delayed techniques, amongst women undergoing implant-based post-mastectomy breast reconstruction.

Methods: This was a Stanford University Institutional Review Board-approved retrospective cohort study of women undergoing implant-based breast reconstruction in the United States between 2010-2018, using the National Inpatient Sample database. National trends in utilization of direct-to-implant breast reconstruction were characterized over time, as a proportion of all implant-based breast reconstructions. Chi square and Kruskal-Wallis analyses were used to compare study cohorts. Poisson regression analyses were used to determine changes in procedure utilization over time. All study analyses were undertaken using Stata v15.0.

Results: Overall, the weighted study sample consisted of 287,093 women who underwent implant-based breast reconstruction during the study period (2010-2018), of whom 43,063 women (15%) underwent direct-to-implant reconstruction, 224,028 (85%) underwent staged/delayed reconstruction. In the past decade, the proportion of patients undergoing direct-to-implant procedures significantly increased (Poisson estimate: p=0.03), while the rate of staged/delayed procedures demonstrated no significant changes over time. While the cohort of patients who underwent direct-to-implant breast reconstruction were younger, more likely to be non-Hispanic white and more likely to be privately-insured, a significantly greater proportion of non-white and publicly-insured patients underwent direct-to-implant breast reconstruction nationwide (chi square: p=0.02) by the end of the study period. In fact, when specifically comparing Medicaid expansion states to non-expansion states, the rate of increase in direct-to-implant breast reconstruction among Medicaid patients was 2.2 times greater across the study period in expansion states than non-expansion states. Additionally, direct-to-implant patients had significantly higher APR-DRG risk scores (indicating greater degrees of underlying comorbidities) in 2018 than at earlier timepoints (p=0.02), indicating expanding clinical indications for this procedure. In terms of costs, direct-to-implant breast reconstruction was significantly less expensive than staged/delayed implant-based procedures (Kruskal-Wallis: p=0.03), without increasing median length of stay after mastectomy or rates of inpatient complications.

Conclusion: Overall, utilization of direct-to-implant breast reconstruction has significantly increased over the past decade, in light of expanding clinical indications and policy reform measures (i.e. Medicaid expansion). Additionally, this procedure is less expensive than staged/delayed reconstruction without increasing hospitalization or inpatient complication rates. However, certain disparities continue to exist. Further work is necessary to investigate drivers of disparities and actionable solutions that can further expand utilization of this procedure as clinically appropriate.

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