Geographic Variation Immediate and Delayed Breast Reconstruction Utilization in Ontario, Canada and Plastic Surgeon Availability: A Population-Based Observational Study

World J Surg. 2015 Aug;39(8):1909-21. doi: 10.1007/s00268-015-3060-2.


Background: Utilization of breast reconstruction (BR) is low in many jurisdictions. We studied the geographical and surgical workforce factors that contribute to access and use of BR using a small area analysis approach with a geographical unit of analysis.

Methods: We linked administrative data from Ontario Canada to calculate the age-standardized rates for immediate BR (IBR) (same time as mastectomy) between 2002 and 2011, and delayed BR (DBR) (within 3 years of mastectomy) for each county. The influence of plastic surgeon access on variation in county rates of BR was examined using Poisson random effects models.

Results: 12,663 women underwent mastectomy in Ontario; 2,948 had BR within 3 years (23.3%). Over 50% of the counties had no access to any plastic surgeon. County IBR rates ranged from 0 to 21.5%; plastic surgeon access explained 46% of geographic variation (p<0.0001). IBR rates in counties with very low, low, and moderate access to plastic surgeons were significantly less than counties with high access (relative rate [RR] 0.48 [95% confidence interval (CI) 0.35-0.66], RR 0.61 [CI 0.43-0.87] and RR 0.70 [CI 0.52-0.96], respectively) after adjusting for age and county socioeconomic characteristics. For DBR, while there was less geographic variation, very low access counties demonstrated reduced rates (RR 0.60 [CI 0.47-0.76]).

Interpretation: Geographic access to a plastic surgeon is a major determinant of BR. Targeted interventions for regions without high access to plastic surgeons may improve overall rates and reduce geographic disparities in care, particularly for IBR.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Breast Neoplasms / surgery
  • Female
  • Health Services Accessibility*
  • Humans
  • Mammaplasty / statistics & numerical data*
  • Mastectomy / statistics & numerical data
  • Middle Aged
  • Ontario / epidemiology
  • Surgeons / supply & distribution*
  • Young Adult