Drive Through Mastectomies
Drive Through Mastectomies
ABSTRACT & COMMENTARY
Synopsis: Medicare data from 1986-1995 were reviewed for the incidence of outpatient mastectomy and to determine rates of rehospitalization in comparison to rates for patients after traditional inpatient surgery. The number of mastectomies (both simple and modified) rose dramatically during this period, and, in 1995, about 10% of all cases were done as outpatients. Geographic diversity was striking, with surgeons in 22 states performing less than 5% of their mastectomies as outpatients, whereas two states (Florida and Arizona) accounted for 23% of all of the outpatient mastectomies. Rehospitalization rates were greater for those operated on as outpatients when compared to those who had a one- or two-day post surgery hospital stay, but the numbers were small (4%).
Source: Warren JL, et al. J Natl Cancer Inst 1998;90: 833-840.
In all of medicine, efforts to reduce health care costs have been leading to shorter hospital stays and more outpatient care over the past decade. One example is the increasing use of outpatient mastectomy for patients with newly diagnosed breast cancer. In this report, all Medicare reimbursements for mastectomy from 1986 through 1995 were examined to determine the rates of outpatient surgery, the characteristics of the community in which this approach is taken, and the incidence of rehospitalization within seven or 30 days following discharge from either the outpatient surgery clinic or hospital. In 1995, approximately 10% of all mastectomies were done as outpatients. Enormous geographic diversity was noted, with outpatient operations occurring more frequently in those states where there is a greater penetration of "for-profit" hospitals and more metropolitan areas. Women undergoing outpatient mastectomy had substantially higher rates of rehospitalization within 30 days than women with a one-day hospital stay. However, women with longer hospital stays (3-6 days) were more likely to be readmitted than either those who had outpatient surgery or one-day hospital stays. Patient satisfaction and disease outcomes were not examined in the current study.
COMMENTARY
The Medicare data are good regarding reimbursement for mastectomy, and the data presented are likely to be complete and accurately reflect the trend toward more outpatient surgery for breast cancer. It is estimated that approximately 10% of mastectomies in Medicare recipients (those 65 years and older) were in the outpatient setting (4831 of 44,940 cases in 1995). However, almost half of the states (n = 22) reported that less than 5% of their mastectomies were performed as outpatients, whereas two states (Florida and Arizona) together accounted for 23% of all outpatient mastectomies in the United States. Black women, women with comorbidities, and those who were treated in teaching hospitals were less likely to have outpatient operations. However, for women treated in for-profit hospitals, the likelihood of outpatient surgery was 50% greater than for women treated in non-profit hospitals.
Those operated on in the outpatient setting were more likely to be rehospitalized at seven and 30 days after the operation, compared to those who stayed one day after surgery, but rehospitalization was greater for those who had even longer hospital stays. A wide range of factors may contribute to these differences, including the likelihood that those selected for outpatient surgery or discharged after one day had less comorbidity and were less likely to have complications. When Warren and colleagues examined for readmitting diagnoses suspected to be related to recovery from the surgical procedure (pneumonia, urinary tract infection, sepsis), the rates varied significantly by length of hospital stay. For women operated on as outpatients, the rate of readmission with these diagnoses was greater than those operated on as inpatients, with one or two postoperative days before discharge. The numbers of readmissions, however, were small (about 4% readmission, cumulative by 30 days).
Financial concerns are without a doubt fueling the trend toward outpatient mastectomy. In this regard, however, the Medicare data are interesting. The cost containment incentives are considered to be less influential in the fee-for-service sectors (such as Medicare) than in managed care operations. Nonetheless, hospitals may achieve greater reimbursement from Medicare (relative to costs) for the more limited approach, and this may explain the greater prevalence of outpatient mastectomy in the for-profit hospitals.
The Medicare data also report only on those older than 65 years. Outpatient surgery in younger patients may be even more prevalent, and with even lower readmission rates. However, big questions remain, including those related to patient satisfaction and clinical outcomes. Although in this regard, no data are available as yet about patient satisfaction and clinical outcome after outpatient mastectomy. However, when questioned after discharge following a short post-mastectomy hospital stay, a sizeable fraction of women had concerns about their hospital stay.1 Furthermore, the Medicare data demonstrated that patients selected for outpatient surgery had virtually no comorbidities. As the pressure to contain costs continues, a greater tendency to apply this approach to higher risk patients is likely, and this may result in higher rates of post surgical complications.
Thus, this interesting report is the beginning, rather than the final word on outpatient mastectomy. It is likely that, for selected patients, it will be a satisfactory and well-tolerated approach. However, we have much to learn regarding patient selection, patient satisfaction, and clinical outcomes, including breast cancer control and survival.
Reference
1. Burke CC, et al. Onc Nurs Forum 1997;24:645.
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