National trends and regional variation in immediate breast reconstruction rates R. Jeevan* 1,4, J.C. Mennie* 1,2, P.-N. Mohanna2, J.M. O’Donoghue5, R.M. Rainsbury6, D.A. Cromwell 1,3 1Clinical Effectiveness Unit, The Royal College of Surgeons of England, 2Department of Plastic and Reconstructive Surgery, Guy’s and St Thomas’ NHS Foundation Trust, 3Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, 4Department of Plastic Surgery, Hey Children’s NHS Foundation Trust, Liverpool, 5Department of Plastic and Reconstructive Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne 6Department of Plastic Surgery, Hampshire Hospitals NHS Foundation Royal Hampshire County Hospital, Winchester, UK Correspondence to: Mr R. Jeevan, Clinical Effectiveness Unit, The Royal College of Surgeons of England, Lincoln’s Inn Fields, London WC2A 3PE, UK (e-mail: ). * Joint first authors ABSTRACT Background: Previous studies have identified variation in immediate reconstruction (IR) rates following mastectomy for breast cancer across English regions during a period of service reorganization, a national audit and changing guidelines. This study analyses current variations in regional rates of IR in England. Methods: Patient-level data from Hospital Episode Statistics was used to define a cohort of female patients who underwent primary mastectomy for invasive or in situ breast carcinoma in English National Health Service (NHS) hospitals between April 2000 and March 2014. A time series of IR rates was calculated nationally and within regions in 28 cancer networks. Regional IR rates before and
(NICE) published breast cancer guidelines which stated that surgeons should discuss reconstruction with all patients and that it should be available at the first surgical operation13. Revised NICE guidelines in February 2009 clarified that all women undergoing mastectomy should be provided with information about reconstruction, and that IR should be offered to all patients if not precluded by their fitness for surgery or an urgent need for adjuvant therapy14. Concurrent with these developments, a national prospective audit was undertaken in England to evaluate the offer and uptake of IR, and the outcomes of mastectomy surgery2. It collected data prospectively between January 2008 and March 2009, and reported an IR rate of 21 per cent, which compared favourably with a rate of 11 per cent observed between April 2005 and March 2006. The audit found substantial regional variation in reconstructive uptake across the English cancer networks, findings broadly consistent with a population-based study that examined the period between 2006 and 200915. This regional variation is undesirable and may have reflected different rates at which cancer networks’ referral pathways were being implemented16, and it could also be related to breast cancer services being audited17–19. The present undertook an analysis of the change in patterns of IR in the English NHS from April 2000 to March 2014. This time period includes the service reconfiguration that resulted from the NHS Cancer Plan, the publication of both sets of NICE guidelines, the national audit, and the publication and dissemination of its findings. A particular aim was to analyse whether the regional variation in IR rates was a transient phenomenon or remains apparent across England. Methods Patient population and data set This study used data extracted from the Hospital Episode Statistics (HES) database of the English NHS20. The database captures information on all patients’ hospital admissions, including both sociodemographic and clinical data (such as diagnoses and operative procedures). Patients are allocated a unique pseudonymized identifier (HESID) that allows their admission history to be tracked over time.
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