The site of care matters: An examination of the relationship between high Medicaid burden hospitals and the use, cost, and complications of immediate breast reconstruction after mastectomy

BACKGROUND: Diminished use and worse outcomes after immediate breast reconstruction (IBR) have been documented for Medicaid beneficiaries. However, to the authors' knowledge, the contribution of patient clustering at hospitals with a high percentage of Medicaid patients to these inequalities in IBR delivery is unknown. METHODS: A cross-sectional analysis of patients undergoing IBR after mastectomy using the 2007 to 2011 Nationwide Inpatient Sample database was performed. Hospital Medicaid status was calculated as the percentage of all patients with Medicaid as a primary payer. Tertile groupings were generated to enable statistical analysis. Hierarchical regression models were used to investigate the link between Medicaid status and IBR use, outcomes, and costs. A subgroup of patients undergoing IBR for noninvasive cancer or those with increased genetic risk were used to study IBR use. RESULTS: A total of 30,086 IBR cases in 1199 hospitals were analyzed. Hierarchical regression analysis demonstrated an association between high Medicaid burden hospitals and significantly decreased odds of IBR among patients with in situ disease and/or an elevated risk of cancer (odds ratio, 0.64; 95% confidence interval [95% CI], 0.507-0.806). Increasing age, obesity, being nonwhite, having more comorbid conditions, and having government insurance were found to be associated with diminished odds of IBR (P<.001 in all instances). In-hospital surgical and medical complication rates were comparable across the 3 strata of hospital Medicaid status. Log-adjusted costs of care were found to be positively associated with a higher hospital Medicaid burden status (coefficient of 0.038 [95% CI, 0.011-0.066] for medium Medicaid burden hospitals and coefficient of 0.053 [95% CI, 0.015-0.093] for high Medicaid burden hospitals). CONCLUSIONS: High Medicaid burden hospital status is associated with an attenuation of IBR use and increased total inpatient costs. Structures of care such as hospital resources partially explain disparities in IBR delivery. Cancer 2018;124:346-55.