Multilevel analysis of the impact of community vs patient factors on access to immediate breast reconstruction following mastectomy in Maryland

Objective: To determine whether various individual factors such as patient demographics and various community factors such as characteristics of the neighborhood in which the patient lives would influence access to immediate breast reconstruction. Design: Multilevel analysis of the Maryland Hospital Discharge Database, a prospectively collected observational database of inpatient care for all hospitals in Maryland. Setting: Database analysis. Patients: We queried for International Classification of Diseases, Ninth Revision procedure codes for all patients undergoing mastectomy and reconstruction during the same hospitalization in Maryland from January 1, 1995, through December 31, 2004. Main Outcome Measures: Disparities in immediate reconstruction rates via analysis of the impact of patientlevel and community-level factors. Results: A total of 18 690 patients underwent mastectomy in Maryland during the study period, 27.9% of whom had immediate reconstruction. On multivariate analysis, patient factors such as African American race/ethnicity and older age had a negative association. Community factors such as increasing household income, increasing population density, and increasing proportion of the community with at least some college education had a positive association, while increasing home value and increasing African American composition of the patient's neighborhood had a negative association. The impacts of ethnic/racial mix and educational level of the patient's neighborhood were independent of the patient's race/ethnicity. Conclusions: Community factors beyond patient characteristics have a significant association with immediate reconstruction. Prospective community-level public health policy measures should be developed to address these inequalities (particularly racial/ethnic disparities based on neighborhood) and to increase the likelihood of obtaining immediate reconstruction.