Paris D. Butler

Racial and age disparities persist in immediate breast reconstruction: an updated analysis of 48,564 patients from the 2005 to 2011 American College of Surgeons National Surgery Quality Improvement Program data sets

BACKGROUNDnImmediate breast reconstruction (IBR) rates continue to rise, yet recent patterns based on race, age, and patient comorbidities have not been adequately assessed.nnnMETHODSnWomen undergoing mastectomy only or mastectomy with IBR from 2005 to 2011 were identified in the American College of Surgeons-National Surgical Quality Improvement (NSQIP) data sets. A multivariate logistic regression was performed to determine factors independently associated with receipt of IBR. Thirty-day surgical complication rates after IBR were also assessed.nnnRESULTSnRates of IBR increased significantly over the study period from 26% of patients in 2005 to 40% in 2011. Non-Caucasian race, older age (≥45xa0years), obesity, and presence of comorbid conditions including diabetes mellitus, current smoking, and cardiovascular disease were all negatively associated with receipt of IBR. Surgical complication rates after IBR were not predicted by non-Caucasian race, older age, or presence of diabetes mellitus.nnnCONCLUSIONSnThis current assessment of IBR using the American College of Surgeons-National Surgical Quality Improvement data sets demonstrates that non-Caucasian and older women (≥45xa0years) continue to receive IBR at lower rates despite the lack of association of added risk of surgical morbidity.

Ethnic diversity remains scarce in academic plastic and reconstructive surgery.

Background: Plastic surgery has been dedicated to advancing academic surgery in education, research, innovation, and patient care. Thus, as U.S. health care disparities persist, it would be befitting for plastic surgery to assume the lead in alleviating these disparities. As part of a multifaceted approach to ameliorate health care disparities, increasing diversity in the health care workforce will be imperative. Investigating the demographics of the U.S. plastic surgery residents and faculty can bring attention to a deficit that, if corrected, could benefit the field and improve the entire health care system. Methods: Medical students, plastic surgery residents/fellows, and plastic surgery faculty demographic information from 1966 to 2006 was analyzed from the Association of American Medical Colleges’ data files. Results: Caucasians encompass 68.7 percent of U.S. plastic surgery residents/fellows, while Asian-, African-, and Latino-Americans encompass 20.9, 3.7, and 6.2 percent, respectively. Caucasians comprise 74.9 percent of academic plastic surgeons, while Asian-, African-, and Latino-Americans comprise 10.9, 1.4, and 3.6 percent, respectively. Caucasians constitute 82.0 percent of tenured full professors, while Asian-, African-, and Latino-Americans constitute 4.9, 1.6, and 4.9 percent, respectively. In 2004, African-Americans and Latino-Americans comprised 3.6 percent and 5.7 percent of all U.S. plastic surgeons, but only 1.5 percent and 4.9 percent of plastic academicians, respectively. Conclusions: Over the last 40 years, plastic surgery has been ineffective in adequately increasing the number of minority residents and faculty. Expanding the number of minority academic plastic surgeons could establish a health care environment more accommodating to minority patients, increase studies highlighting minority health needs, and provide additional role models and mentors.

Abdominal perforator vs. muscle sparing flaps for breast reconstruction.

Abdominally based free flaps have become the mainstay for women that desire to use their own tissue as a means of breast reconstruction after mastectomy. As the techniques have evolved, significant effort has been invested in finding the best means of minimizing morbidity to the abdominal donor site while ensuring a viable reconstructed breast that is aesthetically pleasing. This manuscript reviews and compares the muscle sparing free transverse rectus abdominis myocutaneous (MsfTRAM), the deep inferior epigastric artery perforator (DIEP), and the superficial inferior epigastric artery (SIEA) flaps, regarding flap success rate, operative times, abdominal donor site morbidity and residual functionality, hospital lengths of stay and associated costs, impact of co-morbid conditions, and resilience after adjuvant radiation treatment.

African-American women have equivalent outcomes following autologous free flap breast reconstruction despite greater preoperative risk factors.

BACKGROUNDnDisparities along racial and ethnic lines exist in breast cancer treatment and reconstruction. This study compares preoperative characteristics among female breast cancer patients who received autologous breast reconstruction to determine if race affects clinical outcomes.nnnMETHODSnWomen receiving autologous breast reconstruction at a single institution from 2005 to 2011 were identified within a prospectively maintained database. Preoperative risk factors and rates of postoperative morbidity and mortality were assessed with respect to race.nnnRESULTSnAfrican-American patients had significantly higher rates of preoperative comorbidities than Caucasian patients. Despite the heightened preoperative risk factors, postoperative complications did not significantly differ between racial categories.nnnCONCLUSIONnAs the alleviation of healthcare disparities remains a focus of healthcare reform, these findings are beneficial in further educating African-American breast cancer patients and their providers of the safe and viable option of autologous tissue transfer for breast reconstruction.

The Diverse Surgeons' Initiative: Longitudinal Assessment of a Successful National Program

BACKGROUNDnThe Diverse Surgeons Initiative (DSI) is a program that was created to provide underrepresented minority surgical residents with the clinical knowledge and minimally invasive surgical skills necessary to excel in surgical residency and successfully transition into surgical practice. The early success of the graduates of the program has been published; however, a more longitudinal assessment of the program was suggested and warranted. This study provides a 5-year follow-up of the 76 physicians that participated in the DSI from 2002 to 2009 to determine if the trend toward fellowship placement and academic appointments persisted. Additionally, this extended evaluation yields an opportunity to assess these young surgeons professional progress and contributions to the field.nnnSTUDY DESIGNnThe most current professional development and employment information was obtained for the 76 physicians that completed the DSI from 2002 to 2009. The percentage of DSI graduates completing surgical residency, obtaining subspecialty fellowships, attaining board certification, receiving fellowship in the American College of Surgeons, contributing to the peer-reviewed literature, acquiring academic faculty positions, and ascending to professional leadership roles were calculated and compared with the original assessment.nnnRESULTSnOf the 76 DSI graduates, 99% completed general surgery residency. Of those eligible, 87% completed subspecialty fellowships; 87% were board certified; 50% received fellowship in the American College of Surgeons; 76% had contributed to the peer-reviewed literature; 41% had obtained faculty positions; and 18% held local, regional, or national professional leadership positions.nnnCONCLUSIONSnThis longitudinal analysis has revealed sustained success of the DSI in preparing underrepresented minority residents to excel in their training and transition into practice, obtain postsurgical fellowships, acquire faculty appointments, and contribute to the advancement of the field of surgery.

Geographic Variation in Access to Plastic Surgeons.

Introduction: While recent studies project a national shortage of plastic surgeons, there may currently exist areas within the United States with few plastic surgeons. We conducted this study to describe the current geographic distribution of the plastic surgery workforce across the United States. Methods: Using the 2013 to 2014 Area Health Resource File, we estimated the number of plastic surgeons at the health service area (HSA) level in 2010 and 2012. The density of plastic surgeons was calculated as a ratio per 100,000 population. The HSAs were grouped by plastic surgeon density, and population characteristics were compared across subgroups. Characteristics of HSAs with increases and decreases in plastic surgeon density were also compared. Results: The final sample included 949 HSAs with a total population of 313,989,954 people. As of 2012, there were an estimated 7600 plastic surgeons, resulting in a national ratio of 2.42 plastic surgeons/100,000 population. However, over 25million people lived in 468HSAs (49.3%)without a plastic surgeon, whereas 106 million people lived in 82 HSAs (8.6%) with 3.0 or more/100,000 population. Plastic surgeons were more likely to be distributed in HSAs where a higher percentage of the population was younger than 65 years, female, and residing in urban areas. Between 2010 and 2012, 11 HSAs without a plastic surgeon increased density, whereas 15 HSAs lost all plastic surgeons. Conclusions: Plastic surgeons are asymmetrically distributed across the United States leaving over 25 million people without geographic access to the specialty. This distribution tends to adversely impact older and rural populations.

The Relationship Between Geographic Access to Plastic Surgeons and Breast Reconstruction Rates Among Women Undergoing Mastectomy for Cancer

Introduction Despite a national health care policy requiring payers to cover breast reconstruction, rates of postmastectomy reconstruction are low, particularly among minority populations. We conducted this study to determine if geographic access to a plastic surgeon impacts breast reconstruction rates. Methods Using 2010 inpatient and ambulatory surgery data from 10 states, we identified adult women who underwent mastectomy for breast cancer. Data were aggregated to the health service area (HSA) level and hierarchical generalized linear models were used to risk-standardize breast reconstruction rates (RSRR) across HSAs. The relationship between an HSAs RSRR and plastic surgeon density (surgeons/100,000 population) was quantified using correlation coefficients. Results The final cohort included 22,997 patients across 134 HSAs. There was substantial variation in plastic surgeon density (median, 1.4 surgeons/100,000; interquartile range, [0.0–2.6]/100,000) and the use of breast reconstruction (median RSRR, 43.0%; interquartile range, [29.9%–62.8%]) across HSAs. Higher plastic surgeon density was positively correlated with breast reconstruction rates (correlation coefficient = 0.66, P < 0.001) and inversely related to time between mastectomy and reconstruction (correlation coefficient = −0.19, P < 0.001). Non-white and publicly insured women were least likely to undergo breast reconstruction overall. Among privately insured patients, racial disparities were noted in high surgeon density areas (white = 79.0% vs. non-white = 63.3%; P < 0.001) but not in low surgeon density areas (34.4% vs 36.5%; P = 0.70). Conclusions The lack of geographic access to a plastic surgeon serves as a barrier to breast reconstruction and may compound disparities in care associated with race and insurance status. Future efforts to improve equitable access should consider strategies to ensure access to appropriate clinical expertise.

Surgical time out: Our counts are still short on racial diversity in academic surgery

BACKGROUNDnThis study provides an updated description of diversity along the academic surgical pipeline to determine what progress has been made.nnnMETHODSnData was extracted from a variety of publically available data sources to determine proportions of minorities in medical school, general surgery training, and academic surgery leadership.nnnRESULTSnIn 2014-2015, Blacks represented 12.4% of the U.S. population, but only 5.7% graduating medical students, 6.2% general surgery trainees, 3.8% assistant professors, 2.5% associate professors and 2.0% full professors. From 2005-2015, representation among Black associate professors has gotten worse (-0.07%/year, pxa0<xa00.01). Similarly, in 2014-2015, Hispanics represented 17.4% of the U.S. population but only 4.5% graduating medical students, 8.5% general surgery trainees, 5.0% assistant professors, 5.0% associate professors and 4.0% full professors. There has been modest improvement in Hispanic representation among general surgery trainees (0.2%/year, pxa0<xa00.01), associate (0.12%/year, pxa0<xa00.01) and full professors (0.13%/year, pxa0<xa00.01).nnnCONCLUSIONnDespite efforts to promote diversity in surgery, Blacks and Hispanics remain underrepresented. A multi-level national focus is imperative to elucidate effective mechanisms to make academic surgery more reflective of the US population.

Influence of race, insurance status, and geographic access to plastic surgeons on immediate breast reconstruction rates

BACKGROUNDnThis study evaluates the rates of immediate breast reconstruction (IBR) among racial and insurance status subgroups, in the setting of a changing plastic surgeon workforce.nnnMETHODSnUsing state level inpatient and ambulatory surgery data, we identified discharges for adult women who underwent mastectomy for breast cancer. This information was supplemented with plastic surgeon workforce data and aggregated to the health service area-level (HSA). Hierarchical linear models were used to risk standardized IBR rates for 8 race-payer subgroups.nnnRESULTSnThe final cohort included 65,246 women treated across 67 HSAs. The plastic surgeon density per 100,000 population directly related to the IBR rate. While all subgroups saw a modest increase in IBR rates, Caucasian women with private insurance realized the largest absolute increase (46%) while African-American and Asian women with public insurance saw the smallest increase (6%).nnnCONCLUSIONnSignificant disparities persist in the provision of IBR according to the form of insurance a patient possesses. Of heightened concern is the novel finding that even within privately insured patients, women of color have significantly lower IBR rates compared to Caucasian women.

The Relationship Between Geographic Access to Plastic Surgeons and Immediate Breast Reconstruction Rates Among Women Undergoing Mastectomy for Cancer.

INTRODUCTION: Breast reconstruction is an important component of breast cancer treatment. Despite healthcare policy requiring payers to cover and referring physicians to discuss such procedures, reconstruction rates remain low, particularly among minority populations1. We conducted this study to determine if geographic access to a plastic surgeon contributes to the likelihood of receiving breast reconstruction; the type of reconstruction received; or when reconstruction is performed. Additionally, we explored the relationship between plastic surgeon distribution and healthcare disparities in breast reconstruction.