Abstract
PURPOSE
As surgery rapidly moves to the outpatient setting, patients, patients and politicians are increasingly concerned over the quality of care. Until now, evaluation of outpatient quality has focused primarily on mortality, complications and readmission outcomes. For breast-conserving surgery, our objective is to broaden the analysis of quality to include the reason for surgery, and whether other indicated procedures occurred.
METHODS
Data are from the Healthcare Cost and Utilization Project at AHRQ, which collects all discharges from community hospitals and ambulatory surgery centers. Five states (CO, CT, MD, NJ, NY) and 7 years are included (1990–1996). The dataset includes all women undergoing inpatient and outpatient subtotal mastectomy (STMAS) and lumpectomy (LUMP) identified through ICD-9 coding. Age-adjusted rates/100,000 women are calculated. The diagnoses (reason for surgery) are categorized and compared across inpatient and outpatient settings. The proportion of benign (dysplasia and benign neoplasm) versus cancer diagnoses, and the proportion of women receiving recommended lymph node (LN) dissection are compared as well.
RESULTS
There has been a 16–46% increase in rate of STMAS and LUMP combined in each of five states, consistent with recommended guidelines. From 1990–1996, 95% of LUMPs are performed as outpatient procedures. Approximately 75% of the outpatient LUMPs have a benign diagnosis. Specifically, in 1996, 39,663 of 52,884 LUMPs had a benign diagnosis. This compares to inpatient LUMP, which carry a benign diagnosis <20% overall. Seventy percent of the benign diagnoses are fibrocystic disease (ICD-9 610). In CT, MD and NJ, over 70% of STMAS have been performed as outpatient procedures. In these same states, 50–60% of outpatient STMAS have a benign diagnosis compared to <5% of inpatient STMAS. Interesting, the rate of outpatient STMAS increased from 18% in 1990 to 70% by 1996 in CO. Coincident with increased outpatient use, only 10% of STMAS in CO have a benign diagnosis. For those LUMPs in 1996 with a cancer diagnosis, ∼80% performed inpatient had a LN dissection. This compares to 5–18% which received a LN dissection at the time of the outpatient LUMP. Similarly, in 1996, for those STMAS with a cancer diagnosis, ∼90% performed inpatient had a LN dissection. This compares to 10–66% which received a LN dissection at the time of the outpatient STMAS.
CONCLUSION
There are dramatic differences in the quality of care when comparing outpatient and inpatient breast-conserving surgeries. These differences may reflect incorrect coding, increased use and sensitivity of mammography, and fragmented delivery of care. Further analyses will identify and follow incident STMAS and LUMP cases, determine rates and reasons for repeat inpatient and outpatient encounters, and determine outcomes of care.