Surgeon Perspectives on Determinants of Same-Day Mastectomy: A Roadmap for Implementing Change

Abstract

Background Same-day discharge after mastectomy without immediate reconstruction (MwoR) has been shown to be safe, with improved patient satisfaction when compared with patients discharged 1 or more days after surgery. Nevertheless, only 16% of patients undergoing MwoR in Michigan are discharged on the day of surgery, with significant variation between facilities (3–88%). Our objective was to explore determinants of same-day discharge and offer strategies for broader implementation of this practice. Methods We conducted semi-structured interviews with surgeons performing MwoR across the state of Michigan. Recruitment utilized purposeful and snowball sampling methods. The Tailored Implementation in Chronic Disease (TICD) framework was used to inform the creation of the interview guide. Interviews were transcribed and then analyzed using directed content analysis guided by the TICD framework. Salient determinants were organized into patient, provider, and system-level factors. Results Participants ( n = 26) included general surgeons, breast surgeons, and surgical oncologists. Most surgeons ( n = 18, 69%) reported that they discharged fewer than 60% of patients the same day after MwoR. The most common barriers included patient knowledge at the patient level; awareness of evidence, surgeon dogma, and peer influence at the provider level; and team processes and operating room logistics at the system level. Conclusion We identified surgeon-defined determinants of same-day discharge after MwoR. For the identified barriers, potential implementation strategies could include incorporation of preoperative drain teachings for patients, utilizing consensus statements and opinion leaders to disseminate evidence supporting same-day mastectomies, and conducting workshops with relevant stakeholders to establish consistent facility practice patterns among surgical teams. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-022-12934-x.

Safety and factors affecting same‐day discharge following mastectomy and immediate alloplastic reconstruction

“…We found the leading cause of admission to be patient request following surgery, which notably decreased with time from implementation of the ERAS protocol (Table 5 and Figure 2). This phenomenon was also noted by Oxley et al and Ellsworth et al, who determined patient expectations, along with institutional biases and prior surgical dogma, to be some of the main reasons preventing same‐day discharge following mastectomy and reconstruction 24,25 . We also found postoperative pain control and nausea/vomiting to be significant issues warranting over night admission.…”

“…This phenomenon was also noted by Oxley with institutional biases and prior surgical dogma, to be some of the main reasons preventing same-day discharge following mastectomy and reconstruction. 24,25 We also found postoperative pain control and nausea/vomiting to be significant issues warranting over night admission.…”