Immediate reconstruction, infection, and hematoma associated with increased odds of refusing breast reconstruction procedures

Purpose: Breast reconstruction may be a prolonged process.^[1] Patients may grow fatigued and refuse some procedures suggested by their plastic surgeons. The authors aimed to analyze factors associated with this phenomenon.

Methods: Patients undergoing breast reconstruction since 2003 with follow up in our institution’s medical record system were reviewed. Chi-squared and independent t-tests were used to identify variables associated with refusal of procedures; significantly associated variables (p<0.05) were used to build a logistic regression.

Results:

433 patients were included. Women underwent an average of 3.01±1.96 procedures (range 1-12) with reconstructive courses averaging 588.38±655.58 days. 79 patients (18.2%) refused at least one procedure suggested by their plastic surgeon, of whom 60 never underwent the proposed procedure. Sixty-seven of the procedures were suggested as cosmetic revisions and twelve were suggested as salvage reconstructions or procedures to manage complications; there was no difference between procedures types regarding whether patients eventually underwent the procedure or not. Adjuvent therapies, number of comorbidities, demographic factors (age, children, marriage, ethnicity), surgeon, and number of complications were not associated with refusing procedures in univariate analysis. A logistic regression predicting refusal of procedures controlling for hematomas, superficial infections, implant infections, immediate reconstruction, private insurance, and number of implant removals was constructed. Patients with private insurance were more likely to refuse procedures (OR 4.90, 1.15-8.06).

Conclusions:

Nearly one fifth of women refused breast reconstruction procedures. The fact that number and type of complications did not influence refusal of procedures is a testament to the relationship between a patient and her surgeon. The authors hypothesize that the association between private insurance and procedure refusal may be a reflection of differences in co-payment and cost-sharing patterns between public and private insurance. In New York State, publicly insured patients have a co-payment limit (typically $25.00 per inpatient stay), while privately insured patients often have co-payments assessed on a percentage basis. Prospective research about the factors affecting reconstructive decisions must be done to determine whether privately-insured patients’ reconstructive choices are constrained by health care costs.