Mastectomy hospital stays brief Md. breast surgery patients often sent home the same day

November 15, 1996|By Jonathan Bor | Jonathan Bor,SUN STAFF

Driven by insurance rules and new attitudes toward recovery, Maryland hospitals are limiting most mastectomy patients to an overnight stay or an outpatient routine that has women going home hours after surgery.

A decade ago, women were hospitalized for up to a week after having a cancerous breast removed. It was a time for nurses to check drains and dressings, and for patients to begin recovering from an operation that can be painful and disfiguring.

But in an era when hospitals do outpatient hernia repairs and discharge patients a day after gallbladder operations, they are preparing breast cancer patients to recover at home.

Dr. William Dooley, a surgeon who runs the breast program at the Johns Hopkins Oncology Center, said cost-conscious insurance companies are generally limiting cancer patients to a one-night stay after having a breast removed. Lumpectomy -- removal of a cancerous lump and nearby lymph nodes -- is limited to an outpatient procedure.

Some hospitals, including Hopkins and Greater Baltimore Medical Center, are also giving mastectomy patients the option of going home the same day. Nurses visit the patients the evening and day after surgery to ensure that they are healing properly and that they understand how to manage drainage tubes.

Some women have complained that even an overnight stay isn't enough to begin their physical and emotional healing, but some doctors contend that patients often do better when they leave the hospital quickly.

Dr. Lauren Schnaper, who runs the breast center at GBMC, said she pushes outpatient surgery for mastectomy patients because she believes it speeds recovery, not because of insurance limitations.

"My philosophy is that breast cancer surgery is more of a psychological trauma than it is a physical trauma," she said.

When patients go home the same day, "they are ensconced with their families in their own homes, in their own surroundings," Schnaper said. "They get a better night's sleep. The nurse comes into their environment and helps them deal with their environment rather than the hospital's."

She said the patients are encouraged to bathe and dress the next day, use their arms normally and even go out to eat if they feel like it. "They will be tired, but I feel this keeps them from being depressed," Schnaper said.

Dr. Francis Rotolo, a GBMC surgeon, said he lets patients decide whether to spend a night in the hospital or go home the same day. "Some feel more comfortable staying in the hospital overnight," he said.

Whatever their wishes, Maryland's breast cancer patients are unlikely to spend more than a night in the hospital unless they have complications. In Connecticut, two large insurers have gone even further, limiting uncomplicated mastectomies to an outpatient procedure.

Yesterday, a trade group representing managed-care organizations recommended that health plans allow overnight stays for mastectomies. The move by the American Association of Health Care Plans was aimed at defusing criticism and the possibility of federal legislation.

Last year, an estimated 7.6 percent of the 110,000 mastectomies performed in the United States were outpatient procedures, according to HCIA Inc., a Baltimore research company. That compares with 1.6 percent in 1991.

Linda Wilkinson, a 48-year-old Dundalk woman, went home from GBMC the evening after her lumpectomy in September. Soon, she will have the entire breast removed because of concerns that her cancer was more widespread than expected. She has chosen again to have outpatient surgery.

"I know I'd feel more comfortable at home," said Wilkinson, a patient of Schnaper's. "I feel that when you're in the hospital, all you have to do is worry about what's going on at home."

Not all patients share that view.

Pat Bloom, a school crossing guard in Columbia, said she felt "pushed out" after being discharged from a local hospital a day after her mastectomy. She said nurses did a poor job demonstrating how to manage her drains and that she was emotionally unprepared.

"After the operation, you're swollen, you're taped down, you don't move right," she said. "You feel like you can't hold anything. Nothing much was explained."

Marsha Oakley, president of the breast cancer support group Arm in Arm, said that at a meeting Tuesday, three women expressed fears about their pending operations. They were anxious about being discharged without adequate coaching or time to adjust.

"We are concerned that women are going home very quickly, not prepared to handle their incisions, their drainage tubes -- 24 hours after surgery, or less," she said. "Patients are very frightened and concerned."

Dr. Scott Graham, who runs the breast surgery program at the University of Maryland Medical Center, said he is not ready to welcome outpatient mastectomies. Women in his program spend the night, a precaution against infection or the lingering effects of anesthesia.

Hopkins' Dooley said an outpatient mastectomy saves insurers about $1,000 compared with a one-night stay. But he called that "a drop in the bucket" considering the many thousands spent on a woman's surgery, anesthesia, chemotherapy and other services.

Last year, 20 percent of Hopkins' mastectomy patients chose outpatient surgery when presented with the options. After they received instructions before surgery, the figure doubled.

This year, 60 percent to 70 percent of the hospitals' mastectomy patients are choosing to go home the same day.

Patients -- and the spouses of those who are married -- get advance training in the management of surgical wounds and preparation for the emotional ordeal, Dooley said.

"There is an amputation component to mastectomy," he said. "We feel that it's better to deal with it emotionally within the family long before you ever get to the operating room."

Pub Date: 11/15/96

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