Implementation Barriers and Recommendations for a Multisite Community Health Worker Intervention in Palliative Care for African American Oncology Patients: A Qualitative Study.

Background: Palliative care remains underutilized by African American patients with advanced cancer. Community health workers (CHWs) may help improve palliative care outcomes among this patient population. Objectives: To explore barriers to success of a proposed CHW intervention and synthesize design and implementation recommendations to both optimize our intervention and inform others working to alleviate palliative care disparities. Design: Semi-structured qualitative interviews. Setting/Subjects: Key informants were health care professionals across clinical, leadership, and community health fields. Participants were recruited through purposive sampling from Baltimore, Maryland; Birmingham, Alabama; and Salisbury, Maryland. Measurements: Interviewers used an interview guide grounded in established implementation science models. Data were analyzed through a combined abductive/deductive approach by independent coders. A framework methodology was used to facilitate thematic analysis. Results: In total, 25 professionals completed an interview. Key informants discussed multiple barriers, including at the patient level (lack of knowledge), clinician and facility level (decreased workflow efficiency), and health system level (limited funding). Recommendations related to the intervention's design included high quality preintervention CHW training and full integration of CHWs into the care team to "bridge" divides between outpatient, inpatient, and at-home settings. Intervention delivery recommendations included clearly defining care team roles and balancing flexibility and standardization in CHW support approaches. These recommendations were then used to adapt the planned intervention and its implementation process. Conclusions: Clinicians, cancer center leaders, and CHWs identified multilevel potential barriers to the intervention's success but also described recommendations that may mitigate these barriers. Key informant input represents an important step prior to initiating CHW-based interventions.

Trends in access to minimally invasive pancreaticoduodenectomy for pancreatic cancers.

BACKGROUND: Minimally invasive pancreaticoduodenectomy (MIPD), including robotic (RPD) and laparoscopy (LPD), is becoming more frequently employed in the management of pancreatic ductal adenocarcinoma (PDAC), though the majority of operations are still performed via open approach (OPD). Access to technologic advances often neglect the underserved. Whether disparities in access to MIPD exist, remain unclear. METHODS: The National Cancer Database (NCDB) was queried (2010-2020) for patients who underwent pancreatoduodenectomy for PDAC. Cochran-Armitage tests assessed for trends over time. Social determinants of health (SDH) were compared between approaches. Multinomial logistic models identified predictors of MIPD. RESULTS: Of 16,468 patients, 80.03 % underwent OPD and 19.97 % underwent MIPD (22.60 % robotic; 77.40 % laparoscopic). Black race negatively predicted LPD (vs white (OR 0.822; 95 % CI 0.701-0.964)). Predictors of RPD included Medicare/other government insurance (vs uninsured or Medicaid (OR 1.660; 95 % CI 1.123-2.454)) and private insurance (vs uninsured or Medicaid (OR 1.597; 95 % CI 1.090-2.340)). Early (2010-2014) vs late (2015-2020) diagnosis, stratified by race, demonstrated an increase in Non-White patients undergoing OPD (13.15 % vs 14.63 %; p = 0.016), but not LPD (11.41 % vs 13.57 %;p = 0.125) or RPD (14.15 % vs 15.23 %; p = 0.774). CONCLUSION: SDH predict surgical approach more than clinical stage, facility type, or comorbidity status. Disparities in race and insurance coverage are different between surgical approaches.

Prospective Study of a System-Wide Adrenal Incidentaloma Quality Improvement Initiative.

BACKGROUND: Appropriate follow-up of incidental adrenal masses (IAMs) is infrequent. We implemented a quality improvement (QI) program to improve management of IAMs. STUDY DESIGN: This system-wide initiative targeted primary care providers (PCPs) after IAM detection. It incorporated (1) chart-based messages and emails to PCPs, (2) an evidence-based IAM evaluation algorithm, (3) standardized recommendations in radiology reports, and (4) access to a multispecialty adrenal clinic. Patients diagnosed with an IAM from January 1, 2018, to December 31, 2019, were prospectively included (the "QI cohort") and compared with a historical, preintervention cohort diagnosed with IAMs in 2016. The primary outcomes were the initiation of an IAM investigation by the PCP, defined as relevant clinical history-taking, laboratory screening, follow-up imaging, or specialist referral. RESULTS: The QI cohort included 437 patients and 210 in the historical cohort. All patients had 12 months or more of follow-up. In the QI cohort, 35.5% (155 of 437) met the primary endpoint for PCP-initiated evaluation, compared with 27.6% (58 of 210) in the historical cohort (p = 0.0496). Among the subgroup with a documented PCP working within our health system, 46.3% (74 of 160) met the primary endpoint in the QI cohort vs 33.3% (38 of 114) in the historical cohort (p = 0.035). After adjusting for insurance status, presence of current malignancy, initial imaging setting (outpatient, inpatient, or emergency department), and having an established PCP within our health system, patients in the QI cohort had 1.70 times higher odds (95% CI 1.16 to 2.50) of undergoing a PCP-initiated IAM evaluation. Adrenal surgery was ultimately performed in 2.1% (9 of 437) of QI cohort patients and 0.95% (2 of 210) of historical cohort patients (p = 0.517). CONCLUSIONS: This simple, moderately labor-intensive QI intervention was associated with increased IAM evaluation initiated by PCPs.

The Evaluation of Gallstone Disease in the Year Before Pancreatic Cancer Diagnosis.

INTRODUCTION: Patients with pancreatic cancer can present with a variety of insidious abdominal symptoms, complicating initial diagnosis. Early symptoms of pancreatic cancer often mirror those associated with gallstone disease, which has been demonstrated to be a risk factor for this malignancy. This study aims to compare the incidence of gallstone disease in the year before diagnosis of pancreatic ductal adenocarcinoma (PDAC) as compared to the general population, and evaluate the association of gallstone disease with stage at diagnosis and surgical intervention. METHODS: Patients with PDAC were identified from SEER-Medicare (2008-2015). The incidence of gallstone disease (defined as cholelithiasis, cholecystitis and/or cholecystectomy) in the 1 year before cancer diagnosis was compared to the annual incidence in an age-matched, sex-matched, and race-matched noncancer Medicare cohort. RESULTS: Among 14,654 patients with PDAC, 4.4% had gallstone disease in the year before cancer diagnosis. Among the noncancer controls (n = 14,654), 1.9% had gallstone disease. Both cohorts had similar age, sex and race distributions. PDAC patients with gallstone disease were diagnosed at an earlier stage (stage 0/I-II, 45.8% versus 38.1%, P < 0.0001) and a higher proportion underwent resection (22.7% versus 17.4%, P = 0.0004) compared to patients without gallstone disease. CONCLUSIONS: In the year before PDAC diagnosis, patients present with gallstone disease more often than the general population. Improving follow-up care and differential diagnosis strategies may help combat the high mortality rate in PDAC by providing an opportunity for earlier stage of diagnosis and earlier intervention.

How surgeons use risk calculators and non-clinical factors for informed consent and shared decision making: A qualitative study.

BACKGROUND: The discussion of risks, benefits, and alternatives to surgery with patients is a defining component of informed consent. As shared-decision making has become central to surgeon-patient communication, risk calculators have emerged as a tool to aid communication and decision-making. To optimize informed consent, it is necessary to understand how surgeons assess and communicate risk, and the role of risk calculators in this process. METHODS: We conducted interviews with 13 surgeons from two institutions to understand how surgeons assess risk, the role of risk calculators in decision-making, and how surgeons approach risk communication during informed consent. We performed a qualitative analysis of interviews based on SRQR guidelines. RESULTS: Our analysis yielded insights regarding (a) the landscape and approach to obtaining surgical consent; (b) detailed perceptions regarding the value and design of assessing and communicating risk; and (c) practical considerations regarding the future of personalized risk communication in decision-making. Above all, we found that non-clinical factors such as health and risk literacy are changing how surgeons assess and communicate risk, which diverges from traditional risk calculators. CONCLUSION: Principally, we found that surgeons incorporate a range of clinical and non-clinical factors to risk stratify patients and determine how to optimally frame and discuss risk with individual patients. We observed that surgeons' perception of risk communication, and the importance of eliciting patient preferences to direct shared-decision making, did not consistently align with patient priorities. This study underscored criticisms of risk calculators and novel decision-aids - which must be addressed prior to greater adoption.

The impact of social risk factors on the presentation, treatment and survival of patients with hepatocellular carcinoma at an urban, academic safety-net hospital.

BACKGROUND: Vulnerable populations have worse hepatocellular carcinoma (HCC) outcomes. We sought to understand if this could be mitigated at a safety-net hospital. METHODS: A retrospective chart review of HCC patients was conducted (2007-2018). Stage at presentation, intervention and systemic therapy were analyzed (Chi-square for categorical variables and Wilcoxon tests for continuous variables) and median survival calculated by Kaplan-Meier method. RESULTS: 388 HCC patients were identified. Sociodemographic factors were similar for stage at presentation, except insurance status (diagnosis at earlier stages for commercial insurance and later stages for safety-net/no insurance). Higher education level and origin of mainland US increased intervention rates for all stages. Early-stage disease patients had no differences in receipt of intervention or therapy. Late-stage disease patients with higher education level had increased intervention rates. Median survival was not impacted by any sociodemographic factor. CONCLUSION: Urban safety-net hospitals with a focus on vulnerable patient populations provide equitable outcomes and can serve as a model to address inequities in HCC management.

Combined High-Volume Common Complex Cancer Operations Safeguard Long-Term Survival in a Low-Volume Individual Cancer Operation Setting.

BACKGROUND: We previously demonstrated the importance of combined complex surgery volume on short-term outcomes of high-risk cancer operations. This study investigates the impact of combined common complex cancer operation volume on long-term outcomes at hospitals with low cancer-specific operation volumes. PATIENTS AND METHODS: A retrospective cohort of National Cancer Data Base (2004-2019) patients undergoing surgery for hepatocellular carcinoma, non-small cell lung cancers, or pancreatic, gastric, esophageal, or rectal adenocarcinomas was utilized. Three separate cohorts were established: low-volume hospitals (LVH), mixed-volume hospitals (MVH) with low-volume individual cancer operations and high-volume total complex operations, and high-volume hospitals (HVH). Survival analyses were performed for overall, early-, and late-stage disease. RESULTS: The 5 year survival was significantly better at MVH and HVH compared with LVH, for all operations except late-stage hepatectomy (HVH survival > LVH and MVH). The 5 year survival probability was similar between MVH and HVH for operations on late-stage cancers. Early and overall survival for gastrectomy, esophagectomy, and proctectomy were equivalent between MVH and HVH. While early and overall survival for pancreatectomy were benefited by HVH over MVH, the opposite was true for lobectomy/pneumonectomy, which were benefited by MVH over HVH; however, none of these differences were likely to have an effect clinically. Only hepatectomy patients demonstrated statistical and clinical significance in 5 year survival at HVH compared with MVH for overall survival. CONCLUSIONS: MVH hospitals performing sufficient complex common cancer operations demonstrate similar long-term survival for specific high-risk cancer operations to HVH. MVH provide an adjunctive model to the centralization of complex cancer surgery, while maintaining quality and access.

A propensity score matching analysis: Impact of senior resident versus fellow participation on outcomes of complex surgical oncology.

BACKGROUND: Teaching hospitals that train both general surgery residents and fellows in complex general surgical oncology have become more common. This study investigates whether participation of a senior resident versus a fellow has an impact on outcomes of patients undergoing complex cancer surgery. METHODS: Patients who underwent esophagectomy, gastrectomy, hepatectomy, or pancreatectomy between 2007 and 2012 with assistance from a senior resident (post-graduate years 4-5) or a fellow (post-graduate years 6-8) were identified from the ACS NSQIP. Based on age, sex, body mass index, ASA classification, diagnosis of diabetes mellitus, and smoking status, propensity-scores were created for odds of undergoing the operation assisted by a fellow. Patients were matched 1:1 based on propensity score. Postoperative outcomes including risk of major complication were compared after matching. RESULTS: In total, 6934 esophagectomies, 13,152 gastrectomies, 4927 hepatectomies, and 8040 pancreatectomies were performed with assistance of a senior resident or fellow. After matching, overall rates of major complications were equivalent across all four anatomic locations between cases performed with the participation of a senior resident versus a surgical fellow: esophagectomy (37.0%% vs 31.6%, p = 0.10), gastrectomy (22.6% vs 22.3%, p = 0.93), hepatectomy (15.8% v 16.0%, p = 0.91), and pancreatectomy (23.9% vs 25.2%, p = 0.48). Operative time was shorter for gastrectomy (212 vs. 232 min; p = 0.004) involving a resident compared to a fellow, but comparable for esophagectomy (330 vs. 336 min; p = 0.41), hepatectomy (217 vs. 219 min; p = 0.85), and pancreatectomy (320 vs. 330 min; p = 0.43). CONCLUSIONS: Senior resident participation in complex cancer operations does not appear to negatively impact operative time or postoperative outcomes. Future research is needed to further assess this domain of surgical practice and education, particularly with regard to case selection and operative complexity.

Disparities in the Receipt of Recommended Curative Treatment for Patients with Early-Stage Hepatocellular Carcinoma.

BACKGROUND: In early-stage hepatocellular carcinoma (HCC), the receipt of recommended care is critical for long-term survival. Unfortunately, not all patients decide to undergo therapy. We sought to identify factors associated with the decision to decline recommended intervention among patients with early-stage HCC. METHODS: The National Cancer Database was queried for patients diagnosed with clinical stages I and II HCC (2004-2017). Cohorts were created based on the receipt or decline of recommended interventions-hepatectomy, liver transplantation, and ablation. Multivariable logistic regression identified predictors for declining intervention, and propensity score analysis was used to calculate the respective odds. Survival analysis was performed using the Kaplan-Meier method. RESULTS: Of 20,863 patients, 856 (4.1%) declined intervention. Patients who were documented as having declined intervention were more often Black (vs. other: OR, 1.3; 95% CI, 1.1-1.6; p = 0.0038), had Medicaid or no insurance (vs. Private, Medicare, or other government insurance): OR, 1.9; 95% CI, 1.6-2.3; p < 0.0001), lived in a low-income area (vs. other: OR, 1.4; 95% CI, 1.2-1.7; p < 0.0001), and received treatment at a non-academic center (vs. academic: OR, 2.1; 95% CI, 1.9-2.5; p < 0.0001). Patients who declined recommended interventions had worse survival compared to those who received treatment (22.9 vs. 59.2 months; p < 0.0001, respectively). CONCLUSIONS: Racial and socioeconomic disparities persist in the decision to undergo recommended treatment. Underutilization of treatment acts as a barrier to addressing racial and socioeconomic disparities in early-stage HCC outcomes.

A Standardized Radiology Template Improves Incidental Adrenal Mass Follow-Up: A Prospective Effectiveness and Implementation Study.

PURPOSE: Incidental adrenal masses (IAMs) are common but rarely evaluated. To improve this, we developed a standardized radiology report recommendation template and investigated its implementation and effectiveness. METHODS: We prospectively studied implementation of a standardized IAM reporting template as part of an ongoing quality improvement initiative, which also included primary care provider (PCP) notifications and a straightforward clinical algorithm. Data were obtained via medical record review and a survey of radiologists. Outcomes included template adoption rates and acceptability (implementation measures), as well as the proportion of patients evaluated and time to follow-up (effectiveness outcomes). RESULTS: Of 4,995 imaging studies, 200 (4.0%) detected a new IAM. The standardized template was used in 54 reports (27.0%). All radiologists surveyed were aware of the template, and 91% affirmed that standardized recommendations are useful. Patients whose reports included the template were more likely to have PCP follow-up after IAM discovery compared with those with no template (53.7% versus 36.3%, P = .03). After adjusting for sex, current or prior malignancy, and provider ordering the initial imaging (PCP, other outpatient provider, or emergency department or inpatient provider), odds of PCP follow-up remained 2.0 times higher (95% confidence interval 1.02-3.9). Patients whose reports included the template had a shorter time to PCP follow-up (log-rank P = .018). PCPs ultimately placed orders for biochemical testing (35.2% versus 18.5%, P = .01), follow-up imaging (40.7% versus 23.3%, P = .02), and specialist referral (22.2% versus 4.8%, P < .01) for a higher proportion of patients who received the template compared with those who did not. CONCLUSIONS: Use of a standardized template to communicate IAM recommendations was associated with improved IAM evaluation. Our template demonstrated high acceptability, but additional strategies are necessary to optimize adoption.

Impact of Race, Ethnicity, Primary Language, and Insurance on Reconstruction after Mastectomy for Patients with Breast Cancer at an Urban, Academic Safety-Net Hospital.

BACKGROUND: Disparities in breast reconstruction have been observed in national cohorts and single-institution studies based on race, ethnicity, insurance, and language. However, little is known regarding whether safety-net hospitals deliver more or less equitable breast reconstruction care in comparison with national cohorts. STUDY DESIGN: We performed a retrospective study of patients with either invasive breast cancer or ductal carcinoma in situ diagnosed and treated at our institution (January 1, 2009, to December 31, 2014). The rate of, timing of, and approach to breast reconstruction were assessed by race, ethnicity, insurance status, and primary language among women who underwent mastectomy. Reasons for not performing reconstruction were also analyzed. RESULTS: A total of 756 women with ductal carcinoma in situ or nonmetastatic invasive cancer were identified. The median age was 58.5 years, 56.2% were non-White, 33.1% were non-English-speaking, and 48.9% were Medicaid/uninsured patients. A total of 142 (18.8%) underwent mastectomy during their index operation. A total of 47.9% (n = 68) did not complete reconstruction. Reasons for not performing reconstruction included patient preference (n = 22), contraindication to immediate reconstruction (ie, locoregionally advanced disease prohibiting immediate reconstruction) without follow-up for consideration of delayed reconstruction (n = 12), prohibitive medical risk or contraindication (ie, morbid obesity; n = 8), and progression of disease, prohibiting reconstruction (n = 7). Immediate and delayed reconstruction were completed in 43.7% and 8.5% of patients. The rate of reconstruction was inversely associated with tumor stage (odds ratio 0.52, 95% CI 0.31 to 0.88), but not race, ethnicity, insurance, or language, on multivariate regression. CONCLUSIONS: At a safety-net hospital, we observed rates of reconstruction at or greater than national estimates. After adjustment for clinical attributes, rates did not vary by race, ethnicity, insurance or language. Future research is needed to understand the role of reconstruction in breast cancer care and how to advance shared decision-making among diverse patients.

COVID-19 Did Not Stop the Rising Tide: Trends in Case Volume Logged by Surgical Residents.

INTRODUCTION: The coronavirus pandemic has profoundly impacted all facets of surgical care, including surgical residency training. The objective of this study was to assess the operative experience and overall case volume of surgery residents before and during the pandemic. METHODS: Using data from the Accreditation Council for Graduate Medical Education annual operative log reports, operative volume for 2015 to 2021 graduates of Accreditation Council for Graduate Medical Education -accredited general, orthopedic, neuro- and plastic surgery residency programs was analyzed using nonparametric Kendall-tau correlation analysis. The period before the pandemic was defined as AY14-15 to AY18-19, and the pandemic period was defined as AY19-20 to AY20-21. RESULTS: Operative data for 8556 general, 5113 orthopedic, 736 plastic, and 1278 neurosurgery residency graduates were included. Between 2015 and 2021, total case volume increased significantly for general surgery graduates (Kendall's tau-b: 0.905, p = 0.007), orthopedic surgery graduates (Kendall's tau-b: 1.000, p = 0.003), neurosurgery graduates (Kendall's tau-b: 0.905, p = 0.007), and plastic surgery graduates (Kendall's tau-b: 0.810, p = 0.016). Across all specialties, the mean total number of cases performed by residents graduating during the pandemic was higher than among residents graduating before the pandemic, though no formal significance testing was performed. Among general surgery residents, the number of cases performed as surgeon chief among residents graduating in AY19-20 decreased for the first time in 5 years, though the overall volume remained higher than the prior year, and returned to prepandemic trends in AY20-21. CONCLUSIONS: Over the past 7 years, the case volume of surgical residents steadily increased. Surgical trainees who graduated during the coronavirus pandemic have equal or greater total operative experience compared to trainees who graduated prior to the pandemic.

The Persistence of Poverty and its Impact on Cancer Diagnosis, Treatment and Survival.

OBJECTIVE: To determine the effect of persistent poverty on the diagnosis, surgical resection and survival of patients with non-small cell lung (NSCLC), breast, and colorectal cancer. BACKGROUND: Disparities in cancer outcomes exist in counties with high levels of poverty, defined as ≥20% of residents below the federal poverty level. Despite this well-established association, little is known about how the duration of poverty impacts cancer care and outcomes. One measure of poverty duration is that of "persistent poverty," defined as counties in high poverty since 1980. METHODS: In this retrospective cohort study, patients with NSCLC, breast and colorectal cancer were identified from SEER (2012-2016). County-level poverty was obtained from the American Community Survey (1980-2015). Outcomes included advanced stage at diagnosis (stage III-IV), resection of localized disease (stage I-II) and cancer-specific survival. Hierarchical generalized linear models and accelerated failure time models with Weibull distribution were used, adjusted for patient-level covariates and region. RESULTS: Overall, 522,514 patients were identified, of which 5.1% were in persistent poverty. Patients in persistent poverty were more likely to present with advanced disease [NSCLC odds ratio (OR): 1.12, 95% confidence interval (CI): 1.06-1.18; breast OR: 1.09, 95% CI: 1.02-1.17; colorectal OR: 1.00, 95% CI: 0.94-1.06], less likely to undergo surgery (NSCLC OR: 0.81, 95% CI: 0.73-0.90; breast OR: 0.82, 95% CI: 0.72-0.94; colorectal OR: 0.84, 95% CI: 0.70-1.00) and had increased cancer-specific mortality (NSCLC HR: 1.09, 95% CI: 1.06-1.13; breast HR: 1.18, 95% CI: 1.05-1.32; colorectal HR: 1.09, 95% CI: 1.03-1.17) as compared with those without poverty. These differences were observed to a lesser magnitude in counties with current, but not persistent, poverty and disappeared in counties no longer in poverty. CONCLUSIONS: The duration of poverty has a direct impact on cancer-specific outcomes, with the greatest effect seen in persistent poverty and resolution of disparities when a county is no longer in poverty. Policy focused on directing resources to communities in persistent poverty may represent a possible strategy to reduce disparities in cancer care and outcomes.

Surveillance Patterns for Hepatocellular Carcinoma among Screening-Eligible Patients in the Medicare Population.

INTRODUCTION: Routine screening plays a critical role in the diagnosis of hepatocellular carcinoma (HCC), but not all patients undergo consistent surveillance. This study aims to evaluate surveillance patterns and their association with diagnosis stage and survival among Medicare patients at risk for HCC. PATIENTS AND METHODS: Patients with HCC and guideline-based screening eligibility who underwent imaging with ultrasound or abdominal magnetic resonance imaging (MRI) in the 2 years prior to diagnosis were identified from SEER-Medicare (2008-2015). Three surveillance cohorts were created: diagnostic (imaging only within 3 months prior), intermittent (imaging only once within 2 years prior, excluding diagnostic), and routine (at least two imaging encounters within 2 years prior, excluding diagnostic). Multivariable logistic regression was used to predict early-stage diagnosis (stage I-II), and 5-year survival was evaluated using the accelerated failure time method with Weibull distribution. RESULTS: Among 2261 eligible patients, 26.1% were classified as diagnostic, 15.8% as intermittent, and 58.1% as routine surveillance. The median age was 74 years (IQR 70-78 years). The majority of patients had a preexisting cirrhosis diagnosis (81.5%). Routine and intermittent, compared with diagnostic, surveillance were predictive of early-stage disease (routine: OR 2.05, 95% CI 1.64-2.56; intermittent: OR 1.43, 95% CI 1.07-1.90). Patients who underwent routine surveillance had significantly lower risk of mortality (HR 0.84, 95% CI 0.75-0.94) compared with the diagnostic group. CONCLUSIONS: A large proportion of screening-eligible patients do not undergo routine surveillance, which is associated with late-stage diagnosis and higher risk of mortality. These findings demonstrate the impact of timely and consistent healthcare access and can guide interventions for promoting surveillance among these patients.

Impact of Patient Primary Language upon Immediate Breast Reconstruction After Mastectomy.

BACKGROUND: Preoperative decision-making in patients who speak a primary language other than English is understudied. We investigated whether patient primary language is associated with differences in immediate breast reconstruction (IBR) after mastectomy. PATIENTS AND METHODS: This retrospective observational study analyzed female patients undergoing mastectomy in the New Jersey State Inpatient Database (2009-2014). The primary outcome was the odds of IBR with a prespecified subanalysis of autologous tissue-based IBR. We used multivariable logistic regression and hierarchical generalized linear mixed models to control for patient characteristics and nesting within hospitals. RESULTS: Of 13,846 discharges, 12,924 (93.3%) specified English as the patient's primary language, while 922 (6.7%) specified a language other than English. Among English-speaking patients, 6178 (47.8%) underwent IBR, including 2310 (17.9%) autologous reconstructions. Among patients with a primary language other than English, 339 (36.8%) underwent IBR, including 93 (10.1%) autologous reconstructions. Unadjusted results showed reduced odds of IBR overall [odds ratio (OR) 0.64, 95% CI 0.55-0.73], and autologous reconstruction specifically (OR 0.52, 95% CI 0.41-0.64) among patients with a primary language other than English. After adjustment for patient factors, this difference persisted among the autologous subgroup (OR 0.64, 95% CI 0.51-0.80) but not for IBR overall. A hierarchical model incorporating both patient characteristics and hospital-level effects continued to show a difference among the autologous subgroup (OR 0.75, 95% CI 0.58-0.97). CONCLUSIONS: Primary language other than English was an independent risk factor for lower odds of autologous IBR after adjustments for patient and hospital effects. Focused efforts should be made to ensure that patients who speak a primary language other than English have access to high-quality shared decision-making for postmastectomy IBR.