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Kristen Zarfos, M.D., FACS
Senior Attending, Middlesex Hospital, Middletown, Conn.
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YES
Physicians and surgeons take the blame for complications resulting from early discharge after a mastectomy, patients take the risks, and HMOs pocket the profits.
Until a year ago, the standard of care for a mastectomy was that the length of the hospital stay was based on the patient’s age, family situation, support system, tolerance of pain, how comfortable the patient is with drains, and other comorbid conditions.
Now some HMOs have decided arbitrarily-without consulting physicians or patients and with no supporting data-that the length of stay should be hours instead of days. No studies show it’s safe for a woman to go right home or, even if she can, that her needs for pain control, drain management, and emotional support can be met there.
Mastectomy is painful. A retrospective look at 100 charts in our hospital found that 90% of women who had mastectomies or lymph node removal needed IM or IV pain medication for 24 to 48 hours.
I surveyed 250 of my patients who’d had a mastectomy and lymph-node dissection, and 100% were outraged by the outpatient concept.
Women who undergo a mastectomy have two rubber drains that usually need to stay in for 48 hours. Most said they’d be afraid to empty the drains and worried about infection. I can tell a woman there is no increased risk of infection, but her perception is her reality.
HMOs say that physicians have the final word. Not so. When I challenged the denial of hospitalization for one of my patients, the HMO’s medical director said outpatient surgery was the standard of care in Connecticut for mastectomies and that the patient could have her pain controlled with pills. Neither was true.
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Steven R. Baker, M.D.
Health Care Consultant, Milliman & Robertson
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NO
Although ambulatory mastectomies are by no means for every patient, experience has shown that some patients and physicians, properly educated, are comfortable with them.
Still, physicians should make the final decision on the appropriate length of stay, a point that we emphasize in Milliman & Robertson’s Healthcare Management Guidelines.
We know of no studies that show how lengthy stays improve healthy outcomes of mastectomies, or how short stays worsen them. In uncomplicated cases, hospitals offer no advantage over ambulatory support.
The M&R guidelines presuppose an infrastructure in place to support the continuum of home care for any procedure, including mastectomies. Ahead of time, the procedure must be carefully discussed, questions answered, and concerns addressed. It is important to evaluate cases individually and train the patient in advance for specific postsurgery home care.
Some women are particularly concerned about infection. In our experience, physicians deal well with that prior to surgery. But if a woman remains uncomfortable with the idea of self-care, a home nursing visit should be scheduled.
A stay in the hospital does not necessarily mean better support. A woman at home is in more familiar surroundings, with family or friends who can help and support her.
Although large, detailed outcome studies don’t exist for ambulatory mastectomies, health plans and physician groups show no increase in readmission rates from complications. That’s not the whole outcome picture, but it suggests that women who elect ambulatory surgery do well.
The future most likely will see shorter hospital stays for a variety of procedures, to the benefit of the patient and the health-care system.
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