I am an experienced academic writer with degrees in Philosophy and in Art at B.A. (First Class and 2:1 respectively) and Masters level (Distinction) and have further post-graduate research experience at a Ivy League university. Having run my own business successfully for six years, as well as working for large organisations as a data analyst (using a range of software including SPSS) on commercial research projects, I have 'hands on' experience of both enterprise and corporate culture which adds depth to my writing and analysis. I am deputy director of a small textiles and arts educational charity and am a trustee of a local heritage charity. These roles have given me an in-depth knowledge of the public sector in general and social and education issues in particular. I am also a practicing artist, represented by a London gallery, and have shown and sold work internationally. I will resume my PhD studies in September 09, investigating the role of theory in current art practice.

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An Examination of the Effects of Early Discharge from Hospital Post-Mastectomy for Breast Cancer Patients: Literature Review

1. Introduction
Studies into the effects of early discharge from hospital for post-mastectomy patients divide into two groups, those written between the late 80's to early 90's and those from the late 90's onwards. Early studies concentrate on objective data, while researchers from the second group also consider the subjective and psychological responses of the patients in terms of assessing such treatment. Carer and financial perspectives were also focused upon in later studies.

2. The First Wave of Studies of Early Patient Discharge: Focus on Cost Savings.
Traditionally, women treated by surgery for breast cancer have suction drains inserted into the wound until the amount of draining has decreased sufficiently for release from hospital (Clark and Kent 1992). These drains are generally removed approximately one week after the operation (Purushotham et al. 2002). This approach characterised the period until the late 1980's, when early discharge for some appropriate patients began to be trialed (Wells et al. 2004).

From the late 80's the impact of early post-operative release for breast cancer surgery patients was investigated. The early studies were mainly US based, and concentrated on the cost benefits of early discharge. This should be seen in the economic and social context: whereas in the United Kingdom and most of Europe some form of government funded health service is in operation, in the USA most medical care is provided by private insurance. At the time therefore the USA had more interest in cost-cutting as hospitals were run as businesses.

The message of these early studies was consistent: early release produces no significant problems with patients and allows great cost-cutting benefits, therefore is to be recommended. Most trials took the form of randomised control trials comparing patients treated in the traditional way with a longer period in hospital until drains were removed with patients discharged more quickly after surgery and drains remaining in place.

Litvak et al. (1987), for example, started from the premise that health facilities need to remain in profit in order to remain open, and patient care should be developed with this in mind. Their study in the US compared patients discharged early (mean 2.65 days) against ones kept in until drains removed (mean 9.65 days) and found that providing the right after-care was in place not only were hospital charges reduced significantly but allowed the hospital to make a profit rather than a loss (Litvak et al. 1987).

These findings were backed up by Edwards et al. in their 1988 study of mastectomy patients in Houston. Here 59 patients treated between 1983 and 1984 were compared with 61 treated (by the same surgeon) between 1986 and 1987, measuring the impact of a change in policy regarding mastectomy post-operative care in the hospital. The time difference between the groups studied raise the question whether other differences between patient group or care influence the results, but given that the time periods are fairly close together, and given that the procedures are carried out by the same surgeon this seems unlikely. Edwards et al. also focused upon the savings, projected at $750,000 per year at the hospital for the 400 breast cancer patients treated by surgery, but did so in the context of complication rates, which were not significantly different between the two groups. They concluded that early admission and discharge should be an aim, with the provison that outpatient nursing care and administration as well as patient information and education would need to improve to ensure effective implementation (Edwards et al. 1988).

These findings were confirmed by other researchers. Orr et al., for example (1987) studied 73 patients treated by 4 different surgeons over a one year period and discharged on average 2.9 days post operation. Although there were some complications found, for example seromas and skin necrosis, these were managed easily. They concluded that not only was early discharge with drains safe, it was also well tolerated by patients. They confirmed the potential for cost savings for the hospital (Orr et al. 1987).

Cohen et al. (1986) again reiterated the cost-saving message. They studied 39 patients in a USA hospital and found only a small number of complications. They recommended a stay of 3 to 5 days before discharge in order to reap the cost-saving benefits (Cohen et al. 1986). Wagman et al. (1989) again found no significant differences in healing rates, wound infection, erythema or seroma formation between a test group of 75 longer-stay patients and a control group of 44 short-stay patients. They noted that the patients were all similar in age and cultural background as well as diagnosis and surgery (Cohen et al. 1986). The 'early discharge is safe and cost effective' message was further confirmed by Clark et al.'s (1992) study of 29 patients, which found hospital costs could be reduced by 36%.

A fairly early study by Bonman et al. (1993) showed that the results were not confined to US hospitals. They looked at the effects of early discharge in Karolinska Hospital, Sweden. They looked at 28 patients who elected to leave with drains still in place (after a median stay of 2 days) against 90 who left when the drain had been removed (after a median of 6 days). They found no difference in incidents of complications. They also assessed patient satisfaction, and found it was equal. One interesting aspect of this study is that the patients who were discharged early made the decision about leaving for themselves. In other studies this was not the case. No investigation was made regarding whether self-selection contributed to the positive results of the study. It might be interesting to investigate the extent to which allowing the patient input into decisions of this kind facilitated positive recovery.

It has been seen above that a large part of the motivation for investigating early discharge is economic. However, early discharge only became possible because of advances in surgical and anaesthetic techniques. A 1995 study by Weltz et al. looked at early discharge in the context of a new anaesthetic technique. Paraverebral block offers pain relief and limits the nausea often associated with normal forms of anaesthesia, particularly in women and breast cancer patients. The technique involves injecting local anaesthetic at the point where the spinal nerve emerges from interverebral foramina and divides into two. Of the patients studied, 14 reported the technique as 'very satisfactory'. They concluded that the use of paraverebral block allows further reduction in hospital stay and thus can contribute significantly to reduction in costs of performing mastectomy as well as making the experience less unpleasant for the patient by reducing post-operative pain and nausea (Weltz et al. 1995).

While the early, mostly US based, studies are remarkable in the consistency of their message and the seemingly obvious conclusion for cost-cutting, there are several drawbacks. We have seen that only one paid much attention to background details of the patients aside from type of treatment and age. To some extent this is unavoidable: because the sample is by its nature limited, and because there is generally a fairly high drop-out rate in such studies, there is little opportunity to pick particular respondents based on age, socio-economic background, support and family background and so on. However all these factors might impact upon results of the study.

3. More Recent Studies: A Broader Sweep
From the late 1990's onwards, the focus widened. Studies were carried out in countries outside the USA, and while cost-benefit analyses remained a main consideration, the assumptions underpinning early investigations were questioned. At the same time, other considerations began to be addressed.

Bundred et al. carried out the first UK study which looked at the effect of reducing hospital stay periods in 1998. This also supported earlier findings. Their randomised trial of women discharged after 2 days looked at both physical issues - rate of infection and seroma formation as well as mobility in the shoulder - as well as psychological factors including anxiety and depression. Women were assessed at one and three months after discharge. Bundred also placed the results in the context of economic savings: if a similar 4/5 day reduction in stay took place the saving would be around £1000 per patient. UK practice, they point out, has tended to avoid early discharge because of perception it would affect patient adversely psychologically and because of an unwillingness to move specialist hospital-based breast nurses to outpatient clinics. However, they found that a shorter hospital stay did not produce any significant increase in rate of illness, nor did it increase psychological problems. By contrast, women who were discharged early reported increased confidence and reassurance. They conclude that early discharge should be used more often, but warn that comprehensive instructions to carers and patient and attention to post-operative care should be in place (Bundred et al. 2002).

While some studies, for example Evans et al. (2000) simply reiterated the message about cost benefits, most later studies, like that of Bundred, added new insights. One of the first of the second wave of studies, carried out in Rotterdam, assessed psychological results as well as medical ones. While psychological aspects of patient response had been taken into account earlier, the focus was firmly on cost savings. Bonnema et al. (1998) shifted focus and made these considerations equal to medical and cost ones. A group discharged after 4 days was compared with a group discharged after drain removal. The groups were given psychosocial tests before surgery and afterwards at 1 and 4 months. Patient satisfaction with a short stay was high, with only 4% preferring to have stayed longer. Other psychological factors were constant across the two groups, including uncertainty, anxiety, sleep problems and loneliness. Medical factors across the two groups were similar also, leading to a conclusion that early discharge is both safe and well-received (Bonnema et al. 1998). A study by Chadha et al. (2004) also gave equal weight to subjective experience and objective medical data. They looked at 124 patients in the UK. Notably, there was a high degree of anxiety about early discharge, with only 6% of patients feeling confident about their early release. This anxiety dissipated rapidly, and overall of the 60% who responded to the questionnaire 90% felt the care was at least equal to that received in hospital. In terms of objective data, there were low rates of complications together with a saving of 4.7 bed days per patient. The message supports early release, but they emphasised the need for patients to be better informed of specifics of discharge plan and anxieties to be allayed (Chadha et al. 2004).

Further studies of the psychological impact of early release include that by Wells et al. (2004). Wells accurately points out that earlier studies omit consideration of subjective data, but curiously seems to think they also fail to consider financial impact, which is clearly not the case. Their own study looks at a nurse-led model of early release in terms of quality of life and burden for carer as well as patient satisfaction, impact on nurses and costs. They found again that early discharge had no adverse effects, and also that it had little impact of carer burden, intra-hospital communication or reduced cancellations. They also point out that although early discharge reduces bed days, it also increased the work load of community nurses and organisational problems for the nursing team (Wells et al. 2004). This consideration had been overlooked by earlier studies. While hospital costs might well be reduced, the true costs of early release need to be calculated, including costs of outpatient clinics, in home nursing and cost to families and other non-official carers.

The second wave of investigation into early release also introduced some critical voices. Early studies had been in favour of early release and its cost benefits. Later writers were more aware of possible drawbacks. Fallowfield, for example, points out that the evidence for early discharge should be treated with care. Doubtless, hospitalisation is to be avoided if possible; it is both costly for the funder and stressful for the patient. Surgery procedures are particularly stressful forms of hospital treatment. Surely then, he asks, less hospital care is a good thing? This is not necessarily the case. Breast cancer tends to be found in elderly women, who also tend not to have family support structures to ease the burden of home care. Early discharge also relies on visits by community health team members, and is inappropriate if the patient lives too far away to allow visits. Fallowfield's point is a good one, however given that early discharge is stressful for the patient, it is possible that with adequate post-operative care outside the hospital seeming difficulties can be avoided. This need for a strong support structure has in fact been highlighted by later researchers, above. One more robust point Fallowfield makes is that the costs need to be very carefully worked out. Studies tend to highlight the reduction in hospital costs while ignoring the costs of community and outpatient nursing care, and also fail to take into account the costs to the informal carer network. The responsibility is shifted onto the family, who may not have the resources to cope with it (Fallowfield 1998).

Clarke and Rosen (2001) also widen out the context of the discussion in a useful way, pointing out that it should be considered against a background of health care system policy. It has already been mentioned that the US emphasis on cost/benefit analysis should be seen in the context of the specific economic system in that country, however Clarke and Rosen further emphasise that length of hospital stay is, since the late 1990's, one of the UK governments six performance dimensions highlighted as potential sources for increasing efficiency (Department of Health 1997). While it is the case that there is no correlation between length of stay (LOS) in hospital and poorer health outcomes, there are some questions about the quality and appropriateness of the care offered in the place of in-hospital care (Clarke and Rosen 2001). Clarke & Rosen discuss post-operative care in general, not specific to breast cancer, but make some interesting points. A reduction in LOS may, for instance, also increase expenditure in some cases, as first the in-hospital days are high in treatment intensity and second the cost burden is shifted from hospital to community care teams and cost to family and friends. They suggest that LOS might be an ineffective measure of efficiency as it fails to account for these further factors. They also ask if there are ethical or moral constraints regarding minimum LOS, citing a recent US study of the public outcry over what was dubbed 'drive through' (or ultra short stay) mastectomy (Clarke & Rosen 2001). This however raises a further question regarding the importance of ethical considerations given that patients seem happy with early release.

4. Conclusion
The evidence seems to suggest strongly that early discharge is not detrimental to the recovery of post-mastectomy cancer patients.   However, early studies concentrating upon data about the clinical recovery need to be set against later examinations of other factors: financial, care structure, burden on carers, psycho-social well being of patients. The initial enthusiasm for early-release after mastectomy and other breast surgery should be tempered by awareness of these factors. However it seems clear that if care structure is taken into account and patients are properly informed, early-release continues to be a viable option. Certainly given the current UK government guidelines for hospital standards, it would seem to be an option which will become increasingly popular.

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