Quality of Care for Mastectomy Patients Treated at VA Hospitals: Results from a National Study

Hynes DM, Weaver FM, Ippolito D. Quality of Care for Mastectomy Patients Treated at VA Hospitals: Results from a National Study. Paper presented at: Addiction Health Services Research Conference; 1999 Jun 1; Chicago, IL.

Research Objective: To explore and examine relationships between patient sociodemographic, preoperative risk, structure and process characteristics and clinical outcomes of patients undergoing mastectomies at VAMCs.Study Design: Using information collected from the Department of Veterans Affairs (VA) National Surgical Quality Improvement Program (NSQIP), we identified all mastectomy procedures (CPT codes 19120; 19125;19126;19160;19162;19180;19182;19200;19240) performed at VA facilities between October, 1992 and September, 1997. The NSQIP contains data on 62 preoperative risk and demographic characteristics, four process, and 23 outcome variables. We supplemented the NSQIP with data from the VA's Patient Treatment File for readmission data, pathology reports from sites, and facility characteristic data. Data from these sources were merged on patient identifiers and procedure date. Any hospitalizations that occurred within one year of the procedure were captured. Outcomes of interest include: postoperative length of stay, morbidity within 30 days (i.e., one or more of 21 complications monitored by the NSQIP), and any readmissions that occurred as a result of a complication of the procedure within one year post surgery. Complications were defined by an expert panel of surgeons who identified relevant diagnostic codes and assigned a time period within which the diagnosis would be considered a complication. Principal Findings: Over a six year period, VA performed 1,333 mastectomies (60% female; 40% male). For women, the leading indication for surgery was malignant neoplasm of breast (75%). Women were predominately white (80%), average age was 54.8 years, and only 28% were married. Preoperatively, 36% were smokers, 32% had a history of hypertension requiring medications, and 5% were frequent alcohol users. Surgical procedures for mastectomy included 4% radical, 28% modified radical and 67% partial mastectomy/lumpectomy or other. The mean length of stay was 4.2 days (sd = 6.0). For both men and women, within 30 days of the procedure, 8% experienced one or more of the 21 complications defined by the NSQIP. Logistic regression modeling of 30-day morbidity identified 5 significant predictors. Preoperative patient variables, including presence of diabetes, cognitive impairment, presence of wound infection, diagnosis of cancer, and longer operation times were associated with greater probability of morbidity (c-index = 0. 72). Hospital structural characteristics, including whether the VA hospital was a designated Women Veteran Comprehensive Health Care Center, were not significant predictors in the model. Additional modeling focusing on readmission outcomes is in process. Conclusions: Research on mastectomy outcomes have focused on single outcomes and limited examination of preoperative characteristics. This work examining multiple preoperative characteristics and outcomes indicates that risky health behaviors and poorer health status prior to surgery were significant predictors of 30-day morbidity.