Early Postoperative (POD1) Discharge in Pituitary Adenoma Patients: The Effect of Socioeconomic Factors

Introduction: Neoplasms of the sellar/parasellar regions are unique tumors that require distinct diagnostic and treatment considerations. Their treatment paradigm has been aided by recent advances in endoscopic transsphenoidal surgery and neuroimaging. This has resulted in shorter lengths of stay and quicker recoveries. At our institution, we have implemented a postoperative day 1 discharge paradigm through detailed preoperative evaluation and review of both medical and socioeconomic factors. This paradigm involves a multidisciplinary approach including contributions from endocrine, neuro-ophthalmology, and ENT. We analyze our initial pilot series of POD1 pituitary patients and their clinical outcome with attention to the global limitations to discharge.

Methods: The experience of a single neurosurgeon/ENT surgeon team was reviewed, and a retrospective database was generated to identify patients who underwent resection of pituitary lesions from October 1, 2011, to July 1, 2014. Our institutional comprehensive pituitary tumor database was interrogated, of which 30 patients were identified that met inclusion criteria for the study. Statistical analysis via statistical analysis system (SAS) was used to assess the significance of the results. We assessed multiple axes of this patient population from both their preoperative, in-house, and postoperative care. Among the factors studied were tumor pathology, size, neuro-ophthalmology studies, endocrine evaluations, postoperative complications, insurance status, and disposition status.

Results: Of the 30 patients in our case series, there were 14 males and 16 females. The average age was 53.8 years (range, 27–76 years). There were 22 nonsecretory and 8 secretory tumors (four growth hormones three prolactinoma, and one gonadotroph-secreting). The average size of the tumors was 2.80 cm (range, 1.3–5.0 cm). All 30 patients underwent preoperative ENT evaluation to investigate sinus anatomy and any sinus pathology. The average length of stay was 1.5 ± 0.7 days. The insurance status of the patients consisted of 15 with public insurance such as Emergency Medicaid and 15 with private insurance. There was one 30-day readmission, for a patient who came in with SIADH. There were four patients with transient diabetes insipidus (Na > 145) and none with permanent DI. Of the 30 patients, 28 were administered postoperative steroids. Factors that contributed to length of stay greater than 1 day included diabetes mellitus, pan hypopituitarism, poor visual acuity, diabetes insipidus, and public insurance status. The most significant correlative factor to their delay in discharge was their socioeconomic disposition and not medical or surgical status.

Conclusion: The implementation of a POD1 discharge plan for pituitary tumors is feasible and safe for elective patients. No increased morbidities or follow-up complications are encountered. The thorough evaluation by a multidisciplinary team enables identification of appropriate risk factors, which can almost all be addressed. Interestingly, the consistent limitation to early discharge was their socioeconomic status. Therefore, efforts that incorporate analysis of social disposition parameters, such as insurance status, with proper management of clinical sequelae are crucial to maintenance of ideal length of stay and optimal patient outcomes. In the growing model of quality assessment and health care cost analysis, we believe that socioeconomic factors will become even more relevant for improved patient outcomes.