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Racial Disparities in Postoperative Breast Reconstruction Outcomes: A National Analysis

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Abstract

Background

Studies have shown that Black patients are more likely to experience complications following breast reconstruction compared to other racial groups. Most of these studies have been conducted on patient populations focusing on either autologous or implant-based reconstruction without possible predictive indicators for complication disparities for all types of reconstruction procedures. The aim of this study is to elucidate disparities among patient demographics by identifying predictors of complications and postoperative outcomes among different racial/ethnic patients undergoing breast reconstruction utilizing multi-state, multi-institution, and national level data.

Methods

Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction were identified via CPT codes. Demographics, medical history, and postoperative outcome data were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. Outcomes analysis was limited to the 90-day global postoperative period. A multivariable logistic-regression analysis was performed to ascertain the effects of age, patient reported ethnicity, coexisting conditions, and reconstruction type on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated.

Results

From over 86 million longitudinal patient records, our study population included 104,714 encounters for 57,468 patients who had undergone breast reconstruction between January 2003 and June 2019. Black race (relative to White), autologous reconstruction, hypertension, type II diabetes mellitus, and tobacco use were independent predictors of increased likelihood of complication. Specifically, the odds ratios for complication occurrence for Black, Hispanic, and Asian ethnicity (relative to White) were 1.09, 1.03, and 0.77, respectively. Black patients had an overall breast reconstruction complication rate of 20.4%, while the corresponding rate for White, Hispanic, and Asian patients were 17.0%, 17.9%, and 13.2%, respectively.

Conclusion

Our analysis of a national-level database shows that Black patients undergoing implant-based or autologous reconstruction have increased risk of complications, likely due to multifactorial components that play a role in the care of this patient population. While higher rates of comorbidities have been cited as a possible cause, providers must consider racial influences involving cultural context, historical mistrust in medicine, and physician/health institution factors that may drive this disparity of outcomes among our patients.

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Data Availability

Data/materials are not available publicly, but can be shared if requested and permitted by Stanford PHI Offices.

Code Availability

Code is not available publicly but can be shared if requested and approved by Stanford PHI offices.

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Acknowledgements

Data for this project were accessed using the Stanford Center for Population Health Sciences Data Core. The PHS Data Core is supported by a National Institutes of Health National Center for Advancing Translational Science Clinical and Translational Science Award (UL1 TR001085) and from internal Stanford funding. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

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Author notes

  1. Thomas Johnstone and Kometh Thawanyarat are first co-authors.

Authors and Affiliations

  1. Stanford University School of Medicine, Stanford, CA, USA

    Thomas Johnstone & Shannon Francis

  2. Medical College of Georgia at Augusta University, Augusta, GA, USA

    Kometh Thawanyarat & Yelissa Navarro

  3. State University of New York, Upstate Medical University, Syracuse, New York, NY, USA

    Mallory Rowley

  4. Drexel University College of Medicine, Philadelphia, PA, USA

    Justin M. Camacho

  5. University of Hawaii, John A. Burns School of Medicine, Honolulu, HI, USA

    Dylan Singh

  6. Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 770 Welch Road, Suite 400, Stanford, CA, 94304, USA

    Jennifer K. Shah & Rahim S. Nazerali

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Contributions

KT and TJ are lead authors, project management, idea formation, editing, analysis, and writing. MR, SF, JC, DS, and YN helped with manuscript writing, paper direction, and editing. JS assisted with more data analysis and study formation. RN is the corresponding author, and PI is the mentor of the projects.

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Correspondence to Rahim S. Nazerali.

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Appendices

Appendix 1

CPT codes used to identify patients in the Clinformatics® Database undergoing breast reconstruction, fat grafting, and complications requiring surgical intervention

Procedure

CPT

Implant-based breast reconstruction

19,357, 11,970, 19,340, 19,342

Autologous breast reconstruction

19,361, 19,364, 19,367, 19,368, 19,369

Fat grafting

15,771, 15,772, 15,769, 20,926

Incision and drainage, deep abscess or hematoma, soft tissues of neck, or rhorax

21,501

Image-guided fluid collection drainage by catheter (e.g., abscess, hematoma, seroma, lymphoma, and cyst)

10,030

Incision and drainage of hematoma, seroma, or fluid collection

10,140

Incision drainage of complex wound infection

10,180

Secondary closure of surgical wound or dehiscence

13,160

Tissue debridement

11,042, 11,045

Muscle debridement

11,043

Bone debridement

11,044

Appendix 2

ICD-9 and ICD-10 codes used to identify patients in the Clinformatics® Database experiencing complications as a result of the index procedure

Diagnosis

ICD-9

ICD-10

Hematoma or hemorrhage

99,812

M7981, R58, T792XXD, T792XXXS, T792XXA, L7602, L7622

Seroma

99,813

L7634, M7098, T792XXD, T792XXS, T792XXA

Deep vein thrombosis (DVT) or other vascular complication

4510, 4511, 45,111, 45,119, 4512, 45,181, 45,189, 4519, 4531, 4532, 4534, 45,341, 45,342, 45,350, 45,351, 45,352, 4536, 4538, 45,389, 4539, 99,779, 9972

T81718D, T81718S, T81718A, T8172XD, T8172XS, T8172XA

I80201, I80202, I80203, I80221, I80222, I80223, I80229, I80231, I80232

I80233, I80239, I80241, I80242, I80243, I80251, I80252, I80253, I80291

I80292, I80293, I80299, I80209, I80249, I80259, I808, I82401, I82402

I82403, I82409, I82431, I82432, I82433, I824Y1, I824Y2, I824Y3, I82439

I824Y9, I82441, I82442, I82443, I82451, I82452, I82453, I82461, I82462

I82463, I82491, I82492, I82493, I824Z1, I824Z2, I824Z3, I82449, I82459

I82469, I82499, I824Z9, I8010, I8011, I8012, I8013, I82411, I82412

I82413, I82419, I80211, I80212, I80213, I80219, I82421, I82422, I82423

I82429, I82621, I82622, I82A11, I82A12, I82A13, I82A19, I82B11, I82B12

I82B13, I82B19, I82C11, I82C12, I82C13, I82C19

Breast reconstruction deformity and wound dehiscence

8750, 8751, 8790, 8791, 9983, 99832x

T8130XD, T8130XS, T8130XA, T8132XD, T8132XS, T8132XA, T8131XD, T8131XS

T8131XA, T8183XD, T8183XS, T8183XA, T8189XD, T8189XS, T8189XA, T8133A, T8133D, T8133S, S21002A, S21001A

Postoperative infection

9985, 99,850–99,859

T8140XA, T8140XD, T8140XS, T8141XA, T8141XD, T8141XS, T8142XA, T8142XD, T8142XS, T8143XA, T8143XD, T8143XS, T8144XA, T8144XD, T8144XS, T8149XA, T8149XD, T8149XS, N611, T86822

Fat necrosis

6113, 56,782

N641, K654

Tissue necrosis

99,883

T8189XA

Nonspecified complication of surgical care

61,189

T888XXD, T888XXS, T888XXA, N6489

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Johnstone, T., Thawanyarat, K., Rowley, M. et al. Racial Disparities in Postoperative Breast Reconstruction Outcomes: A National Analysis. J. Racial and Ethnic Health Disparities 11, 1199–1210 (2024). https://doi.org/10.1007/s40615-023-01599-1

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