Annelotte van Bommel

91 Organizational factors affect the use of immediate breast reconstruction Figure 2. Funnel plot demonstrating the variation in the use of immediate breast reconstruction for invasive breast cancer between hospitals in the Netherlands with and without case-mix correction for patient and tumor factors, combined with multilevel analyses to adjust for hospital factors. In the adjusted data; Case-mix correction performed for age, tumor type, clinical tumor stage, clinical lymph node stage, grade, multifocality and social economic state combind with multilevel analysis to correct for hospital organizational factors DISCUSSION It is known that various patient and tumor characteristics significantly affect IBR rates. 10 However, these characteristics were not fully responsible for the observed large hospital variation in the use of IBR following mastectomy in the current cohort. 10 Like other studies, we were able to show that hospital organizational factors such as hospital type, patient volume or presence and availability of a plastic surgery facility may additionally explain part of the hospital variation. 8–12 In previous research, Jagsi et al., demonstrated the influence of radiation therapy on the chance of receiving a reconstruction. 16 Although the focus of the current study was hospital characteristic, we performed an analysis to determine the possible influence of radiation therapy. This revealed similar results as demonstrated 95%Cl Observedvaluesfor districthospitals Adjustedvaluesfor districthospitals Observedvaluesfor teachinghospitals Adjustedvaluesfor teachinghospitals Observedvaluesfor universityhospitals Adjustedvaluesfor universityhospitals Observedvaluesfor cancerspecifichospitals Adjustedvaluesfor cancerspecifichospitals Number of patients undergoing a mastectomy (for invasive breast cancer) Percentage of patients undergoing an immediate breast reconstruction 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 0 100 200 300 400 500 600 700 5