HMO stirs debate with push for mastectomies on outpatient basis

Patient education and support components net positive outcomes

When a Connecticut HMO last year encouraged outpatient mastectomies, women’s health clinicians were shocked. The move even prompted a legislative proposal that could result in a federal law mandating insurance coverage for at least 48-hour inpatient stays for mastectomies and 24-hour stays for lymph node dissections.

At press time, Rep. Rosa De Lauro’s (R-CT) Breast Cancer Patient Protection Act awaits reintroduction in the new congressional session. Originally introduced Sept. 28, 1996, the bill proposes coverage for minimum two-day stays for major breast surgery.

In a pre-emptive move, the Washington, DC-based American Association of Health Plans adopted a hands-off position. "We would look at legislation, but we’re inclined not to support it," says association spokesman Don White. The Association’s position states that a decision regarding inpatient or outpatient mastectomy "should be made by the woman’s physician after consultation with the patient."

"Legislating medical practice makes bad medicine," White says. "Lawmakers went to law school, not medical school."

While the proposed federal law doesn’t conflict with the Association’s position, "it sets a dangerous precedent," White says. "Medical technology and research progress swiftly, and the political process can’t keep pace."

Meanwhile, at St. Charles Medical Center in Bend, OR, clinicians watch the trends in breast surgery and will alter their current practice when they see sufficient evidence to warrant a change. At the moment, they are not receiving pressure from payers to perform outpatient mastectomies, says Cancer Program Director Peggy Carey, RN, BSN. "We’re not advocating them at all, and we hope outside forces won’t force us to do that," Carey says.

Current mastectomy practice at St. Charles involves at least a two-day hospital stay. "But maybe we’re just prejudiced, " Carey says. "We’re all looking for solid outcomes."

Patients prompt same-day surgery

In the wake of this controversy, you might be surprised to find that patients often fare better when they go home the same day they have surgery.

Outcomes favoring same-day departures have emerged over the past 31¼2 years at the Johns Hopkins Breast Center in Baltimore. It was patients — not payers — who nudged the clinicians toward shorter hospital stays, says center director William Dooley, MD.

"One night at 11 o’clock, a patient called me from her hospital bed," Dooley says. "She couldn’t get any sleep because there was so much activity on the ward. She said she had no nausea, her drain was functioning, and she could get more rest in her own bed. So I let her go home."

Although the clinicians had dramatically reduced post-mastectomy nausea and pain and patient surveys supported outpatient treatment, the staff worried about adequate emotional support if patients left the hospital so soon.

Once again, Dooley’s team sounded out patients through regular patient satisfaction questionnaires. "They told us that they and their families would rather have a lot of education before they’re admitted for surgery," Dooley says. "When they’re admitted, everyone’s busy with medical procedures. Patient teaching is rushed, and there’s little time to digest the information."

Consequently, patients and their families now attend an intensive half- to full-day education session a week before admission. It covers surgery, post-surgical care, and emotional issues. On hand are photo albums of patients whose mastectomies are in various stages of healing.

"This gives patients a better basis for making their decisions and choosing options," Dooley says. "They tell us the pictures make the process of breast removal and recovery more real to them."

Close to 80% of mastectomies at Johns Hopkins are performed as outpatient procedures, and infection complications are almost zero. Still, patients may choose between outpatient or inpatient care.

The staff encourage them to delay the decision until after surgery so the patient and her family caregiver(s) can base their choice on how they feel with the outcome of the surgery. Dooley adds that no patient may leave the recovery room until her drain is working perfectly. Outpatients may go to their own homes or one of five hotels near the hospital that routinely accommodate Johns Hopkins’ patients. Hospital emergency care is available within minutes.

Outpatients receive a visit from a Hopkins Homecare nurse and one from a Reach to Recovery volunteer. Volunteers are breast cancer survivors who go through rigorous screening and patient support training through the American Cancer Society’s Reach to Recovery program. They provide assurance on matters such as post-surgical mood swings and prostheses that best comes from a former patient. The nurses address medical concerns such as taking pain medications and resuming daily activities. Dooley notes that some patients and caregivers want time to themselves when they return to the hotel, so they determine when the nurse and volunteer will visit. He explains that during their visits, which last 60 to 90 minutes, the nurse and volunteer shower more undivided attention on a patient than she is likely to receive in 24 hours on a regular hospital unit.

In addition to one visit each from a nurse and volunteer, patients have 24-hour telephone access to physicians and nurses for any medical or emotional concerns for as long as they wish after they go home.

"As we’ve gotten better at troubleshooting ahead in the pre-education, patients use the hotline less," Dooley says, noting that they usually check out of the hotel the morning after surgery.

The center has faced only one potential readmission when a patient developed facial cellulitis where the eyelid tape had been applied during surgery, he says.

"When the call came, we were in the midst of a blizzard," Dooley says. "Otherwise we would have readmitted her immediately."

Under the circumstances, the hospital arranged for a visiting nurse from a community hospital near the patient to go to her house and start antibiotic treatment.

Lifestyle figures into care plan

Would outpatient mastectomy programs that lacked such strong family and community service components as those in the Johns Hopkins model work nearly as well?

"You can do darn near anything on an outpatient basis," observes Maxine Brinkman, BSN, director of Women’s and Children’s Services at Northern Iowa Mercy Health Network in Mason City and president of the Chicago-based National Association of Women’s Health Professionals. "But the kind of support those women are going to receive depends on their age and their network of family and friends," Brinkman says.

"We have elderly women living alone in rural areas where a single visiting nurse serves the whole county," says Brinkman. "I would want to know how those women would be cared for before sending them home." Factors such as lack of support buttress the arguments for individual care plans, according to Sharon Green, MHA, executive director of Y-ME National Breast Cancer Organization in Chicago, a nonprofit information, referral, and patient support organization. Y-ME’s toll-free hotline [(800) 221-2141] is staffed by breast cancer survivors.

"Our medical advisors see no clinical reason for hospital stays for most mastectomy patients, Green says. "When the Connecticut [HMO] incident hit the papers, our hotline got 4,000 calls. They didn’t oppose outpatient mastectomies; they opposed a precedent of payers dictating the terms of medical care."

By the same token, Y-ME would rather not see legislation shaping the terms of medical practice. "There ought to be flexibility," Green says. "When that doesn’t work, however, we’ll force [federal or state] legislation."

Carey supports a medical planning environment in which social, medical, and economic factors hold equal sway. "What are the trade-offs for outpatient mastectomies? Are we just shifting the costs to families and community agencies?" Carey asks. "We need to manage our cost reductions in a holistic way."