105. Association of Housing Instability and Breast Reconstruction Outcomes in the US

PURPOSE: The influence of housing instability on health outcomes is gaining increasing attention. Previous work suggests poor surgical outcomes for patients experiencing housing instability; however, most of this focus is in the context of emergency surgery, where preoperative optimization is limited. Less is known about outcomes in the elective setting, specifically with patients undergoing breast reconstruction. To better understand the specific risk profile of breast reconstruction patients experiencing housing instability, we sought to compare the breast reconstruction outcomes among patients with and without coded housing instability. METHODS: This retrospective cohort study identified unilateral and bilateral female breast reconstruction patients 18 years and older using the 2012-2023 Pearl Diver Mariner national all-payer claims database. Patients were stratified by implant-based reconstruction and autologous reconstruction. Housing instability was operationalized using 6 International Classification of Diseases (ICD) -10 Social Determinants of Health Z-Codes addressing problems related to housing: homelessness; inadequate housing; discord with neighbors, lodgers, and landlords; residential institution problems; other related issues; and other associated problems. The primary outcome was three-month surgical complications (skin and soft tissue infections, hematomas, wound dehiscence, seromas, fat necrosis, and microvascular complications). Secondary outcomes included three-month medical complications (pneumonia, acute myocardial infarction, urinary tract infection, deep vein thrombosis, pulmonary embolism, and sepsis following a procedure) and 30-day readmissions. Descriptive statistics and multivariable logistic regression were used to assess the association of housing instability with complications. RESULTS: Of the 276,153 patients undergoing breast reconstruction, 351 (0.12%) had coded housing instability within three years before surgery. These patients were more likely to have chronic medical problems and be on Medicaid insurance. Implant-based reconstruction patients with housing instability experienced significantly higher rates of surgical complications (8.1% vs 13.7%; odds ratio [OR], 1.80; 95% confidence interval [CI],1.28-2.54; P<.001), medical complications (4.8% vs 14.4%; OR, 3.37; 95% CI, 2.41-4.72; P<.001), and 30-day readmissions (2.9% vs 7.9%; OR, 2.91; 95% CI, 1.88-4.50; P<.001). Autologous reconstruction patients with housing instability experienced significantly higher rates of medical complications (6.4% vs. 13.5%; OR, 2.30; 95% CI, 1.18-4.49; P=.02) and 30-day readmissions (7.1% vs. 17.6%; OR, 2.78; 95% CI, 1.53-5.07; P=.001). After adjusting for age, Elixhauser comorbidities, and coded tobacco use, diabetes, hypertension, and radiation within one year before breast reconstruction, there was only a significant difference in medical complications for implant-based reconstruction patients (adjusted OR, 1.63; 95% CI, 1.14-2.28; P=.005). CONCLUSION: Among patients in this all-payer national claims database undergoing breast reconstruction, patients with coded housing instability were at greater risk for complications and readmissions. After adjusting for patient factors, these differences largely disappeared. This suggests that optimizing modifiable risk factors such as tobacco use, diabetes, and hypertension before breast reconstruction could improve outcomes. These findings underscore the potential to improve outcomes for patients experiencing housing instability through pre-surgery optimization of modifiable risk factors. Once these risk factors are optimized, patients with housing instability can safely receive breast reconstruction.