May 2, 1988 - effect, were admitted from the recovery room after surgery and were discharged with .... (F.C.A.) and using actual cost data, we could examine.
Economic Impact of Reducing for Mastectomy Patients
Hospitalization
MICHAEL J. EDWARDS, M.D., J. RALPH BROADWATER, M.D., JOHN L. BELL, M.D., FREDERICK C. AMES, M.D., and CHARLES M. BALCH, M.D. In 1985, two policies designed to reduce hospitalization charges for mastectomy patients were instituted at the M.D. Anderson Cancer Center at Houston. The first was a policy of "same-day" admissions for elective surgery patients, and the second was early postoperative discharge for mastectomy patients with suction catheter drains in place. The economic savings resulting from these policies was analyzed by comparing demographics, operation, stage of disease, hospital stay, hospital charges, and complications for two groups of patients. Fifty-nine consecutive mastectomy patients treated between 1983 and 1984, before these policy changes, had "standard management" consisting of hospital admission 24 hours before surgery and discharge only after the surgical drains were removed. Sixty-one consecutive mastectomy patients treated between 1986 and 1987, after these policy changes went into effect, were admitted from the recovery room after surgery and were discharged with drainage catheters in place, usually within 72 hours. All operations were performed by the same faculty surgeon as a representative experience of the General Surgery faculty. The average hospital stay was reduced from 10.5 to 43 days. A mean 39% reduction in hospital charges (from $4867.00 to $2981.00) was achieved by instituting the policies of "same-day" admission and early postoperative discharge with drainage catheters in place. Complication rates were not changed. Implementation of this policy resulted in an estimated savings of $750,000.00 in the hospital care of approximately 400 patients treated at the M.D. Anderson Cancer Center at Houston each year. Adjustments in patient care delivery systems from a predominantly inpatient to an outpatient setting required changes in outpatient nursing responsibilities (although not in new personnel). Patient education and written instructions for home care of surgical wounds and drainage catheters were essential for implementing an early discharge policy. With these facts in mind, hospital admission on the day of operation and early postoperative discharge with drainage catheters in place should be the goal for most mastectomy patients. Presented at the 108th Annual Meeting of the American Surgical Association, San Francisco, California, May 2-4, 1988. Reprint requests and correspondence: Charles M. Balch, M.D., UT M.D. Anderson Hospital and Tumor Institute, 1515 Holcombe Blvd., Box 112, Houston, TX 77030. Submitted for publication: May 5, 1988.
From the Department of General Surgery, Division of Surgery at the University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute, 1515 Holcombe Boulevard, Houston, Texas
I INCREASING HEALTH CARE COSTS (especially hospi-
tal costs) have placed a burden on patients, insurance carriers, the government, and employers. The surgical community has intensified its efforts to reduce hospital charges, and insurance carriers have implemented financial inducements to reduce both the cost and duration of hospitalization. During the years 1983-1986, for example, the length of hospital stay nationally for mastectomy patients was reduced from 8.8 to 5.5 days.* Although these changes from inpatient to outpatient care are an important step in reducing hospital charges, such policies should not compromise the quality and outcome of surgical care. In 1985, the Department of General Surgery at the University of Texas M.D. Anderson Hospital Cancer Center at Houston instituted two changes in the perioperative management of patients undergoing major breast surgery: "same-day" admission and early discharge with drains in place. Prior to 1985, patients undergoing total or segmental mastectomy (each with axillary lymph node dissection) had "standard management" consisting of hospital admission the day before operation for preoperative screening tests and anesthesia consultation. After surgery, wound suction catheters were removed when drainage decreased to 40 ml over a 24-hour period or after 12-14 days, whichever came first. Patients generally were not discharged with drain* Source: Commission on Professional and Ann Arbor, Michigan.
330
Hospital Activities,
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REDUCED HOSPITALIZATION FOR MASTECTOMY PATIENTS
catheters in place. Since September 1985, mastectomy patients have been admitted to the hospital on the day of surgery ("same-day" admission) and discharged early, with drains in place. These policies to reduce hospital stay were implemented so that most elective surgery patients received their entire preoperative evaluation and anesthesia consultation as outpatients, and they were admitted to a hospital bed from the recovery room after surgery. Early discharge was encouraged as soon as the patients began eating, were ambulatory, had adequate pain control, and had no special nursing care requirements. Patients were carefully instructed by surgeons and nurses about proper catheter drain care and wound management so that they could be discharged with drains in place. Written instructions were given, including a 24-hour telephone number if assistance was needed. Not all patients were able to use this approach, generally because of logistical, language, or educational reasons. At home, patients recorded the amount of wound drainage. Whenever the catheter drainage decreased to 40 ml or less over a 24-hour period, the patients came to the outpatient clinic to have their drains removed. age
Patients and Methods The hospital records of 120 patients who had major breast surgery by the same surgeon were retrospectively reviewed. Two time periods were selected. The first was an 18-month period (during 1983-1984) during which mastectomy patients received "standard management." The second was an 18-month period (during 1986-1987) during which patients were managed by "reduced hospital stay," as outlined above. By comparing two groups of patients treated by the same surgeon (F.C.A.) and using actual cost data, we could examine the economic impact of reduced hospital stay and the incidence of complications. Patients managed in 1985 were excluded from the analysis because this was a transition period when "same-day" admission and early discharge policies were still in the process of being implemented. The operative technique was the same throughout both time periods. The skin incision was made with the scalpel into the deep dermis. Skin flaps were raised using electrocautery. Meticulous hemostasis was maintained throughout the procedure. A total mastectomy included the pectoralis major fascia. The extent of axillary dissection was determined by the clinical stage of the patient. Patients with clinical Stage I or II breast cancer received a standard modified radical mastectomy or segmental mastectomy. For those undergoing modified radical mastectomy, a total mastectomy and complete axillary dissection (Level I, II, and III nodes) was performed.
331
Using cautery, lymphatic tissue-anterior and inferior to the axillary vein was dissected, and the branches were ligated with 4-0 silk. The long thoracic nerve and thoracodorsal neurovascular bundle were isolated and preserved. Patients who were candidates for breast conservation surgery and radiation had a segmental mastectomy. The tumor was excised with a 1-cm margin of normal breast tissue. An axillary dissection was performed through a separate axillary incision. Patients with advanced lesions (Stage III and IV) had a total mastectomy with lateral axillary dissection if their upper axillary nodes were not enlarged. The lateral axillary dissection was defined by removal of all lymphatic contents from the lateral border of the pectoralis minor to the anterior surface of the latissimus dorsi below the axillary vein. Two quarter-inch closed suction catheters were used after total mastectomy. These were placed through separate stab incisions at the base of the inferior skin flap and connected to suction. One drain evacuated the axilla; the other drained the chest wall. Patients undergoing segmental mastectomy had a single axillary catheter (however, no drains were used in the breast parenchyma). The subcutaneous tissue was closed with 3-0 suture, and the skin was approximated with staples. After surgery, a portable closed-container suction device was used that did not hinder ambulation. Prophylactic antibiotics were not used. After discharge, both groups of patients were managed in essentially the same manner during the two time periods, except that patients of the latter group cared for their wound drainage at home. Demographic data that were analyzed included age, sex, and clinical stage of the disease. Information relating to the operation included the length of procedure, estimated blood loss, number of drains, and type of operation. Information regarding hospital stay included admission date, surgery date, discharge date, and the number of days the drainage catheters remained in place. Complications that were analyzed included seroma, wound necrosis, postoperative hematoma, and infection. A seroma is defined as any fluid collection requiring aspiration from the axilla or chest wall. Wound necrosis is defined as any skin loss requiring therapeutic intervention (i.e., administration of topical antibiotics, debridement, or dressing changes). Wound infection is defined as clinical signs of infection requiring antimicrobial therapy. Also identified were patients who had prolonged hospital stay or delay in starting adjuvant treatment. Reasons for prolonged hospital stay were tabulated separately. Total hospital charges, excluding professional fees, were obtained through the hospital Credit and Collections Office. The hospital charges of 1983-1984 were adjusted upwards by 12% to account for actual increases
332
EDWARDS AND OTHERS
Ann. Surg. * September 1988
50r0
0 1983-84 * 1986-87
401
X
*
CU._ 0
30[
'E I-
201
CL
1983-84 1986-87
lo0
a (U to
5
2Ei
10[ 3
mI IV
11
FIG. 1. Distribution of clinical stage for mastectomy patients treated before and after reduced hospital stay was implemented.
in charges that occurred by the 1986-1987 period so that they could be directly compared. Data was analyzed, using D-Base III Plus on an IBM-PC." Statistical analysis was performed with SPSS-PC + .. Significant difference between groups was tested, using the MannWhitney test. The following null hypotheses were tested: 1) there is no significant difference in duration hospital stay between the 1983-1984 patients and the 1986-1987 patients; 2) there is no significant difference in hospital cost between the 1983-1984 patients and the 1986-1987 patients; and 3) there is no significant difference in complications after mastectomy between "standard management" patients and "reduced hospital stay" patients.
Results The average age for patients of both groups was 54 years. The clinical stage of disease was similar for both groups (Fig. 1). The proportion of Stage I patients (47%) in the standard management group was virtually the same as in the reduced hospital stay group (44%). The distribution of various procedures among the two * 1983-84 0
* 1986-87
801 0
0
601
L.
40[
28
0 I-
20[ 8 nL
INX
Bilateral
Total
Segmental
FIG. 2. Distribution of patients in the two periods according to the type of mastectomy.
0
erations
Total Mastectomy
Segmental Mastectomy FIG. 3. Hospital stay for the two periods, comparing the entire group of patients and subgroups according to type of mastectomy.
similar, with the exception of an increase in breast conservation procedures in the later time period (Fig. 2). Hospital stay was decreased for all patients and for the subgroups undergoing total and segmental mastectomy (Fig. 3). Mean hospital stay was 10.5 days for the "standard management" patients and 4.3 days for the "reduced hospital stay" patients (p < 0.001). When the data was subgrouped according to the type of operation, "standard management" patients undergoing modified radical mastectomy had a mean hospital stay of 10.8 days, whereas reduced hospital stay patients had a mean of 4.9 days (p < 0.001). For those patients having segmental mastectomy, the mean hospital stay was 8.0 days in the standard management group and 2.8 days in the reduced hospital stay group (p < 0.01). Early discharge was defined as discharge by the fourth postoperative day. However, we were unable to achieve either early discharge or "same-day" admission in one quarter of the patients. Of 61 patients ofthe 1986-1987 group, 46 (75%) were admitted on the day of operation. Early discharge was likewise achieved in 46 (75%) patients (Fig. 4). Prolonged hospital stay (>4 days) was due largely to underlying chronic illness, insufficient patient education, language barriers, or not having a care partner at home (Table 1). Hospital charges were obtained for all patients (Table 2). The actual mean hospital charges for mastectomy patients treated during the 1983-1984 period was $4345.00. This was adjusted for a 12% increase in charges due to inflation to $4867.00 for comparison purposes. Average hospital charges for mastectomy patients treated during 1986-1987 were $2981.00. Thus, a mean total savings of$ 1886.00 per patient was achieved through the policies of "same-day" admission and early postoperative discharge with drainage catheters in place. Complication rates were not significantly different between groups (Fig. 5). For example, the incidence of seroma was 22% in the "standard management" group groups was
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REDUCED HOSPITALIZATION FOR MASTECTOMY PATIENTS
333
TABLE 2. Cost Analysis of Hospital Charges for 120 Mastectomy Patients 4C
401
Median Charges ($) (Range)
30[ 'a 0
1983- (N = 59) actual
201
3,752 (612-9,705) adjusted* 4,202 (685-10,870) 1986-87 (N = 61) 2,733t (659-11,029) Savings/patient
16
I--l
10o 0O
