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Impact of Patient Primary Language upon Immediate Breast Reconstruction after Mastectomy
Alison P. Woods, Marianna V. Papageorge, Susanna W. de Geus, Andrea Alonso, Sing Chau Ng, Andrea Merrill, Michael R. Cassidy, Daniel S. Roh, Teviah E. Sachs, David McAneny, Jennifer F. Tseng, Frederick T. Drake
Surgery, Boston Medical Center, Washington, District of Columbia, United States

Objective: Surgical shared decision-making in patients who speak a non-English primary language is understudied. Our objective was to study whether non-English patient language has an independent association with surgeon/patient decision-making in complex situations, such as whether to undergo immediate breast reconstruction (IBR) after mastectomy. Design: Retrospective cohort study. Setting: Statewide administrative database. Patients: Females undergoing mastectomy identified from the New Jersey State Inpatient Database (2009-2014). Intervention: Mastectomy with or without IBR. Main Outcome Measures: Odds of IBR with a prespecified stratified analysis by reconstruction type. A conceptual model was constructed to identify potential confounders; final covariates were selected based on baseline between-group differences and significance in a multivariable model. Results: Of 13,846 discharges involving mastectomy, 12,924 (93.3%) specified English as the primary language, and 922 (6.7%) specified a non-English primary language. In total, 6517 (47.1%) patients underwent IBR, with 1838 (13.3%) autologous, 4114 (29.7%) implant-based, and 565 (4.1%) combination reconstructions. Among English-speaking patients who underwent mastectomy, 6178 (47.8%) underwent IBR, including 1763 (28.5%) autologous, 3868 (62.6%) implant-based, and 547 (8.9%) combination reconstructions. Among patients with a non-English primary language, 339 (36.8%) underwent IBR, including 75 (22.1%) autologous, 246 (72.6%) implant-based, and 18 (5.3%) combination reconstructions. Unadjusted results showed reduced odds of IBR overall (odds ratio [OR] 0.64, 95%CI 0.55-0.73), autologous reconstruction (OR 0.52, 95%CI 0.41-0.64), and implant-based reconstruction (OR 0.77, 95%CI 0.67-0.90) among non-English primary language vs. English primary language patients. After adjustment for patient-level covariates using a model including age, race, primary payer, and diabetes, this difference persisted among the autologous subgroup (OR 0.64, 95%CI 0.51-0.80) but not for IBR overall or the implant-based subgroup. A hierarchical model incorporating patient factors as well as hospital-level effects showed a difference only among the autologous subgroup (OR 0.75, 95%CI 0.59-0.98). Finally, the difference among the autologous subgroup persisted after adjustment for a community-level socioeconomic marker (whether income within the patient"s ZIP code was above or below state median) with OR 0.77, 95%CI 0.60-0.998. Conclusions: Non-English primary language was an independent risk factor for lower odds of immediate breast reconstruction with autologous tissue after adjustments for patient, hospital, and community-level factors. Focused efforts may be necessary to ensure that patients who speak a non-English primary language have access to high quality shared decision-making for breast reconstruction after mastectomy.


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