Hospital organizational factors affect the use of immediate breast reconstruction after mastectomy for breast cancer

Background: Aims of the current study were to identify which hospital organizational factors determine the variation in the use of immediate breast reconstruction (IBR) after mastectomy for ductal carcinoma in situ (DCIS) or invasive breast cancer and to investigate whether these factors explain the variation in IBR between hospitals in the Netherlands. Material and Methods: From the NABON Breast Cancer Audit (NBCA) patients with DCIS or primary invasive breast cancer without distant metastatic disease, diagnosed between January 1, 2011 and December 31, 2013 were selected. Hospital organizational factors were identified with an online web-based survey on different organization factors such as the number of weekly multidisciplinary team (MDT) meetings, number of (breast and plastic) surgeons in the hospital and the presence of plastic surgeons in weekly MDT. Logistic regression analyses were used to analyze whether the identified organizational factors significantly affected IBR rates. Patient, tumor and hospital organizational factors that demonstrated to significantly affect IBR rates in univariate analyses were included in the multivariate analyses. Results: In total, 72 hospitals (78% of all Dutch hospitals) participated in the survey. In these hospitals 16,471 female patients were treated with a mastectomy for DCIS (n = 1,980) or non-metastatic breast cancer (n = 14,491) during the study period. In total 20% (n = 3,244) of these patients underwent IBR for DCIS (mean, 42%; hospital range, 0−80%) or invasive breast cancer (mean, 17%; hospital range, 0−62%). Patients who underwent a mastectomy in a teaching (OR=2.6, 95% CI: 1.8−3.7) or university hospital (OR=10.8, 95% CI: 5.7–20.5) or in an intermediate volume (OR=2.0, 95% CI: 1.5−2.8) or high volume hospital (OR=3.0, 95% CI: 2.0−4.5) had a significantly higher chance of receiving IBR compared to patients treated in a district or low volume hospital, respectively. More often IBR was performed in hospitals having 3−4 MDT meetings/week organized compared to hospitals with 1−2 MDT meetings/week (OR=1.4, 95% CI: 1.1−1.8). The number of plastic surgeons in-house did not significantly affect the chance of IBR. In almost 70% of the hospitals, a plastic surgeon structurally attended the weekly MDT meeting, which was prognostic for performing more IBRs compared to MDTs with no or incidental plastic surgeon attendance (OR=3.89, 95% CI: 3.00–5.04). Conclusion: Hospital organizational factors affect the use of IBR and consequently could be subject for improvement to make IBR available to more breast cancer patients.