New research shows the majority of Kaiser Permanente Northern California mastectomy patients now go home on the same day with no added risk of post-surgical complications.
Brooke Vuong, MD, lead author of Annals of Surgical Oncology study
“Patient comfort is a big part of this initiative,” said Brooke Vuong, MD, lead author and cancer surgeon at Kaiser Permanente’s South Sacramento Medical Center. “Patients often want to go home. They can sleep in their own beds, and they have the ability to recover in their own familiar environment.”
Several years ago, Kaiser Permanente surgeons launched an integrated program of post-surgical best practices across the Northern California region’s 21 medical centers, to facilitate home recovery for most mastectomy patients with same-day discharge from the hospital.
Now a new study in Annals of Surgical Oncology, “Implementation of a Post-mastectomy Home Recovery Program in a Large, Integrated Health Care Delivery System,” shows that the rate of home recovery after mastectomy increased from 23% regionwide to 61% in the 6 months after the program started, with no significant changes in emergency-department visits, reoperations, or readmissions.
Gillian Kuehner, MD, senior author and surgeon with Kaiser Permanente Vallejo Medical Center
“This is the first large-scale study to evaluate an at-home recovery program for mastectomy patients,” said Gillian Kuehner, MD, senior author and surgeon at Kaiser Permanente’s Vallejo Medical Center. “We found that our Kaiser Permanente patients are grateful for the opportunity to recover safely at home.”
Preparing for at-home recovery
The Northern California region’s breast clinical performance team developed a new protocol for home recovery post-mastectomy, in coordination with Kaiser Permanente’s successful enhanced recovery after surgery (ERAS) program. The team included surgeons, breast care coordinators, anesthesia providers, and recovery nurses.
Margaret Mentakis, MD, co-author and surgeon with Kaiser Permanente South Sacramento Medical Center
“The team ensures that mastectomy patients are as well-prepared for recovering at home after surgery as they are going into surgery,” said study co-author and surgeon Margaret Mentakis, MD, of Kaiser Permanente’s South Sacramento Medical Center.
The protocol included:
- * Setting patient expectations for home recovery early.
- * Educating patients about managing drains and pain at home, with minimal use of opioid medications.
- * Collaborating with plastic surgeons on reconstruction techniques.
- * Standardizing timely follow-up with patients by phone or email after discharge.
“We make sure patients have excellent pain management and thorough pre-operative teaching, and that they know how to access their providers after hours,” Dr. Kuehner said. “We work closely with all members of the breast care team at every medical center to ensure that our patients are prepared.”
Evaluating outpatient mastectomies
To better understand how the surgical recovery program for mastectomy patients was working, the clinician-researchers looked at the 6-month periods before and after the program was implemented in October 2017.
The study included all mastectomies performed at 21 Kaiser Permanente Northern California hospitals, with and without reconstruction, for any reason except autologous tissue reconstruction, which uses tissue from another part of the body to reconstruct the breast. About 93% of mastectomy patients in the study had a cancer diagnosis.
Eighty-four surgeons performed 1,380 mastectomies during the 1-year study period; 24.9% of the mastectomies were bilateral and 31.5% underwent immediate reconstruction with implants.
Before the program, 22.9% of 717 mastectomies were outpatient, compared with 60.8% of 663 mastectomies afterward; there were no significant differences in rates of emergency department readmissions, reoperations, or readmissions.
New standard of care
“For a long time, standard practice has been for surgical patients to be admitted to the hospital post-operation and sent home the following morning,” Dr. Vuong said. “As surgeons, we visit our patients the next morning, and they’re ready to go. We thought, what’s the added benefit of staying overnight?”
Today, more than 85% of Northern California mastectomy patients are recovering at home after surgery. Mastectomy patients continue to be admitted to the hospital as-needed, including for anxiety, difficulty with pain control, or other post-surgical complications.
“This study was the proof of concept that home recovery is a safe option for the majority of our mastectomy patients,” Dr. Vuong said.
In addition to Drs. Vuong and Kuehner, study co-authors were Amanda N. Graff-Baker, MD, Sharon B. Chang, MD, Veronica Shim, MD, Michele Knox, MD, and Lucinda Romero, MD, all of The Permanente Medical Group; and Mio Yanagisawa, MD, of University of California, Davis, Health System.