HMO stirs debate with outpatient mastectomy push

Patient education and support components net positive outcomes

Health plans did an about-face earlier this year after attempting to impose limits on hospital stays for breast surgery patients. Payers quickly changed their minds on the issue following a public outcry. In the process, case managers seemingly took a slap in the face following allegations of widespread pain and danger linked to "drive-through mastectomies."

Lawmakers were quick to respond to the outpatient controversy. In Congress, HR 135 — introduced by Rep. Rosa L. DeLauro (D-CT) — and a companion bill, SB 143 — introduced by Sen. Tom Daschle (D-SD) — would ensure health plan coverage for 48 hours of hospital care following a mastectomy if the physician deems it necessary, and 24 hours following a lymph node removal.

A second set of bills — SB 249, introduced by Sen. Al D’Amato (R-NY), and its companion, HR 616, introduced by Rep. Susan W. Kelly (R-NY) — doesn’t set a minimum length of stay. Instead, the measure leaves open the time period to be decided by the physicians and their patients.

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 three 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, postsurgical 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 patients to delay that decision until after surgery so the patient and his or her caregivers 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 nearby hotels 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.

Volunteers provide assurance that best comes from a former patient, on matters such as postsurgical mood swings and prostheses. The nurses address medical concerns such as taking pain medications and resuming daily activities. Dooley explains that during the 60- to 90-minute nurse/volunteer visit, they 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.

Lifestyle figures into care plan

Would outpatient mastectomy programs that lack strong family and community service components like 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."

[Editor’s note: For more information on outpatient mastectomy programs, contact:

Lillie Shockney, director of quality assurance, Hurd Room 101, Johns Hopkins Hospital, 600 Wolfe St., Baltimore, MD 21287-5155. Telephone: (410) 955-2940. Fax: (410) 955-9156.]