Changes in and predictors of length of stay in hospital after surgery for breast cancer between 1997/98 and 2004/05 in two regions of England: a population-based study

Abstract

Background: Decreases in length of stay (LOS) in hospital after breast cancer surgery can be partly attributed to the change to less radical surgery, but many other factors are operating at the patient, surgeon and hospital levels. This study aimed to describe the changes in and predictors of length of stay (LOS) in hospital after surgery for breast cancer between 1997/98 and 2004/05 in two regions of England.

Methods: Cases of female invasive breast cancer diagnosed in two English cancer registry regions were linked to Hospital Episode Statistics data for the period 1st April 1997 to 31st March 2005. A subset of records where women underwent mastectomy or breast conserving surgery (BCS) was extracted (n = 44,877). Variations in LOS over the study period were investigated. A multilevel model with patients clustered within surgical teams and NHS Trusts was used to examine associations between LOS and a range of factors.

Results: Over the study period the proportion of women having a mastectomy reduced from 58% to 52%. The proportion varied from 14% to 80% according to NHS Trust. LOS decreased by 21% from 1997/98 to 2004/05 (LOSratio = 0.79, 95%CI 0.77-0.80). BCS was associated with 33% shorter hospital stays compared to mastectomy (LOSratio = 0.67, 95%CI 0.66-0.68). Older age, advanced disease, presence of comorbidities, lymph node excision and reconstructive surgery were associated with increased LOS. Significant variation remained amongst Trusts and surgical teams.

Conclusion: The number of days spent in hospital after breast cancer surgery has continued to decline for several decades. The change from mastectomy to BCS accounts for only 9% of the overall decrease in LOS. Other explanations include the adoption of new techniques and practices, such as sentinel lymph node biopsy and early discharge. This study has identified wide variation in practice with substantial cost implications for the NHS. Further work is required to explain this variation.

Figure 1

Proportion of surgically treated women undergoing mastectomy and breast conserving surgery by NHS Trust (1997/98-2004/05). NB: The NHS Trusts are numbered from highest to lowest percentage of mastectomies; the numbers in Figure 1 do not necessarily correspond with those in Figures 2 and 3.

Figure 2

Median LOS for patients undergoing mastectomy in 1997/98 and 2004/05 and the change over the study period by NHS Trust. NB: The NHS Trusts are numbered from highest to lowest LOS; the numbers in Figure 2 do not necessarily correspond with those in Figures 1 and 3.

Figure 3

Median LOS for patients undergoing breast conserving surgery in 1997/98 and 2004/05 and the change over the study period by NHS Trust. NB: The NHS Trusts are numbered from highest to lowest LOS; the numbers in Figure 3 do not necessarily correspond with those in Figures 1 and 2.