Thursday, November 29, 2012


Today, as I am running around the Grand Hyatt, hopefully gathering some wonderful information to share tomorrow, I am stepping well out of my comfort zone and BEING AN ADVOCATE.  I'm risking my relationship with an institution I hold very dear to me.  I hold everyone in such high regard, but the well-being of patients trumps all else.  And so.....

I recently learned there is a new policy in place regarding hospital stays post mastectomy.  It is not an insurance mandate. It's hospital policy at one hospital (that I know of at the moment) and, it appears it's being driven by fiscal concerns.  Can't stress this enough: I don't know how many hospitals are doing this, I'm just discussing what I learned about ONE hospital.

Breast cancer surgical patients will be discharged from the hospital 24 hours post surgery.  This includes bilateral mastectomy with placement of tissue expanders.  I had that surgery and I can assure you, there is NO WAY I was equipped either physically or mentally to be released from the hospital in 24 hours.

This is a No Exception Rule.  You are not permitted to cry to your doctor that you need just 12 more hours.  Unless there are obvious signs of infection, fever or uncontrolled vomiting, don't even bother trying.  No amount of pain, lightheadedness, nausea or anything else for that matter, is reason enough to forgo hospital policy.  No Exceptions.  That was made indisputably clear when the information was shared with me.

I am saddened by this and I am on many levels, outraged.  This is a major cancer center.  This is an institution whose fellows must participate in "talk training" before completing their fellowship.  Doctor patient communication is high on their list of priorities.  It is one of only a few formal training programs to teach new doctors what we lay folk call "bedside manner."  This is a hospital that has more programs available for current patients, former patients, caregivers of patients and the quality of those programs is like nothing I have seen or heard about, in any other hospital, from any of the other advocates with whom I speak.

This is a place where a holistic approach to care is not only embraced, it is encouraged.  Chairside acupuncture or reflexology during chemotherapy.  Appointments can be made with Reiki masters and massage therapists during a hospital stay.  And this care will be provided in your hospital bed.  Integrative medicine is so important, it is housed in its own building.  Patients who are post treatment can utilize the services (there is a fee for outpatient care) for as long as they like.  Guided meditation, yoga..... you get the picture.

I am involved in many different volunteer activities with several organizations.  I have met and collaborated with advocates from all over the world.  No, I'm not "all that" but in a world where social media affords us this opportunity, it's easy to connect with like-minded people and join forces for the greater good.

A few years ago, there was tremendous hype and equally vocal pushback to stop "drive through mastectomies."  Laws were passed in several states to compel insurance companies to step aside and allow doctors to do what was best for their patients.  Within those laws, the patient has an equal voice.  Some states mandate 48 hours.  New York is not one of those states.

The NYS law reads as follows:

"HMO's and insurers that provide coverage for inpatient hospital care must provide inpatient hospital coverage for a mastectomy.  After a mastectomy, a woman has the right to stay in the hospital until she and her doctor decide she is ready to go home."

And there's the catch.  In the world of empowered patients,  self advocacy, patient centered care, personalized medicine and patients as partners, the decision making process regarding what constitutes "ready to go home" involves only one person.  And, it's not even a person.  It's a policy.  A decision between a woman and her doctor which was previously dictated by insurance companies is now being dictated by hospital policy.

This is a gigantic backward step and it is a step being taken by one of the finest institutions in the world.  I am bitterly disappointed.  I learned of this policy a couple of weeks ago even though it was put into place two months prior.  I waited to get definitive information before sharing my disappointment.  Faced with a surgery that leaves us scarred physically and emotionally, likely still crippled with fear over a cancer diagnosis, staring at drains hanging from their bodies, women will now be told they don't get a voice in their own care which is their right under the laws of the state of NY.

If the woman says yes and the doctor says no in accordance with "hospital policy," I'm guessing the insurance company will have enough medical information to deny to cover the additional time.  In other words, leave quietly OR pay the bill OR spend the next several months fighting for coverage through the NYS appeal process.  That's just the thing to throw at someone who is physically compromised, emotionally drained and quite possibly facing chemotherapy.

I did not have to go far to read the writing on the wall and it is crystal clear.  Some policy decisions may be driven by cost and that most certainly appears to be the case with this policy.  We have once again, ceased being women with diseases that require what most of us see as radical treatment.  Instead, we are ONCE AGAIN, tied to that financial bottom line.

As my heart sank for those whose care, in my opinion, is being compromised by "policy" THIS hit my medical feed:

From Medical News Today, the title of the article?

Over 40% Of Post-Op Complications Occur Following Discharge

I cut and pasted the article exactly as it appeared on my screen.  In other words, where there is bold type or any other emphasis, that is not MY emphasis.  It is the opinion of the writer.  The part that is most upsetting?  When they examined the TYPES of procedures where complications occurred, 78.7% of breast procedures had post discharge complications.  I get it.  They are playing the numbers.  I'm sure they examined their own incidences of post-op complications before boldly (and quietly) instituting a policy that I find rather distasteful.  I am not raging against the machine because I'm secretly hoping that sticking to the point without going over the top might open a dialogue.  And I'm secretly hoping this new policy will be revisited and revised so that breast cancer patients can continue to receive the type of care that is consistent with one of the finest cancer hospitals in the world.

And now, the article which I hope will bolster the case to rethink what I believe is an AWFUL decision, in its entirety:

A new US study finds that over 40% of complications after general surgery procedures arise after patients have been discharged, with three quarters occurring within the first two weeks of leaving hospital. At least one expert suggests the study highlights the importance of focusing on patient needs and calls for insurers to invest the proposed savings they would make into research for safer surgery.

Lead author Hadiza S. Kazaure, of Stanford University at Palo Alto in California, and colleagues, analyzed 2005 to 2012 data from the American College of Surgeons National Surgical Quality Improvement Program, and found, overall, 16.7% of general surgery patients experienced a postdischarge (PD) complication, and 41.5% of complications occurred postdischarge.

They write about their retrospective study online in the November issue of Archives of Surgery, a JAMA Network publication.
Postdischarge Period is Vulnerable Time
The period following discharge from hospital is a vulnerable time for surgery patients, and it can also be an expensive one for the healthcare system when patients have to go back into hospital because of a complication related to the procedure.

In their background information the researchers refer to the Patient Protection and Affordable Care Act, which says one of the targets to save costs is to reduce avoidable postdischarge hospitalization.
The Study
For their study, Kazaure and colleagues examined postdischarge (PD) complications that occurred within 30 days of leaving hospital in 21 groups of inpatient general hospital procedures. They were particularly interested in the types of procedure, the rates and the risk factors for PD complications.

The data they used covered 551,510 patients whose average age was nearly 55 years.

They found 75% of PD complications occurred within 14 days of leaving hospital.

They also note:

"We found that more than 40 percent of all post-operative complications occurred PD; approximately 1 in 14 general surgery patients who underwent an inpatient procedure experienced a PD complication."
Varied By Type of Procedure
When they ranked PD complications by type of procedure, at the highest end they found 14.5% were for proctectomy (surgery involving the rectum), 12.6% were for enteric fistula repair (abnormal passageway repair) and 11.4% were for pancreatic procedures.

When they looked within each type of procedure, they found 78.7% of breast procedures had PD complications, followed by 69.4% of bariatric, and 62% of hernia repair procedures.

For all procedures, they found surgical site complications, infections and blood clots (thromboembolisms) were the most common complications, while a complication while still in hospital increased the chances of having one after discharge (12.5% compared with 6.2% without an inpatient complication).
Re-operation Rates Higher
The researchers also note that patients with a PD complication had higher rates of re-operation (17.9% compared with 4.6% without a PD complication).

Death was also more likely within 30 days after surgery in patients with a PD complication (6.9% versus 2% without a PD complication).

And the highest rates of re-operation and death were among patients whose PD complication was preceded by an inpatient complication.
Need to Improve Quality in Inpatient General Surgery
The researchers conclude their study shows "PD complications account for a significant burden of postoperative complications and are an important avenue for quality improvement in inpatient general surgery".

They call for more research to develop and explore the usefulness of a cost-effective and "fastidious" postdischarge follow-up system for surgical patients.

Desmond C. Winter of St. Vincent's University Hospital, Dublin, Ireland, notes in an invited critique of the study published in the same issue of the journal, that every surgeon will read the paper from Kazaure and colleagues with interest, because "complications are the statistics that define us all".

He says the need to reduce disease is what drives the scientific evolution of surgery.

"Patient needs, not financial penalties, should be everyone's primary focus. Let us see further advancements in surgical care through research funded by the proposed insurer savings and together strive for safer surgery," urges Winter.

Written by Catharine Paddock PhD
Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today


  1. Agreed. I too would not have faired as well as I did after my bilateral if I had of been forced out of the hospital in 24 hours. My husband and family would not have been ready for that either. Luckily we don't have that policy here. Until the policy-makers are also breast cancer patients these types of uncaring decisions in an industry of caregivers will continue to happen I'm afraid. Thankful for patient voice advocates like you to push back and hopefully make an impact in future decisions.

  2. Please continue to fight for us! I am a doctor ally prepared nurse. You would think that I would have a problem free post double mastectomy experience. Not so! After the inimitable surgery with placement of tissue expanders I was back in the hospital at about 2weeks for revision of my incision due to tissue necrosis. Then about 3-4 weeks later for removal of the expanders due to infection. 3 surgeries in two months

  3. dear annemarie,

    though i have no personal experience with mastectomy surgery, i can never say never with st IV metastatic BC, even though i am now deemed NED. so i add my voice to yours. i am sickened and bewildered at such overt disregard for patient well-being, for patients who have had to or will at some future date be summarily discharged within 24 hours of a bilateral mastectomy. i thank you for alerting all of us to this untenable, inhumane, and seemingly unethical policy that heaps on such post-surgical risks for patients on top of the trauma and life-altering surgery they endure. keep us posted; and know you are appreciated for all you do to advocate for us.

    love, XOXO,

    karen, TC

  4. This policy was instituted in our hospital here more than 5 years ago. I was stunned beyond belief that 24 hours later I would be sent home after major surgery having my left breast removed!! We are not talking about a hang nail being removed a very significant body part taken.. As luck or bad luck the next morning I developed a fever. My fever spiked high 103.4 I was developing an infection . I had surgery on the Friday I didn't go home till the next Tuesday. The same after my second breast was removed.. I ended up staying nearly a week because I suddenly developed redness it was painful my breast was filling up with infection it wasn't draining fluid it was draining gunk.I ended up having my incision opened up again drained and packed with gauze. The last time my incision was opened up 4 inches..This infection lasted 5 weeks that i had to have opened 2 more times. Had I gone home the next day it could have gone septic.

    I don't know the moron who thought sending women home after major surgery was a brilliant idea. In fact she may end up coming back spending twice the time that was necessary.. It is just WRONG!!

    Love Alli xxx

  5. Thank you for highlighting this - I am shocked to read it. I was 10 days in hospital after my surgery - I could barely get out of bed after one day, never mind return home!

  6. I was also released less then 24 hours after a bilateral masectomy. Trying to ride home was terribly painful, every little bump made me cry out. My sisters and I had to try to care for me when I couldn't even lay down and get up in bed and had to try to sleep in a recliner for several nights. I ended up with drain problems (manual drainage for weeks after they were removed), and an infection. More importantly, I could barely walk or move at less then 24 hours, I belonged in the hospital!!!!

  7. Thanks for fighting the good fight. I only got a 24 hour stay at the hospital hotel after my bilateral mastectomy and tissue expander inserts. The next 3-4 days at home were pure hell. Thank you for being so tireless in your efforts. Sending you huge support! T xo

  8. My HMO does a 24 hour discharge as well, but a doctor can override it. Mine did as I was not getting good pain control, so I did have 2 days in-hospital post surgery.

    I have to say though, there are lots of studies that show a hospital is NOT the best place to heal from routine surgeries. You can't sleep, there are infectious diseases everywhere, and it's uncomfortable. After my c-diff experience, I would not take being in a place full of sick people and the chance of nosocromial infection lightly again.

    I only spent five days in the hospital after a liver resection too - that wasn't policy but it was a MUCH bigger, more painful surgery. I think I healed faster at home.

    I guess, in short, if a doctor can override this policy for health reasons, I really don't have a problem with it. I do have a problem if "no matter what" they make the patient leave but I suspect a misreading as that would be easy lawsuit territory.

    Social reasons are not good reasons to stay in a hospital and it's not what they are for. I did not get over the pain from my mastectomy for a couple of weeks - definitely don't think I belonged in the hospital though.

    1. I can state unequivocally that the policy is "no matter what" ... Specifically... the only things that will allow more than 24 hours are vomiting or a fever. Pain level can be at a 10. Unmanaged pain is not reason enough. That is where I have a problem and yes, easy lawsuit territory is exactly where they are positioned. This isn't an insurance issue. For the most part, the insurance companies automatically approve 48 hours in NYS. Beyond that, the doctor has to gain further approval.

      I completely agree with you about the infections and the lack of good rest but I DO remember how I felt after being under anesthesia for over three hours to complete a bilateral w/TE's. I remember how I needed help to move my upper body because the muscles were too tender. I remember how quickly I was able to get my act together, but it most certainly wasn't at the 24 hour point. I'd say, in my case, I was okay at the 36 hour point..... and that's the issue. Once you go into hour 25, it's Day Two and it's all about money. And that's just wrong. I could have and would have managed it if I only had one side done or I didn't have TE's but I had the whole thing. My upper body was out of commission for a long time.

      It's just a lousy policy...... I don't think it's unreasonable to say "maximum 48 hours" unless other things are happening. I'm not on board with 24 hours for both breasts and TE's. I think that went a step too far.


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