J. Yu1, M. Rendulic2, M. A. Olsen2, A. E. Cyr1, J. A. Margenthaler1 1Washington University,Surgery,St. Louis, MO, USA 2Washington University,Medicine,St. Louis, MO, USA
Introduction:
Despite advances in surgical technique and perioperative care, most women who undergo mastectomy for breast cancer are still commonly admitted as inpatients for pain control, perceived patient satisfaction, and closer monitoring for possible complications. However, even one night of inpatient admission represents a substantial cost burden to the patient and has not been shown to reduce the odds of 30-day postoperative complications. It is unclear which patients might be most suitable for same-day or outpatient mastectomy. We sought to assess patient factors in relation to the utilization of outpatient vs. inpatient mastectomy in U.S. women with breast cancer.
Methods:
Using the Healthcare Cost and Utilization Project State Ambulatory Surgery and Services Databases and State Inpatient Databases for California and Florida from 2006-2011, we analyzed clinical and demographic factors in women over age 18 undergoing unilateral mastectomy for invasive breast cancer, breast cancer in situ, or history of breast cancer. Clinical data assessment was performed using ICD-9 and CPT codes and the Elixhauser comorbidity index. Descriptive statistics were performed to analyze the relationship between patient factors and admission status after mastectomy.
Results:
Of 71,619 women who underwent unilateral mastectomy, 23,503 (33%) were treated as an outpatient and 48,116 (67%) were admitted as inpatients postoperatively. Significant geographic and temporal differences were clear: patients in Florida (9,440; 38%) were much more likely to have outpatient procedures compared to patients in California (14,063; 30%), and fewer outpatient mastectomy procedures were performed in 2010-2011 (6,350; 31%) compared to 2006-2009 (17,153; 33%). Outpatients were more likely to undergo simple mastectomy (OR 1.61 [95% CI 1.56-1.66]) and less likely to undergo modified radical mastectomy (OR 0.65 [95% CI 0.63-0.67]) or to have simultaneous implant or expander reconstruction (OR 0.77 [95% CI 0.75-0.81]). Women undergoing mastectomy as outpatients were also more likely to be younger (≤50 years), have private insurance, be Caucasian, and have fewer comorbidities (p<0.05).
Conclusion:
The utilization of outpatient mastectomy varies widely based on clinical and geographic factors. Patients with private insurance, fewer comorbidities, and limited disease who do not undergo immediate reconstruction are more likely to undergo mastectomy without inpatient admission. Assessment of short- and long-term patient outcomes may provide additional evidence to support outpatient mastectomy as a patient-centered and cost-effective approach for certain breast cancer patients.