Efficiency of Sorting Site of Care for Frail Patients Undergoing Mastectomy

BACKGROUND: Patients undergo mastectomy in both ambulatory surgery centers (ASCs) and inpatient settings. Guidelines for site selection are poorly defined. Older adults, particularly those with frailty, are at increased risk of adverse outcomes postoperatively. Transfer to an acute hospital is a unique adverse event suggesting potentially inappropriate ASC care. METHODS: The authors used logistic regression modeling to describe the association of frailty with site of care and transfer, and modeled expected costs associated with ambulatory mastectomy for robust and prefrail or frail patients. RESULTS: In ASCs, 85.3% of all patients and 51.3% of prefrail or frail patients underwent mastectomy. Frailty or prefrailty was associated with increased odds of inpatient care (odds ratio [OR], 5.856; p < 0.001). Odds of transfer were higher among prefrail and frail patients (OR, 2.640; p < 0.05), but rates remained low (< 0.4%). Rates of transfer needed to negate cost-savings from ambulatory procedures are more than 100 times the current rate (38%; standard error, 4.7%). If all prefrail and frail patients received care at ASCs, expected cost savings would be $8404 per patient. CONCLUSIONS: Despite slightly higher rates of transfer, clinicians should consider treating frail and prefrail older adults in ASCs given possible economic benefits.