Outpatient mastectomy: Clinical, payer, and geographic influences

Objective. To determine (1) the use of outpatient services for all surgical breast procedures for breast cancer and (2) the influence of payer and sta te on the use of outpatient services for complete mastectomy in light of st ate and federal length-of-stay managed care legislation. Data Sources. Healthcare Cost and Utilization Project representing all disc harges from hospitals and ambulatory surgery centers for five states (Color ado, Connecticut, Maryland, New Jersey, and New York) and seven years (1990 -96). Study Design. Longitudinal, cross-sectional analyses of all women undergoin g inpatient and outpatient complete mastectomy (CMAS), subtotal mastectomy (STMAS), and lumpectomy (LUMP) for cancer were employed. Total age-adjusted rates and percentage of outpatient CMAS, STMAS, and LUMP were compared. In dependent influence of state and HMO payer on likelihood of receiving an ou tpatient CMAS was determined from multivariate models, adjusting for clinic al characteristics (age < 50 years, comorbidity, metastases, simple mastect omy, breast reconstruction) and hospital characteristics (teaching, ownersh ip, urban). Principal Findings. In 1993, 1 to 2 percent of CMASs were outpatient in all states. By 1996, 8 percent of CMASs were outpatient in Connecticut, 13 per cent were outpatient in Maryland, and 22 percent were outpatient in Colorad o. In comparison, LUMPs were 78 to 88 percent outpatient, and by 1996, 43 t o 72 percent of STMASs were outpatient. In 1996, women were 30 percent more likely to receive an outpatient CMAS in New York, 2.5 times more likely in Connecticut, 4.7 times more likely in Maryland, and 8.6 times more likely in Colorado compared to New Jersey. In addition, women with Medicare, Medic aid, or private commercial insurance were less likely to receive an outpati ent CMAS compared to women with an HMO payer. Conclusions. LUMP is an outpatient procedure, and STMAS is becoming primari ly outpatient. CMAS, while still primarily inpatient, is increasingly outpa tient in some states. Although clinical characteristics remain important, t he state in which a woman receives care and whether she has an HMO payer ar e strong determinants of whether she receives an outpatient CMAS.