Abstract # 257370
Impact of Patient and Operative Factors on 30-day Revisits
Following Outpatient Mastectomy
Jennifer Yu, MD1; Margaret A. Olsen, PhD, MPH2; Amy E. Cyr, MD, FACS1; Julie A. Margenthaler, MD, FACS1
of Surgery and 2Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO
PROCEDURE-RELATED 30-DAY REVISIT INDICATIONS (N = 694)
ABSTRACT
METHODS
Background
Improvements in perioperative care and communication have increasingly shifted breast cancer surgery
into the outpatient setting. Despite this trend, most women who undergo mastectomy are still admitted
as inpatients, and little data exists characterizing outcomes following outpatient mastectomy. We sought
to analyze patient and operative factors associated with 30-day revisits following outpatient mastectomy
in women with breast cancer.
Methods
We used the Healthcare Cost and Utilization Project State Ambulatory Surgery Database and State
Inpatient Database from 2006-2013 to create a cohort of women aged 18 and older who underwent
outpatient mastectomy for invasive breast cancer, breast cancer in situ, or history of breast cancer.
Descriptive statistics and logistic regression were used to analyze associations between clinical factors,
defined by ICD-9-CM and CPT codes and the Elixhauser comorbidity classification, and 30-day revisits.
Results
Of 3,944 women with outpatient mastectomy, 694 (18%) had an inpatient or outpatient encounter within
30 days postoperatively. Mean age was 56.8±13.3 years. Ninety-four percent (650/694) had undergone
unilateral mastectomy, with the majority either simple (344, 53%) or modified radical mastectomy (295,
45%). The most frequent complications requiring revisit were surgical site infection (64, 9%), hematoma
(40, 6%), and seroma (23, 3%), and the majority of revisits were ambulatory surgery or observation stays
(434, 63%). Multivariable logistic regression demonstrated significantly increased odds of 30-day revisit
with any reconstruction (OR 1.25, 95% CI 1.05-1.5), diabetes (OR 1.64, 95% CI 1.21-2.21), and regional
disease (OR 1.64, 95% CI 1.22-2.18). No significant differences were found in odds of 30-day revisit for
race, unilateral vs. bilateral procedures, or other comorbidities.
Conclusions
All-cause revisits within 30 days following outpatient mastectomy are infrequently related to surgical
complications. Women undergoing outpatient mastectomy were younger with relatively few
comorbidities. Analysis of outpatient interventions and unscheduled visits may provide additional
information regarding management trends for complications after mastectomy.
Data Source
•
Healthcare Cost and Utilization Project (HCUP) administrative data
•
State Ambulatory Surgery Database (SASD), State Inpatient Database (SID)
•
New York, 2006-2013
Study Design
•
Retrospective cohort
Patient Population
•
Women age 18 years and older
•
Diagnosis: breast cancer, breast carcinoma in situ, history of breast cancer
(174.0-.6, 174.8, 174.9, 233.0, V10.3)
•
Main procedure: mastectomy – unilateral or bilateral (19180, 19182, 19200, 19220, 19240, 19303-7)
•
Outpatient procedure status
Data Identification
•
Index procedure: Current Procedural Terminology (CPT) codes
•
Revisits: CPT and International Classification of Diseases (ICD-9) codes
•
AHRQ Elixhauser comorbidity classification6
Statistical Analysis
•
Descriptive statistics, multivariable logistic regression
RESULTS
•
•
•
•
Nearly 3 million women in the United States have a history of breast cancer, and annual US incidence
of breast cancer is likely to exceed 250,000 women in 20171
• Up to 40% of patients may undergo mastectomy for the primary treatment of breast cancer2
Postoperative inpatient admission following mastectomy remains a common practice, but
improvements in perioperative care have increasingly shifted mastectomy to the outpatient setting3,4
Slight increased risk of rehospitalization within 30 days following outpatient mastectomy compared to
short-stay (e.g. 1-day admission) mastectomy3,5
• Readmissions costly and possibly preventable
• Substantially increased cost of readmission involving a postoperative complication4
Unknown frequency of outpatient vs. inpatient encounters following outpatient mastectomy
• Lack of data regarding outpatient management of postoperative complications
Study Aim
 To investigate the impact of patient demographics and operative factors on 30-day revisits following
outpatient mastectomy for breast cancer
Inpatient
37.5%
30-DAY
REVISITS
Mean Age: 56.8 ± 13.3 years
30-day Revisit
(N = 694 [17.6%])
%
No 30-day Revisit
(N = 3250 [82.4%])
N
p-value
< 0.001
Race
White
Black
Hispanic
Asian or PI
Native American or Other
Primary Payer
Medicare
Medicaid
Private
Self-pay
Other
Mastectomy Procedure
Unilateral
Simple
Modified radical
Bilateral
Simple
Reconstruction
Implant
31.3
68.7
782
2468
24.1
75.9
75.5
9.9
5.7
1.9
7.0
2321
289
235
140
195
73.0
9.1
7.4
4.4
6.1
25.8
11.1
56.5
2.6
3.9
1173
294
1582
87
78
36.5
9.2
49.2
2.7
2.4
650
344
295
93.7
49.6
42.5
3078
1948
1084
94.7
59.9
33.4
44
41
6.3
5.9
172
163
5.3
5.0
0.7
6.3
3.6
1
1.3
0.4
2
0.9
1.7
2.2
1
0.9
SSI = surgical site infection
DVT/PE = deep venous thrombosis/pulmonary embolism
AKI = acute kidney injury
UTI = urinary tract infection
Odds ratio
95% CI
p-value
Reconstruction
1.25
1.05 – 1.50
0.01
History of diabetes
1.64
1.21 – 2.21
0.001
Regional disease
1.64
1.22 – 2.18
0.001
CONCLUSIONS
• All-cause revisits within 30 days following outpatient mastectomy are
infrequently related to surgical complications
• Women undergoing outpatient mastectomy are young with relatively few
comorbidities
888
27.3
Significantly increased odds of 30-day revisit with any reconstruction, history of diabetes, or
regional disease
• Limitations: code definitions and individual coder-specific assignment,
potential undercoding of diagnoses
ACKNOWLEDGMENTS
This work was supported by the National Cancer Institute at the National Institutes of Health (T32 CA009621 to J.Y.); The Center for Administrative Data Research is supported in part
by the Washington University Institute of Clinical and Translational Sciences grant UL1 TR000448 from the National Center for Advancing Translational Sciences (NCATS) of the National
Institutes of Health (NIH), Grant Number R24 HS19455 through the Agency for Healthcare Research and Quality (AHRQ), and Grant Number KM1CA156708 through the National Cancer
Institute (NCI) at the National Institutes of Health (NIH).
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0.02
31.6
0.4
2.3
2
• Further assessment of outpatient interventions and unplanned visits may
provide additional data regarding management trends for complications after
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4
•
< 0.001
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2.2
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0.01
518
68
39
13
48
Inpatient Revisit
%
Age
217
477
2.9
6
Outpatient
62.5%
30-day Revisits: 694 patients
≤ 50
> 50
Outpatient Revisit
Variable
Outpatient mastectomy procedures:
3,944 patients
N
8
MULTIVARIABLE ANALYSIS – CLINICAL CHARACTERISTICS
STUDY POPULATION CHARACTERISTICS
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