D87. The Association of Surgeon Density on Breast Reconstruction Access, Outcomes, and Cost in the United States

PURPOSE: Breast reconstruction following mastectomy is underused in the United States. Evidence suggests that more competitive hospital markets offer increased access to procedural care across specialties. This study aims to determine the impact of regional plastic surgeon density on use, outcomes, and cost of breast reconstruction following mastectomy for breast cancer. METHODS: We conducted a retrospective cross-sectional analysis using Marketscan claims data from 2009 to 2020. The Herfindahl-Hirschman Index (HHI), a measure of market concentration, was calculated using the sum-of-squares of the proportion of breast reconstruction cases performed by each surgeon in a metropolitan statistical area (MSA). Multivariable logistic regression was used to identify differences in rates, outcomes, and costs of reconstruction by HHI. RESULTS: Of 15,002 included patients who underwent mastectomy, 7,279 received breast reconstruction (autologous = 2,063; implant-based = 5,216). Most patients undergoing breast reconstruction were in a competitive MSA (autologous=50%, implant=54%). Compared with patients in non-competitive regions, those in moderately competitive regions and highly competitive regions had a 53% (95% CI: 1.39 to 1.68; p<0.001) and 76% (95% CI: 1.62 to 1.91; p<0.001) increased likelihood of reconstruction within two years after mastectomy, respectively. No association between market competition and outcomes was found. Compared to noncompetitive MSAs, competitive MSAs were found to cost $3,211 less (95% CI: -$3,904.38 to -$2,519.24, p<0.001). CONCLUSION: Greater surgeon density is associated with improved breast reconstruction rates and decreased cost. These data encourage policymakers to mitigate inequities in breast reconstruction by considering initiatives to bolster care-coordination, improve travel coverage, and enhance pricing transparency.