Factors influencing postoperative length of hospital stay after breast cancer surgery

Differences in Time Burden across Local Therapy Strategies for Early-stage Breast Cancer

"Time burden" (time required during treatment) is relevant when choosing a local therapy option for early-stage breast cancer but has not been rigorously studied. We compared the time burden for three common local therapies for breast cancer: (1) lumpectomy plus whole-breast irradiation (Lump+WBI), (2) mastectomy without radiation or reconstruction (Mast alone), and (3) mastectomy without radiation but with reconstruction (Mast+Recon).

Methods

Using the MarketScan database, we identified 35,406 breast cancer patients treated from 2000 to 2011 with these local therapies. We quantified the total time burden as the sum of inpatient days (inpatient-days), outpatient days excluding radiation fractions (outpatient-days), and radiation fractions (radiation-days) in the first two years postdiagnosis. Multivariable regression evaluated the effect of local therapy on inpatient-days and outpatient-days adjusted for patient and treatment covariates.

Results

Adjusted mean number of inpatient-days was 1.0 for Lump+WBI, 2.0 for Mast alone, and 3.1 for Mast+Recon (P < 0.001). Adjusted mean number of outpatient-days was 42.9 for Lump+WBI, 42.2 for Mast alone, and 45.8 for Mast+Recon (P < 0.001). The mean number of radiation-days for Lump+WBI was 32.4. Compared with Mast+Recon (48.9 days), total adjusted time burden was 4.7 days shorter for Mast alone (44.2 days) and 27.4 days longer for Lump+WBI (76.3 days). However, use of a 15 fraction WBI regimen would reduce the time burden differential between Lump+WBI and Mast+Recon to just 10.0 days.

Conclusions

Although Mast+Recon confers the highest inpatient and outpatient time burden, Lump+WBI carries the highest total time burden. Increased use of hypofractionation will reduce the total time burden for Lump+WBI.

A Single-Institution Case Series of Outpatient Same-Day Mastectomy: Implementation of a Quality Improvement Project and Initiative for Enhanced Recovery After Surgery

Background: National data demonstrate a trend toward outpatient same-day mastectomy. The possible drivers of this change include the costs related to hospital admission and effective management of postoperative pain. We retrospectively analyzed our single-institution experience with outpatient same-day mastectomy that incorporates a multimodal pain management regimen.

Methods: We retrospectively reviewed the medical records of patients who underwent same-day mastectomy at a single academic hospital. All patients received a multimodal, perioperative pain management regimen consisting of the intraoperative administration of 1,000 mg of intravenous (IV) acetaminophen and 30 mg of IV ketorolac, combined with the operating surgeon performing a 4- to 5-level, midaxillary, intercostal nerve block using liposomal bupivacaine. All patients were discharged with a prescription for acetaminophen with codeine, along with options for nonnarcotic alternatives as needed for pain.

Results: We reviewed the data on 72 patients who underwent mastectomies: 11 (15.3%) bilateral and 61 (84.7%) unilateral. The average age was 57 years, and average body mass index was 30 kg/m². The average length of stay of 4 to 6 hours was a marked reduction compared to a 23-hour observational period or an inpatient hospital stay. The average follow-up was 20.1 weeks. Five patients presented to the emergency department (ED) within the 30-day postoperative period, with 2 patients (2.8%) requiring readmission to the hospital for non–pain-related issues. The other 3 patients (4.2%) were evaluated for specific pain-related issues but did not require admission and were discharged home from the ED.

Conclusion: Our data support outpatient same-day mastectomy incorporating a multimodal, perioperative pain management regimen as a safe and feasible treatment option. Potential additional benefits may include decreased oral opioid use and cost savings for the hospital.

Indications for readmission following mastectomy for breast cancer: An assessment of patient and operative factors

We investigated the impact of patient and operative factors on 30-day hospital readmission following mastectomy for breast cancer. Using the 2011 HCUP California State Inpatient Database, we evaluated readmissions in adult women undergoing mastectomy for invasive, in situ, or history of breast cancer. Clinical data assessment was performed using ICD-9-CM codes and the Elixhauser comorbidity index. Chi-square tests and logistic regression were used to analyze patient and operative factors and associations with 30-day hospital readmission. Of 6214 women undergoing mastectomy, 306 (4.9%) were readmitted within 30 days postoperatively, most commonly for surgical site infection (130, 42.5%) and hematoma (29, 9.5%). 30-day readmission was associated with increasing index length of stay (LOS), comorbidities, and non-private insurance (P < .05). Age, mastectomy type (unilateral vs bilateral, with vs without lymph node assessment), immediate reconstruction, and port placement during the index procedure did not significantly influence the odds of 30-day readmission. Multivariable logistic regression showed increased odds of readmission with index LOS > 2 days (OR 1.81, P < .01), metastatic disease (OR 2.16, P = .01), and Medicare insurance (OR 1.72, P < .01). Index LOS > 2 days, metastatic disease, and Medicare insurance are significant predictors of 30-day readmission following mastectomy for breast cancer. Surgical site infection and wound complications were the most common diagnoses requiring readmission and resulted in over half of readmissions in our study population at 30 days.

[Surgical management of breast cancer in outpatient versus overnight hospitalization: Satisfaction study]

OBJECTIVES

Breast cancer is the primary female cancer. In cancerology, it is essential to give to the patient some support. The advent of outpatient surgery optimizes the care path. This need for support of patients raises the question of its compatibility with the day surgery. The purpose is to compare the satisfaction of outpatients with those who stay overnight after surgery of breast cancer. MéTHODS: Patients who underwent breast conservative surgery were included. It is a mixed study, a quantitative, observational and prospective one using a satisfaction survey and a qualitative one which consisted on semi - directive individual interviews. We compared the satisfaction rate (highest marks).

RESULTS

There were 91 patientes, 38 in the ambulatory group and 53 in the overnight group. There was no significant difference in satisfaction between the two groups (P=0.18). The difficulties frequently highlighted by the patients during their stay were the organizational management, the lack of hospital comfort and the sometimes long wait. The need for human support was unanimous.

CONCLUSION

The satisfaction was excellent in the study. The mode of hospitalization does not seem to play a role here on satisfaction. This hospitalization mode can only be envisaged by providing sufficient human and technical resources. Enhanced recovery after surgery appears to be an alternative to outpatient surgery.

Short length of stay and the discharge process: Preparing breast cancer patients appropriately

OBJECTIVE

Breast cancer is the most common cancer among women worldwide, increasing the relevance of an efficient and successful care process. As length of stay (LOS) in the hospital decreases, patients' satisfaction with the LOS varies. We hypothesize that successful discharge planning can improve this evaluation.

METHODS

Data of 4,390 female breast cancer patients from a cross-sectional survey was analyzed. The data was collected in 2017 in 86 German hospitals. Logistic regressions were used to test hypotheses.

RESULTS

The majority of included patients rated their LOS as appropriate. However, patients who felt better prepared for discharge were less likely to rate their stay as too short. A longer stay in the hospital further decreased this likelihood. The effect of LOS was moderated by patient experiences with preparation for discharge.

CONCLUSION

As hospital LOS decreases, one challenge in allowing patients to feel sufficiently informed and ready to go home is the reduced time for face-to-face consultations. Our results indicate, however, that a strong and thorough discharge planning makes the actual number of days for LOS irrelevant for patient's rating of LOS.

PRACTICE IMPLICATIONS

The study results underscore the importance of ensuring the quality and thoroughness of the discharge process.

Parameter Heterogeneity In Breast Cancer Cost Regressions - Evidence From Five European Countries

We investigate parameter heterogeneity in breast cancer 1-year cumulative hospital costs across five European countries as part of the EuroHOPE project. The paper aims to explore whether conditional mean effects provide a suitable representation of the national variation in hospital costs. A cohort of patients with a primary diagnosis of invasive breast cancer (ICD-9 codes 174 and ICD-10 C50 codes) is derived using routinely collected individual breast cancer data from Finland, the metropolitan area of Turin (Italy), Norway, Scotland and Sweden. Conditional mean effects are estimated by ordinary least squares for each country, and quantile regressions are used to explore heterogeneity across the conditional quantile distribution. Point estimates based on conditional mean effects provide a good approximation of treatment response for some key demographic and diagnostic specific variables (e.g. age and ICD-10 diagnosis) across the conditional quantile distribution. For many policy variables of interest, however, there is considerable evidence of parameter heterogeneity that is concealed if decisions are based solely on conditional mean results. The use of quantile regression methods reinforce the need to consider beyond an average effect given the greater recognition that breast cancer is a complex disease reflecting patient heterogeneity.

Factors Affecting the Postsurgical Length of Hospital Stay in Patients with Breast Cancer

OBJECTIVE

Breast cancer is the most common malignancy and the most common cause of mortality in women worldwide. In addition to the increasing incidence of breast cancer, the length of hospital stay (LOS) after breast cancer surgery has been decreasing. Because LOS is key in determining hospital usage, the decrease in the use of hospital facilities may have implications on healthcare planning. The purpose of this study was to evaluate the factors affecting postoperative LOS in patients with breast cancer.

MATERIALS AND METHODS

Seventy-six in patients with breast cancer, who had been treated between July 2013 and December 2014 in the General Surgery Clinic of Dicle University, were included in the study. The demographic characteristics of the patients, treatment methods, histopathological features of the tumor, concomitant diseases, whether they underwent neoadjuvant chemotherapy or not, and the length of drain remaining time were retrospectively recorded.

RESULTS

There was a correlation between drain remaining time, totally removed lymph node, the number of metastatic lymph node, and LOS. LOS of patients treated with neoadjuvant chemotherapy was longer. The patients who underwent breast-conserving surgery had a shorter LOS. Linear regression analysis revealed that the drain remaining time and the number of metastatic lymph nodes were independent risk factors for LOS.

CONCLUSION

Consideration should be given to cancer screening to diagnose the patients before lymph node metastasis occurs. In addition, drains should be avoided unless required and, if used, they should be removed as early as possible for shortening LOS.

Pretreatment health measures and complications after surgical management of elderly women with breast cancer

BACKGROUND

Elderly patients with breast cancer are less likely to be offered surgery, partly owing to co-morbidities and reduced functional ability. However, there is little consensus on how best to assess surgical risk in this patient group.

METHODS

The ability of pretreatment health measures to predict complications was investigated in a prospective cohort study of a consecutive series of women aged at least 70 years undergoing surgery for operable (stage I-IIIa) breast cancer at 22 English breast units between 2010 and 2013. Data on treatment, surgical complications, health measures and tumour characteristics were collected by case-note review and/or patient interview. Outcome measures were all complications and serious complications within 30 days of surgery.

RESULTS

The study included 664 women. One or more complications were experienced by 41·0 per cent of the patients, predominantly seroma or primary/minor infections. Complications were serious in 6·5 per cent. More extensive surgery predicted a higher number of complications, but not serious complications. Older age did not predict complications. Several health measures were associated with complications in univariable analysis, and were included in multivariable analyses, adjusting for type/extent of surgery and tumour characteristics. In the final models, pain predicted a higher count of complications (incidence rate ratio 1·01, 95 per cent c.i. 1·00 to 1·01; P = 0·004). Fatigue (odds ratio (OR) 1·02, 95 per cent c.i. 1·01 to 1·03; P = 0·004), low platelet count (OR 4·19, 1·03 to 17·12: P = 0·046) and pulse rate (OR 0·96, 0·93 to 0·99; P = 0·010) predicted serious complications.

CONCLUSION

The risk of serious complications from breast surgery is low for older patients. Surgical decisions should be based on patient fitness rather than age. Health measures that predict surgical risk were identified in multivariable models, but the effects were weak, with 95 per cent c.i. close to unity.