Targeted Home Nursing Visits Post Breast Surgery Cost-Effective

ORLANDO—Breast cancer patients who received targeted home nursing visits after a short-stay surgery used fewer postoperative health services and had improved social and family well-being, compared with patients receiving no visits or nontargeted visits. Gwen K. Wyatt, RN, PhD, associate professor of nursing, Michigan State University, presented the study results at the Era of Hope Department of Defense Breast Cancer Research Program meeting. The study included 240 female breast cancer patients. Short hospital stay was defined as 48 hours or less. Patients were 21 years of age or older and fluent in English. The majority were white, married, and employed prior to surgery.

Patients were randomized into three groups. The 121 women in the intervention cohort received home nursing visits by a special team of practitioners following a prescribed protocol (see Table). The first control group, with 64 participants, received discharge care by a nurse from a home-care agency after a referral from the surgeon. The 55 patients in the third cohort received no postoperative home nursing care. Data collection included paper and pencil self-reports before surgery but after diagnosis, and a telephone interview 4 weeks after surgery. The quick turnaround on the preoperative questionnaire presented one of the study’s prime challenges, Dr. Wyatt said.

The intervention group received their first in-home nursing visit within 1 to 3 days after discharge. Nurses made at least two home visits and called by telephone at least twice. The women also had 24-hour access to the study nurse. Both the protocol nurses and the agency nurses determined how many visits were ultimately made.

Study Results

"The women in the intervention group were significantly more likely than the controls to receive instruction in postsurgical self-care, including range of motion, lymphedema prevention, and breast self-exams," Dr. Wyatt said.

A significantly higher percentage in the controls exceeded the 48-hour hospital stay, she said. Physicians did not know into which group the women had been randomized. However, the patients knew and may have welcomed the opportunity to leave the hospital confident that they would receive help at home, Dr. Wyatt suggested.

Protocol nurses made significantly fewer home-care visits than their agency counterparts: an average of 2.65 visits per patient vs 6.44 for patients receiving care from the agency nurses. The intervention group also made fewer emergency room visits and had fewer social work needs.

"Over time, in terms of functional status, all groups reported greater limitations 4 weeks after surgery. They did not regain what they felt was adequate range of motion," Dr. Wyatt said. "The upper body functional limitations were associated with lower quality of life and higher anxiety."

Even so, women in all groups experienced lower anxiety levels at the end of the 4-week study, compared with baseline before surgery. And all cohorts reported an increase in emotional well-being. The intervention group, however, was the only one to show improvement in social and family well-being.

"A targeted nursing protocol may be more cost-effective, improve quality of life, and enhance teaching related to range of motion, self-breast examination, and lymphedema, resulting in improved outcomes after surgery," Dr. Wyatt commented. "The intervention women had less than half the home visits of the control groups, and physical, emotional, and educational outcomes that were comparable to or better than those of either of the control groups."

Future Research

In future research, Dr. Wyatt plans to address physical functioning over a longer period of time. She envisions her research contributing to changes in expected lengths of stay for breast cancer surgery. The research could also lead to the inclusion of home visits, following the study protocol, in insurance policies and standards of care.

Dr. Wyatt concluded that an optimal home nursing care plan would require a hospital stay of less than 24 hours, followed by 2.5 home visits from nurses following the established home-care guidelines.

"The protocol was timely, cost-effective, and satisfactory to women, which was very important to us," she concluded. "We have gained information on the amount of nursing care needed."

Dr. Wyatt’s coinvestigators in the study were Charles W. Given, PhD, and Barbara A. Given, RN, PhD.