Implicit racial bias by US region not linked to breast reconstruction utilization rates

Key takeaways:

• Implicit association test scores were not associated with breast reconstruction rates, complications or costs.
• Breast reconstruction ratios were highest in the East South Central regions of the U.S.

U.S. regional variations in implicit bias were not associated with breast reconstruction, complications or cost among women with breast cancer undergoing mastectomy, according to results from a cohort study published in JAMA Network Open.

“This study aims to determine whether differences in breast reconstruction rates for white patients and patients from minoritized racial and ethnic groups are associated with measures of implicit racial bias by region,” Jacob S. Nasser, MD, surgical resident in the department of surgery at the Icahn School of Medicine, New York, and colleagues wrote. “Secondly, this study aims to identify whether differences in complications and cost of care are associated with regional implicit racial bias.”

Nasser and colleagues conducted a cohort study of 52,115 women with a diagnosis of or genetic predisposition for breast cancer who received immediate breast reconstruction at the time of mastectomy from 2009 to 2019. Researchers obtained data from the National Inpatient Sample of women who received both autologous free flap and implant-based reconstructive surgery.

Researchers collected data on demographics, breast reconstruction rates, complications, inpatient cost and implicit association test (IAT) score by region.

Overall, most women in the cohort were white (n = 38,487; mean age, 52 years), whereas others belonged to minoritized racial and ethnic groups including American Indian, Asian, Black and Hispanic women (n = 13,628; mean age, 49.7 years). Most women in the cohort were privately insured (76%) and received implant-based breast reconstruction (72%).

The correlation between IAT score and breast reconstruction utilization rate for white women to women belonging to racial and ethnic groups was 0.1 for all regions including the New England, Middle Atlantic, East North Central, West North Central, South Atlantic, East South Central, West South Central, Mountain and Pacific regions (P = .74). For complications, the correlation between IAT score and breast reconstruction complication rate ratios for all regions was 0.1 (P = .81). Finally, the correlation between IAT score and mean breast reconstruction cost of care for all regions was –0.1 (P = .81).

Researchers observed differences in the white-to-minoritized race and ethnicity utilization ratio among all studied regions. The breast reconstruction utilization ratio was highest in the East South Central regions including Alabama, Kentucky, Mississippi and Tennessee and lowest in the West South Central regions including Arkansas, Louisiana, Oklahoma and Texas (2.17 vs. 0.75).

“Efforts from individual institutions and national surgical organizations are needed to provide culturally competent, evidence-based care to individuals of all racial and ethnic backgrounds,” the researchers wrote. “Qualitative research is an important next step in identifying all the barriers contributing to the observed variation, as it will help guide policy focused on tackling both patient and system-based factors contributing to variation in breast reconstruction care.”