Vora Halley, Chung Alice, Lewis Azaria, Mirocha Jim, Amersi Farin, Giuliano Armando, Alban Rodrigo F
Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California.
J Surg Res. 2018 Mar;223:237-242. doi: 10.1016/j.jss.2017.11.011. Epub 2017 Dec 22.
Surgical deserts (SDs) are defined as the geographic maldistribution of general surgeons of six or less per 100,000 population in underserved/rural counties. Disparities have been reported in breast cancer outcomes; however, the effect of SDs remains unknown. We sought to examine the effect of SDs on breast reconstruction (BR) after mastectomy and the differences between patients in both the cohorts.
Using the Nationwide Inpatient Sample database years 2007-2011, we identified International Classification of Diseases 9th edition codes for breast cancer, mastectomy, and BR in California. SDs were identified using the American College of Surgeons Health Policy Research Institute workforce atlas. Data included patient demographics and socioeconomic status, and the primary outcome was the rates of BR.
A total of 9325 mastectomy patients, with or without BR, were identified. Of this, 12.8% patients were in SDs, whereas 87.2% patients were in nonsurgical deserts (NSDs). Overall, 35.8% of patients received BR, whereas 64.2% did not. Of the patients in SDs, only 14% received BR, whereas in NSDs, 39% received BR. On multivariate analysis, SD patients were significantly less likely to receive BR than NSD patients (odds ratio [95% confidence interval], 0.29 [0.24-0.35]; P < 0.001). SDs had higher rates of low household income, Medicare insurance, and comorbidities. NSDs had higher rates of high household income, Health Maintenance Organization/private insurance, and lower rates of comorbidities.
Patients in SDs are significantly less likely to receive BR. This disparity may be magnified because of differences in demographics and income levels, and decreased access to reconstructive surgeons. Interventions aimed at decreasing disparities caused by SDs are needed.
手术荒漠（SDs）被定义为在医疗服务不足/农村县中，每10万人口中普通外科医生数量为6名或更少的地理分布不均情况。乳腺癌治疗结果方面的差异已有报道；然而，手术荒漠的影响仍不清楚。我们试图研究手术荒漠对乳房切除术后乳房重建（BR）的影响以及两组患者之间的差异。
利用2007 - 2011年全国住院患者样本数据库，我们在加利福尼亚州确定了国际疾病分类第9版中乳腺癌、乳房切除术和乳房重建的编码。使用美国外科医生学会健康政策研究所劳动力地图集确定手术荒漠。数据包括患者人口统计学和社会经济状况，主要结局是乳房重建率。
共确定了9325例接受或未接受乳房重建的乳房切除术患者。其中，12.8%的患者位于手术荒漠地区，而87.2%的患者位于非手术荒漠（NSDs）地区。总体而言，35.8%的患者接受了乳房重建，而64.2%的患者未接受。在手术荒漠地区的患者中，只有14%接受了乳房重建，而在非手术荒漠地区，39%的患者接受了乳房重建。多因素分析显示，与非手术荒漠地区患者相比，手术荒漠地区患者接受乳房重建的可能性显著降低（优势比[95%置信区间]，0.29[0.24 - 0.35]；P < 0.001）。手术荒漠地区家庭收入低、医疗保险为医疗保险以及合并症的发生率较高。非手术荒漠地区高家庭收入、健康维护组织/私人保险的发生率较高，合并症发生率较低。
手术荒漠地区的患者接受乳房重建的可能性显著降低。由于人口统计学和收入水平的差异以及获得重建外科医生的机会减少，这种差异可能会扩大。需要采取干预措施以减少手术荒漠造成的差异。
