Outpatient Mastectomy Research Articles

Utilization of Mastectomy and Reconstruction in the Outpatient Setting

Reconstruction rates after mastectomy have been reported to range from 25-40%; however, most studies have focused on patients treated in an inpatient setting. We sought to determine the utilization of outpatient mastectomy and use of breast reconstruction in Southern California. Postmastectomy reconstruction rates were determined from the California Office of Statewide Health Planning and Development database from 2006-2009 using CPT codes and similarly from an inpatient database using ICD-9 codes. Reconstruction rates were compared between the inpatient and outpatient setting. For the outpatient setting, univariate and multivariate odds ratios with 95% confidence intervals were estimated for relative odds of immediate reconstruction versus mastectomy alone. The percentage of patients undergoing outpatient mastectomy ranged from 20.4 to 23.9% of the total number of all patients undergoing mastectomy. Whereas immediate inpatient reconstruction increased from 29.2 to 41.6% (overall rate 35.5%), the proportion of outpatients undergoing reconstruction only increased from 7.7 to 10.3% (overall rate 9.1%). Similar to the inpatient setting, in multivariate analysis, age, insurance status, race/ethnicity, and type of hospital were significantly associated with the use of reconstruction in the outpatient setting. A substantial number of patients undergo outpatient mastectomy with low rates of reconstruction. Although the choice of an outpatient mastectomy may certainly represent a selection bias for those not choosing reconstruction, an increase in the use of outpatient mastectomy may result in decreases in the use of postmastectomy reconstruction.

Outpatient mastectomy clinical pathway.

144 Background: Many patients require hospitalization after mastectomy, predominantly for pain management and treatment of postoperative nausea and vomiting (PONV). In order to improve a woman's perioperative experience after mastectomy and facilitate mastectomy on an outpatient basis, we initiated a clinical pathway for perioperative management of unilateral mastectomy patients at Mayo Clinic Rochester. Methods: The clinical pathway consists of preoperative oral medications (celecoxib and gabapentin), preoperative ultrasound guided paravertebral block using bupivacaine, intraoperative anesthesia management with total intravenous anesthetic, and minimal use of long-acting opioids and postoperative acetaminophen and oxycodone. All patients are evaluated by the surgical team on the afternoon after surgery and if patients are recovering well are discharged on the day of surgery. The following morning, the surgical team telephones the patient to follow up on management of pain, nausea or vomiting, and drain output. Results: Eighteen patients have been treated on this clinical pathway. Mean age of patients was 66 (range 51-81). Majority of patients (n=16, 89%) underwent unilateral mastectomy with sentinel lymph node biopsy, with 1 patient undergoing bilateral mastectomy and 1 patient undergoing mastectomy and axillary dissection. All patients are evaluated by the surgical team on the afternoon of surgery. Fourteen patients (78%) were without evidence of hematoma or PONV, pain was well-controlled on oral medications and they were discharged on the day of surgery. On morning after telephone calls, pain scale ratings ranged from 1 to 3 and no patients verbalized complaints of nausea. Four patients (22%) treated on this clinical pathway required overnight observation in the hospital, one for urinary retention, two for pain control, and one for high sanguineous drain output. Conclusions: The clinical pathway presented provides preemptive analgesia and regional anesthesia for patients undergoing mastectomy, enabling the majority of patients to be discharged on the day of surgery. The clinical pathway is a safe and effective way to improve the perioperative experience of breast surgery patients and decrease hospital admission.

Spillover Effects of State Mandated Benefit Laws: The Case of Outpatient Breast Cancer Surgery

This paper examines the "spillover effects" of state laws that mandate inpatient coverage for breast cancer surgery. It looks at outpatient utilization of two types of breast cancer surgery among Medicare fee-for-service patients, who are exempt from state regulation. Using data from the Surveillance, Epidemiology and End Results cancer registries and Medicare claims, we performed difference-in-differences analyses of patients in nine states from 1993 to 2002. The analyses show that state laws had a significant impact on only the likelihood of outpatient mastectomy, which was reduced by five percentage points. Such a spillover effect may diminish the expected impact of federal coverage laws for inpatient breast cancer surgery, which have been proposed to achieve similar ends.

Outpatient Mastectomy and Breast Reconstructive Surgery

In the United States, post-mastectomy breast reconstruction is a state (all 51 jurisdictions) and federally mandated benefit. Outpatient mastectomy, which could lower use of breast reconstruction, may raise concerns about whether patients receive adequate post-mastectomy care. Using linked surveillance, epidemiology, and end results (SEER)-Medicare data, we identified Medicare fee-for-service women aged 65-69 years, diagnosed with early-stage breast cancer, and receiving unilateral mastectomy from 1998-2002. The corresponding surgery delivery settings were determined from claims data. The outcome of interest was reconstruction within 4 months of diagnosis. We used multivariable logistic regression models to examine the association of outpatient mastectomy with the likelihood of post-mastectomy reconstruction, controlling for patient's characteristics. Among the 3,419 patients in the sample, 717 (21%) patients received outpatient mastectomy. The proportions of patients receiving reconstruction were 13% for inpatient mastectomy patients and 4% for outpatient mastectomy patients. Outpatient mastectomy patients were younger and had less comorbidities than inpatient mastectomy patients. Multivariable regression analysis suggested that outpatient mastectomy patients were less likely to receive reconstruction (odds ratio = 0.247; 95% confidence interval (CI): 0.166-0.368). Additional analysis suggests that African American patients were less likely than white patients to undergo reconstruction (odds ratio = 0.515; 95% CI: 0.293-0.906) and that this ethnic difference was more manifest among patients undergoing inpatient mastectomies. This study shows that outpatient mastectomy was associated with lower use of breast reconstruction. A better understanding of choice of delivery setting of mastectomy with a focus on younger and minority breast cancer patients should be explored in future research.

Incidence of Complications in Outpatient Mastectomy with Immediate Reconstruction

Although breast surgery, including mastectomy, is increasingly being performed on an outpatient basis, skepticism remains about the safety of outpatient mastectomy with immediate breast reconstruction. Studies have demonstrated a psychologic benefit to outpatient breast surgery in addition to the clear financial benefit. We sought to determine whether or not the postoperative complication rate after outpatient mastectomy with immediate reconstruction is low enough to consider the procedure safe and effective. Charts were retrospectively reviewed for all patients who underwent outpatient mastectomies with immediate breast reconstruction at St Vincent's Comprehensive Cancer Center between December 2000 and June 2004. The presence or absence of postoperative complications was determined from records during the postoperative period and subsequent office visit. Of 29 outpatient mastectomies with immediate reconstruction performed on 28 patients (one had independent procedures on each breast), only one procedure (3%) required subsequent admission to the hospital (for bleeding). Other complications included three seromas, two cases of cellulitis requiring antibiotics, and one hematoma. The overall complication rate was 24% (7 of 29), with only 14% (1 of 7) of the complications requiring hospitalization. These results demonstrate that outpatient mastectomy with immediate reconstruction is a safe and effective procedure for carefully selected patients. The complication rates for our patient population are similar to those in other published reports on outpatient operations, most notably, those of outpatient mastectomy without immediate reconstruction.

The use and outcomes of outpatient mastectomy in Florida

Background: To identify patient characteristics associated with outpatient mastectomies and their outcomes. Methods: Patients diagnosed with breast cancer and treated with mastectomies in Florida in 1994 were identified from state discharge abstracts and the state tumor registry. The relationship between clinical/demographic characteristics and the odds of having an outpatient mastectomy was identified using multiple logistic regression. Outcomes were assessed by calculating the risk of being rehospitalized within 30 days of discharge. Results: Twenty percent of mastectomies were performed on an outpatient basis. Outpatient mastectomies were more likely to be performed on women who were older, who lived in higher income communities, or who were uninsured. Health insurance type was not associated with having an outpatient mastectomy. Women undergoing outpatient mastectomy were more likely to be readmitted within 30 days of discharge; however, the excess risk was very small (0.7%). Conclusions: The risks from outpatient mastectomy are small. Ongoing monitoring of outcomes and assessment of patient satisfaction are needed.

Trends and outcomes of outpatient mastectomy in elderly women.

Considerable public attention has focused on the use of outpatient mastectomy and has resulted in numerous legislative proposals to mandate a minimum hospital stay following mastectomy. To date, only limited scientific data are available regarding the use and the outcomes of outpatient mastectomy. The purpose of this study was to provide population-based information on trends and outcomes for outpatient mastectomy in elderly women. Medicare data for elderly women with fee-for-service coverage were examined for trends and regional variation in the use of outpatient mastectomy. Logistic regression was used to identify patient and provider characteristics associated with having an outpatient mastectomy, and outcomes were assessed by calculating the risk of being rehospitalized and the reasons for rehospitalization. From 1986 through 1995, the proportion of mastectomies performed on an outpatient basis increased from virtually 0% to 10.8%. Outpatient mastectomies were more likely to be performed on women with no coexisting health problems in hospitals that were for-profit or non-teaching or in large metropolitan statistical areas. Women undergoing outpatient mastectomy had substantially higher rates of rehospitalization within 30 days than women with a 1-day stay in the hospital. Both groups had comparable rates of rehospitalization for complications definitely related to their surgery. The percentage of women who required rehospitalization was low, and the actual number of women rehospitalized was relatively small. We conclude that the risks from outpatient mastectomy are modest, although ongoing monitoring of outcomes and assessment of patient satisfaction are needed.