A Cross-Sectional Study of Variations in Reimbursement for Breast Reconstruction: Is A Healthcare Disparity On the Horizon?

BACKGROUND: Despite growing demand for breast reconstruction, financial disincentives to perform breast reconstruction in patients with government-sponsored insurance plans may lead to longer wait times and decreased access to care. We identify the variation in reimbursement for implant and autologous reconstruction as a step toward understanding these financial implications, to develop safeguards to minimize effects on access to care. METHODS: Billing data were collected over a 10-year period for patients undergoing implant-based (19357) or free-flap (19364) breast reconstruction. Patients were placed into cohorts according to insurance type-Medicare, Medicaid, or private insurance, and these were directly compared. RESULTS: A total of 2691 women underwent breast reconstruction between 2003 and 2013; 71.2% had private insurance, 13.3% had Medicaid, and 14.49% had Medicare. For implant-based reconstructions, the average reimbursement of total charges was 16.3% for Medicaid, 28.3% for Medicare, and 67.2% for private insurance. For autologous reconstruction, average reimbursement was 12.37% for Medicaid, 22.9% for Medicare, and 35.35% for private insurance. Hourly reimbursement estimates for Medicaid patients undergoing autologous reconstruction were lowest. The highest hourly reimbursement estimate was for privately insured patients undergoing implant-based reconstruction. Over time, reimbursement for autologous reconstruction has declined significantly for all payor types, whereas implant-based reimbursement disparities are narrowing. CONCLUSIONS: We found that wide variations in reimbursement for breast reconstruction procedures exist and may preclude some surgeons from offering certain reconstructive options to a subset of patients. Understanding these discrepancies is a key first step in minimizing a potential care delivery disparity for this patient population.

Impact of Neoadjuvant and Adjuvant Chemotherapy on Immediate Tissue Expander Breast Reconstruction.

BACKGROUND: Delayed wound healing or infection leads to premature tissue expander (TE) explantation after immediate postmastectomy breast reconstruction. A large study with sufficient duration of follow-up focusing on the impact of chemotherapy (CT) on premature TE removal after immediate breast reconstruction is lacking. METHODS: A retrospective review of patients undergoing immediate TE reconstruction was conducted. Multivariate analyses identified factors contributing to premature removal of TEs including neoadjuvant and adjuvant CT, specific chemotherapeutic regimens, and other factors like cancer stage, body mass index, smoking, radiation, and age. Kaplan-Meier curves were plotted to study the timing of premature TE removal. RESULTS: Of 899 patients with TEs, 256 received no, 295 neoadjuvant, and 348 adjuvant CT. Premature removal occurred more frequently in the neoadjuvant (17.3 %) and adjuvant (19.9 %) cohorts than the no-CT (12.5 %) cohort (p = 0.056). Premature TE removal occurred earlier (p = 0.005) in patients who received no CT than those with adjuvant CT. Radiation in patients receiving neoadjuvant CT prolonged the mean time to premature removal (p = 0.003). In the absence of radiation, premature removal occurred significantly sooner with neoadjuvant than adjuvant CT (p = 0.035). DISCUSSION: Premature removal of a TE occurs more commonly in patients treated with neoadjuvant or adjuvant CT and is most commonly observed 2-3 months after placement-well after the follow-up period recorded by the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database. These findings can be used to aid preoperative counseling and guide the timing of follow-up for these patients.

Prominent hippocampal CA3 gene expression profile in neurocognitive aging.

Research in aging laboratory animals has characterized physiological and cellular alterations in medial temporal lobe structures, particularly the hippocampus, that are central to age-related memory deficits. The current study compares molecular alterations across hippocampal subregions in a rat model that closely mirrors individual differences in neurocognitive features of aging humans, including both impaired memory and preserved function. Using mRNA profiling of the CA1, CA3 and dentate gyrus subregions, we have distinguished between genes and pathways related to chronological age and those associated with impaired or preserved cognitive outcomes in healthy aged Long-Evans rats. The CA3 profile exhibited the most prominent gene expression differences related to cognitive status and of the three subregions, best distinguished preserved from impaired function among the aged animals. Within this profile differential expression of synaptic plasticity and neurodegenerative disease-related genes suggests recruitment of adaptive mechanisms to maintain function and structural integrity in aged unimpaired rats that does not occur in aged impaired animals.