Variation in the provision of immediate breast reconstruction in England
Ranjeet Jeevan, Marialena Trivella, John Browne, Jan van der Meulen
Royal College of Surgeons of England, London, UK
Background
Immediate breast reconstruction at the time of mastectomy aims to return women to their pre-surgical appearance and reduce psychological morbidity. In 2002, NICE stated that it should be made available to all women undergoing breast cancer surgery. The Hospital Episode Statistics (HES) database includes all patients treated within the NHS in England. It records operations performed along with each patient’s age, comorbidity, ethnicity and level of socioeconomic deprivation.
Method
A HES extract was created to include the 40,096 women with breast cancer who underwent mastectomy with or without immediate reconstruction in the three financial years (2003-2006) following the NICE recommendation. Immediate breast reconstruction rates were calculated for the ten Strategic Health Authorities (SHAs) in England. A multivariable logistic regression model was developed to estimate the effects of age, comorbidity, ethnicity and socioeconomic deprivation on the rate of immediate reconstruction. The model was then used to adjust SHA reconstruction rates for case-mix.
Results
4,196 (10.5%) patients had an immediate breast reconstruction after their mastectomy. Unadjusted immediate reconstruction rates varied from 4.4% to 16.5% among the ten SHAs. This variation was highly significant (p<0.001). Immediate reconstruction rates were significantly lower (p<0.001) in women who were older, had comorbidities, were non-white and had higher levels of socioeconomic deprivation. Adjustment for these clinical and sociodemographic factors did not appreciably reduce SHA-level variation.
Conclusion
There is considerable variation in immediate breast reconstruction rates among the ten SHAs in England. This significant geographical inequity persists even after adjustment for age, co-morbidity, ethnicity and social deprivation.
