Trends in breast reconstructive surgeries for mastectomy, 2009–2014

Figure 1 displays the rate of mastectomy (unilateral and bilateral combined) and the rate of reconstructive surgery for mastectomy per 100,000 females in the population aged 18 years or older from 2009 through 2014. Inpatient and ambulatory surgeries are combined. The ratio of reconstructions to mastectomies also is shown. A higher ratio in one year, compared with another suggests that a greater number of women who underwent mastectomy had reconstructive surgery, regardless of whether the mastectomy was in the same year.

Figure 1

Rates of mastectomy and breast reconstructive surgery for mastectomy, 2009–2014. Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project (HCUP), State Inpatient (more...)

• There was a 62 percent increase in the population rate of breast reconstruction for mastectomy from 2009 to 2014.
  For these 22 States, there were 21.7 breast reconstructions per 100,000 women in 2009. The rate steadily increased to 35.1 per 100,000 in 2014, a 62 percent increase over this 6-year period.
• There was a 67 percent increase in the ratio of breast reconstructions to mastectomies between 2009 and 2014.
  In 2009, for every 100 mastectomies there were 24 breast reconstructions performed. This increased to 40 breast reconstructions per 100 mastectomies in 2014, a 67 percent increase.
• The trend in the rate of mastectomy surgeries between 2009 and 2014 remained relatively stable.
  The rate of mastectomy varied less than 10 percent over this time period, from a low of 83.2 per 100,000 women to a high of 90.1 per 100,000 women.

Table 1 presents the ratio of breast reconstructions to mastectomies in 2009 and 2014, by patient and hospital characteristics. Inpatient and ambulatory surgeries are combined. The rate of mastectomy and the rate of breast reconstructive surgery for mastectomy per 100,000 females aged 18 years or older also are presented where population data are available. The population-based rates are presented for reference but are not discussed because they reflect rates of both cancer and mastectomy.

Table 1

Rates of mastectomy and reconstruction, ratio of all reconstructive surgeries to all mastectomies, and percent change, by patient and hospital characteristics, 2009 and 2014.

• Women aged 35–44 and 45–54 years had the largest number of reconstructions for mastectomy, but the fastest growth in reconstructive surgery was for women aged 65 years and older.
  In 2009, women aged 35–44 years had 37 reconstructive surgeries per 100 mastectomies. This ratio increased to 55 in 2014, a 47 percent increase over this 6-year period. Similarly, women aged 45–54 years had 37 reconstructive surgeries in 2009 and 57 in 2014, a 56 percent increase.
  Although women aged 65 years and older had a lower ratio of reconstructions to mastectomies in 2009 and 2014, they experienced the fastest growth in reconstructions. In 2009, among women aged 65 years and older, seven reconstructions were performed for every 100 mastectomies. This increased to 17 reconstructions per 100 mastectomies in 2014, a 140 percent increase.
• Women in the highest quartile of community income had the most breast reconstructive surgeries relative to mastectomies, but the fastest growth in reconstructive surgery was for women in the lowest community income quartile.
  In 2009, women in the highest quartile of community income had 31 reconstructive surgeries per 100 mastectomies, increasing to 49 in 2014, a 58 percent increase over this 6-year period.
  Even though women in the lowest quartile of community income had fewer reconstructions (i.e., a lower ratio of reconstructions to mastectomies) in 2009 and 2014, they experienced the fastest growth in reconstructions. In 2009, there were 17 reconstructions for every 100 mastectomies for women in the lowest income quartile. This increased to 30 reconstructions for every 100 mastectomies in 2014, a 74 percent increase.
• Women residing in rural areas had a lower rate of reconstructions relative to mastectomies than did women in urban areas in both 2009 and 2014.
  Women residing in rural areas had 17 reconstructive surgeries for every 100 mastectomies in 2009 and 29 in 2014. In comparison, women residing in urban areas had 25 reconstructions per 100 mastectomies in 2009 and 41 in 2014.
  Similarly, urban hospitals performed more reconstructions than did rural hospitals in both time periods. The number of reconstructions for every 100 mastectomies performed in rural hospitals increased from 6 in 2009 to 12 in 2014. In comparison, the number of reconstructions for every 100 mastectomies performed in urban hospitals increased from 25 in 2009 to 41 in 2014.
• Compared with 2009, twice as many women with no insurance and twice as many women covered by Medicare received breast reconstruction for mastectomy in 2014.
  The ratio of breast reconstruction to mastectomy for women with Medicare was 8 in 2009 and 19 in 2014, a 130 percent increase. The ratio of breast reconstruction to mastectomy for women without insurance more than doubled—from 21 per 100 mastectomies in 2009 to 44 in 2014, a 104 percent increase.
  Women covered by Medicaid or private insurance also saw increases in breast reconstruction, though to a lesser extent. Among Medicaid-covered women there was a 91 percent increase, from 19 reconstructions per 100 mastectomies in 2009 to 37 in 2014. Women with private insurance had the highest rates of reconstructions in both time periods, increasing 51 percent from 35 reconstructions per 100 mastectomies in 2009 to 52 in 2014.

Figure 2 displays the rate of breast reconstructive surgery for mastectomy per 100,000 females aged 18 years or older from 2009 through 2014 and shows whether the breast reconstruction was performed at the same stay or visit as the mastectomy. Inpatient and ambulatory surgeries are combined.

Figure 2

Rate of reconstructive surgery for mastectomy and the percentage performed at the same stay or visit as the mastectomy, 2009–2014. Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare (more...)

• The growth in reconstructive surgeries from 2009 through 2014 was due to growth in breast reconstructions performed after mastectomy at a separate stay or visit.
  In 2009, among women receiving reconstruction, 39.1 percent received simultaneous mastectomy and reconstruction while 60.9 percent received breast reconstruction without mastectomy at the same time. By 2014, only 29.0 percent received simultaneous reconstruction and the percentage receiving reconstruction separately from mastectomy increased to 71.0 percent. The growth in total reconstructions over this time period was entirely due to nonsimultaneous reconstructions.

Figure 3 examines the population rate of breast reconstructions in the inpatient and ambulatory surgery settings from 2009 to 2014.

Figure 3

Population rate of reconstructive surgery for mastectomy, by surgical setting and whether the reconstruction was performed at the same stay or visit as the mastectomy, 2009–2014. Source: Agency for Healthcare Research and Quality (AHRQ), Center (more...)

• Most of the growth in breast reconstructive surgery was in the ambulatory surgery setting.
  In the ambulatory surgery setting, there was a 152 percent increase in the rate of breast reconstruction performed after a mastectomy at a separate visit between 2009 and 2014; the rate increased from 7.2 to 18.2 per 100,000 women.
  Although the rate was lower than that of breast reconstruction performed at a separate visit in the ambulatory surgery setting, there was also a 155 percent increase in the rate of breast reconstruction with simultaneous mastectomy in the ambulatory surgery setting between 2009 and 2014. The rate increased from 1.1 per 100,000 women in 2009 to 2.8 per 100,000 women in 2014.
• There was minimal to no growth in rates of inpatient breast reconstructive surgery between 2009 and 2004.
  In the inpatient setting, there was only a 12 percent increase in the rate of breast reconstruction following a mastectomy at a separate stay between 2009 and 2014; the rate increased slightly from 6.0 per 100,000 women in 2009 to 6.8 per 100,000 in 2014.
  There was no change in the rate of breast reconstruction with simultaneous mastectomy in the inpatient setting between 2009 and 2014 (7.4 per 100,000 women in 2009 and 7.3 per 100,000 in 2014).
• Breast reconstruction with simultaneous mastectomy is primarily an inpatient procedure, whereas breast reconstruction without simultaneous mastectomy is primarily performed on an outpatient basis.
  In 2014, the rate of inpatient reconstruction was 6.8 per 100,000 women without a simultaneous mastectomy and 7.3 per 100,000 women for simultaneous mastectomy. In contrast, in 2014 the rate of outpatient reconstruction was 18.2 per 100,000 women without a simultaneous mastectomy compared with 2.8 per 100,000 women for simultaneous mastectomy. Thus, 87 percent of all nonsimultaneous reconstructions are performed on an outpatient basis.

Patient and hospital characteristics of breast reconstructive surgeries for mastectomy, 2014

Figure 4 displays patient and hospital characteristics for reconstructive surgeries (simultaneous and subsequent) across all settings in 2014.

Figure 4

Percentage of reconstructions performed at the same or a different encounter as the mastectomy, by patient and hospital characteristics, 2014. Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, (more...)

• In 2014, across the 22 States included in this study, fewer than one-third of women received breast reconstruction with simultaneous mastectomy.
  In 2014, 71 percent of women had breast reconstructive surgery at a separate stay or visit as the mastectomy and 29 percent had breast reconstruction with a simultaneous mastectomy.
• Black women were more likely to receive breast reconstruction with simultaneous mastectomy, compared with Hispanic women.
  In 2014, 33.7 percent of Black women received breast reconstruction with simultaneous mastectomy, compared with 25.5 percent of Hispanic women.
• Women treated in rural hospitals were 59 percent more likely than women treated in urban hospitals to have a breast reconstruction with simultaneous mastectomy.
  Of women treated in rural hospitals, 29.1 percent had breast reconstruction with simultaneous mastectomy compared with 18.3 percent of women treated in an urban hospital.
  There was not a substantial difference across age groups, community income quartiles, patient residence, expected payer, or teaching status in the percentage of women who had breast reconstructive surgery with simultaneous mastectomy versus mastectomy at a separate stay or visit.

Figure 5 displays patient and hospital characteristics for reconstructions across ambulatory surgery and inpatient settings in 2014. Those with a simultaneous and nonsimultaneous mastectomy are combined.

Figure 5

Percentage of reconstructions performed as ambulatory or inpatient surgeries, by patient and hospital characteristics, 2014. Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost (more...)

• In 2014, across the 22 States included in this study, the majority of women received breast reconstruction in an ambulatory setting.
  Most breast reconstruction was performed in an ambulatory setting–59.8 percent of women had breast reconstructive surgery in an ambulatory setting, and the remaining 40.2 percent had breast reconstruction in an inpatient hospital setting.
• Women aged 18–34 years and those aged 65 years and older were more likely than those in the other three age groups to receive breast reconstruction surgeries in an ambulatory setting.
  Among women 18–34 years of age with breast reconstructive surgery, 65.7 percent were performed in an ambulatory surgery setting. Similarly, for women aged 65 years and older, 64.1 percent of reconstructions were performed outpatient. Among women aged 35–64 years undergoing reconstruction, less than 60 percent were ambulatory surgeries.
• Women in the wealthiest communities were more likely to receive breast reconstructive surgery in an ambulatory setting compared with women in the poorest communities.
  In 2014, 61.1 percent of women in the wealthiest communities (income quartiles 3 and 4) had breast reconstruction as an ambulatory surgery compared with 54.8 percent of women in the poorest communities (income quartile 1).
• Women who had Medicaid as their primary payer were less likely to receive breast reconstruction as an ambulatory surgery compared with women with no insurance and those covered by Medicare or private insurance.
  Among women covered by Medicaid, 52.2 percent had reconstructive surgery in an ambulatory setting compared with 60.3 percent of women with private insurance, 61.7 percent with Medicare, and 65.9 of those with no insurance.
• Black women were less likely to receive breast reconstructive surgery in an ambulatory setting, compared with Hispanic and White women.
  Only 45.8 percent of Black women received breast reconstruction as an ambulatory surgery—29 percent less likely than Hispanic women (59.0 percent of whom received ambulatory reconstruction) and 34 percent less likely than White women (61.5 percent of whom received ambulatory reconstruction).
• Women who were treated in rural hospitals were more likely to receive breast reconstruction as an ambulatory surgery compared with women treated in urban hospitals.
  Sixty percent of women treated in rural hospitals received breast reconstruction as an ambulatory surgery compared with 50.7 percent of women treated in an urban hospital.
  There were no differences by location of patient residence or hospital teaching status in the percentage of breast reconstructive surgeries performed in the ambulatory setting versus the inpatient setting.

Diagnoses, procedures, ICD-9-CM, and Current Procedural Terminology (CPT®)

The principal diagnosis is that condition established after study to be chiefly responsible for the patient’s admission to the hospital. Secondary diagnoses are concomitant conditions that coexist at the time of admission or develop during the stay. All-listed diagnoses include the principal diagnosis plus these additional secondary conditions.

All-listed procedures include all procedures performed during the hospital stay, whether for definitive treatment or for diagnostic or exploratory purposes.

ICD-9-CM is the International Classification of Diseases, Ninth Revision, Clinical Modification, which assigns numeric codes to diagnoses and procedures. There are approximately 14,000 ICD-9-CM diagnosis codes. There are approximately 4,000 ICD-9-CM procedure codes.

CPT assigns numeric codes to procedures. There are approximately 9,600 CPT procedure codes.

Procedures on inpatient hospitalization records are coded using the ICD-9-CM; procedures on ambulatory surgery and services records can be coded using either the ICD-9-CM or the CPT.

Case definition

The ICD-9-CM and CPT procedure codes defining mastectomies are shown in Table 2.

Table 2

ICD-9-CM and CPT procedure codes defining mastectomies.

The codes used to define reconstructive surgeries for mastectomy are shown in Table 3. We did not verify that reconstruction occurred after mastectomy by linking records across patients. However, we can assume that all women included did have a mastectomy because we included codes for total breast reconstruction. These procedures would be done following a mastectomy but not following a lumpectomy or for cosmetic reasons unrelated to cancer, which would entail only a partial reconstruction. We also included select codes for partial reconstructions that were unique to ambulatory surgery records, if a code for total breast reconstruction was not present but a diagnosis of V510, Encounter for breast reconstruction following mastectomy, was present in any position.

Table 3

ICD-9-CM and CPT procedure codes defining reconstructions for mastectomies.

Types of hospitals included in HCUP State Inpatient Databases

This analysis used State Inpatient Databases (SID) limited to data from community hospitals, which are defined as short-term, non-Federal, general, and other hospitals, excluding hospital units of other institutions (e.g., prisons). Community hospitals include obstetrics and gynecology, otolaryngology, orthopedic, cancer, pediatric, public, and academic medical hospitals. Excluded for this analysis are long-term care facilities such as rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals. However, if a patient received long-term care, rehabilitation, or treatment for a psychiatric or chemical dependency condition in a community hospital, the discharge record for that stay was included in the analysis.

Types of hospitals included in HCUP State Ambulatory Surgery and Services Databases

This analysis used State Ambulatory Surgery and Services Databases (SASD) limited to data from hospital-owned ambulatory surgery facilities. Although some SASD include data from facilities not owned by a hospital, those facilities were excluded from this analysis. The designation of a facility as hospital-owned is specific to its financial relationship with a hospital that provides inpatient care and is not related to its physical location. Ambulatory surgery performed in hospital-owned facilities may be performed within the hospital, in a facility attached to the hospital, or in a facility physically separated from the hospital. The analysis was further limited to ambulatory surgeries performed at facilities owned by community hospitals. Community hospitals are defined as short-term, non-Federal, general, and other specialty hospitals, excluding hospital units of other institutions (e.g., prisons). The analysis was limited to hospitals that had at least one mastectomy procedure performed in both the SID and the SASD in each data year.

Unit of analysis

The unit of analysis is the hospital discharge (i.e., the hospital stay or ambulatory surgery visit), not a person or patient. This means that a person who is admitted to or visits the hospital multiple times in 1 year will be counted each time as a separate discharge or visit from the hospital.

Location of patients’ residence

Place of residence is based on the Urban Influence Codes (UIC) urban-rural classification scheme for U.S. counties developed by the U.S. Department of Agriculture’s Economic Research Service, as a refinement of the Office of Management and Budget Metropolitan Service Area definition. For this Statistical Brief, we collapsed the UIC categories into either urban or rural according to the following:

Urban:

• Large Metropolitan: includes metropolitan areas with 1 million or more residents
• Small Metropolitan: includes metropolitan areas with fewer than 1 million residents

Rural:

• Micropolitan and Noncore: includes nonmetropolitan counties.

Community-level income

Community-level income is based on the median household income of the patient’s ZIP Code of residence. Quartiles are defined so that the total U.S. population is evenly distributed. Cut-offs for the quartiles are determined annually using ZIP Code demographic data obtained from Claritas, a vendor that adds value to data from the U.S. Census Bureau.⁹ The value ranges for the income quartiles vary by year. The income quartile is missing for patients who are homeless or foreign.

Payer

Payer is the expected payer for the hospital stay. To make coding uniform across all HCUP data sources, payer combines detailed categories into general groups:

• Medicare: includes patients covered by fee-for-service and managed care Medicare
• Medicaid: includes patients covered by fee-for-service and managed care Medicaid
• Private Insurance: includes Blue Cross, commercial carriers, and private health maintenance organizations (HMOs) and preferred provider organizations (PPOs)
• Uninsured: includes an insurance status of self-pay and no charge
• Other: includes Workers’ Compensation, TRICARE/CHAMPUS, CHAMPVA, Title V, and other government programs

Hospital stays billed to the State Children’s Health Insurance Program (SCHIP) may be classified as Medicaid, Private Insurance, or Other, depending on the structure of the State program. Because most State data do not identify patients in SCHIP specifically, it is not possible to present this information separately.

For this Statistical Brief, when more than one payer is listed for a hospital discharge, the first-listed payer is used.

Reporting of race and ethnicity

Data on Hispanic ethnicity are collected differently among the States and also can differ from the Census methodology of collecting information on race (White, Black, Asian/Pacific Islander, American Indian/Alaska Native, Other (including mixed race)) separately from ethnicity (Hispanic, non-Hispanic). State data organizations often collect Hispanic ethnicity as one of several categories that include race. Therefore, for multistate analyses, HCUP creates the combined categorization of race and ethnicity for data from States that report ethnicity separately. When a State data organization collects Hispanic ethnicity separately from race, HCUP uses Hispanic ethnicity to override any other race category to create a Hispanic category for the uniformly coded race/ethnicity data element, while also retaining the original race and ethnicity data. This Statistical Brief reports race/ethnicity for the following categories: Hispanic, non-Hispanic White, non-Hispanic Black, and non-Hispanic Other, including Asian/Pacific Islander, American Indian/Alaska Native, and Other.

Trends were not reported because a higher percentage of records for reconstructive surgeries had missing data on race/ethnicity in 2009 (15.2 percent) than in 2014 (7.4 percent). In 2014, two States (Minnesota and Nebraska) did not provide data on race/ethnicity.

Reporting of hospital location

Hospital location is based on the Core Based Statistical Area (CBSA) urban-rural classification scheme for U.S. counties developed by the Office of Management and Budget. Hospitals residing in counties with a CBSA type of metropolitan were considered urban, whereas hospitals with a CBSA type of micropolitan or noncore were classified as rural.

Reporting of hospital teaching status

The hospital’s teaching status was obtained from information included in the American Hospital Association Annual Survey of Hospitals. A hospital is considered to be a teaching hospital if it has an approved American Medical Association residency program, is a member of the Council of Teaching Hospitals, or has a ratio of full-time equivalent interns and residents to beds of .25 or higher.