Outpatient Mastectomy: Factors Influencing Patient Selection and Predictors of Return to Care

Vuong, Brooke; Dusendang, Jennifer R.; Chang, Sharon B.; Mentakis, Margaret Ann; Shim, Veronica C.; Schmittdiel, Julie; Kuehner, Gillian

BACKGROUND: Following implementation of the Surgical Home Recovery (SHR) Initiative for mastectomy within a large, integrated health delivery system, most patients are discharged on the day of surgery. We sought to identify predictors of SHR and unplanned return to care (RTC). STUDY DESIGN: Mastectomy cases with and without reconstruction from October 2017 to August 2019 were analyzed. Patient characteristics, operative variables, and multimodal pain management were compared between admitted patients and SHR patients using logistic regression. We identified predictors of RTC in SHR patients, defined as 7-day readmission, reoperation, or emergency department visit. RESULTS: Of 2,648 mastectomies, 1,689 (64%) were outpatient and the average age of patients was 58.5 years. Predictors of SHR included perioperative IV acetaminophen (odds ratio (OR) 1.59, 95% Confidence Interval (CI) 1.28-1.97), perioperative opiates (OR 1.47, 95% CI 1.06-2.02), and operation performed by a high-volume breast surgeon (OR 2.12, 95% CI 1.42-3.18). Bilateral mastectomies (OR 0.70, 95% CI 0.54-0.91), immediate reconstruction (OR 0.52, 95% CI 0.39-0.70), and American Society of Anesthesiologists (ASA) Class 3-4 (OR 0.69, 95% CI 0.54-0.87) decreased the odds of SHR. Of SHR patients, 111/1,689 (7%) patients experienced RTC. Patients with ASA Class 3-4 (OR 2.01, 95% CI 1.29-3.14) and African-American ethnicity (OR 2.30, 95% CI 1.38-4.91) were more likely to RTC; receiving IV Acetaminophen (OR 0.56, 95% CI 0.35-0.88) and filling an opiate prescription (OR 0.51, 95% CI 0.34-0.77) decreased the odds of RTC. CONCLUSION: Surgeon volume and multimodal pain medication increased the odds of SHR. Within the SHR group, ASA Class 3-4 and African American patients increased the likelihood of RTC. This study helps optimize patient selection and perioperative practice for successful SHR.