Outpatient Mastectomy: Factors Influencing Patient Selection and Predictors of Return to Care

Abstract

BACKGROUND: After implementation of the Surgical Home Recovery (SHR) initiative for mastectomy within a large, integrated health delivery system, most patients are discharged on the day of the procedure. We sought to identify predictors of SHR and unplanned return to care (RTC). STUDY DESIGN: Mastectomy cases with and without reconstruction from October 2017 to August 2019 were analyzed. Patient characteristics, operative variables, and multimodal pain management were compared between admitted patients and SHR patients using logistic regression. We identified predictors of RTC in SHR patients, defined as 7-day readmission, reoperation, or emergency department visit. RESULTS: Of 2,648 mastectomies, 1,689 (64%) were outpatient procedures and the mean age of patients was 58.5 years. Predictors of SHR included perioperative IV acetaminophen (odds ratio [OR] 1.59; 95% CI, 1.28 to 1.97), perioperative opiates (OR 1.47; 95% CI, 1.06 to 2.02), and operation performed by a high-volume breast surgeon (OR 2.12; 95% CI, 1.42 to 3.18). Bilateral mastectomies (OR 0.70; 95% CI, 0.54 to 0.91), immediate reconstruction (OR 0.52; 95% CI, 0.39 to 0.70), and American Society of Anesthesiologists class 3 to 4 (OR 0.69; 95% CI, 0.54 to 0.87) decreased the odds of SHR. Of SHR patients, 111 of 1,689 patients (7%) experienced RTC. Patients with American Society of Anesthesiologists class 3 to 4 (OR 2.01; 95% CI, 1.29 to 3.14) and African American race (OR 2.30; 95% CI, 1.38 to 4.91) were more likely to RTC; receiving IV acetaminophen (OR 0.56; 95% CI, 0.35 to 0.88) and filling an opiate prescription (OR 0.51; 95% CI, 0.34 to 0.77) decreased the odds of RTC. CONCLUSIONS: Surgeon volume and multimodal pain medication increased the odds of SHR. Within the SHR group, American Society of Anesthesiologists Class 3 to 4 and African American patients increased the likelihood of RTC. This study helps optimize patient selection and perioperative practice for successful SHR.

The Quest for Outpatient Mastectomy in COVID-19 Era: Barriers and Facilitators

“…Bilateral mastectomy was mainly an inpatient treatment: 8 patients underwent bilateral mastectomy of whom only 1 (12.5%) had an outpatient mastectomy. This is in line with earlier studies reporting 35% of bilateral mastectomies as outpatients resulting in lower odds of outpatient treatment (OR 0.70; 95% CI 0.54–0.91) [ 2 , 7 ]. All but one patient undergoing bilateral mastectomy were planned as inpatients before surgery.…”

“…Earlier studies reported no decrease in quality of patient care in patients receiving outpatient mastectomy. It does not affect postoperative complications or return to care, consisting of additional visits to the outpatient clinic or emergency department (ED), readmissions, and reoperations in comparison with inpatient mastectomies [ 1 – 3 , 7 – 10 ]. Advantages of outpatient treatment have been reported; recovery in a familiar environment improves patient satisfaction [ 3 ].…”

Care in the time of COVID-19: impact on the diagnosis and treatment of breast cancer in a large, integrated health care system

“…Comparisons of shorter-term outcomes such as emergency department (ED) visits and readmissions most likely were confounded significantly by pandemic-driven changes in ED workflows, hospital admission criteria, and patient reluctance to seek medical care. With these confounding factors and our historically low rate of complications [ 28 , 29 ], we felt it was unlikely that we could draw meaningful conclusions regarding such shorter-term outcomes. A second limitation is that comparisons between cohorts from the two time periods were not adjusted for potential confounders.…”

Implementation of Intraoperative Ultrasound Localization for Breast-Conserving Surgery in a Large, Integrated Health Care System is Feasible and Effective

“…To optimize the quality and consistency of KPNC breast care further, the Breast Surgery Group developed a process that consists of initiating pilot projects at one or a few facilities, sharing findings with the remainder of the Breast Surgery Group, and then implementing best practices throughout KPNC. Both the KPNC Mastectomy Surgical Home Recovery program 20 , 21 and the adoption of nonopioid postoperative regimens 19 are successful examples of this process.…”