While one welcomes randomised trials, the study by Bonnema et al fails to answer the questions they have sought to address. Firstly, the two groups being compared contain a mixed cohort of patients undergoing breast-conserving surgery and modified radical mastectomy. They therefore have made the fundamental assumption that women undergoing both procedures behave exactly the same way in terms of their post-operative complication rate for eg, volume of seroma fluid drainage and suffer the same degree of psychological morbidity. They should have been stricter in their inclusion criteria and only recruited patients who underwent the same surgical procedure. This would have made their results more meaningful.
The concept of keeping patients in hospital for 9-12 days post-operatively is archaic. In our practice, which probably reflects the practice in the rest of the UK, the mean post-operative hospital stay is in the region of 4 days with drains being removed on day 5, irrespective of volume of drainage of fluid.
One of their aims was to address the complication rate following early discharge. However,in discussion, they state that "the number of patients in this study was too small to detect a difference of 5% in rates of wound complication" and subsequently claim that recruitment of 800 patients, which is what would have been required, would not have been "feasible in this type of research". Why?
It is vital that any study examining shorter hospital stay must involve a detailed analysis of costs with the help of a health economist to calculate in-hospital and community costs. This is particularly important for the UK where NHS funding is central.
The follow-up period to assess psychological morbidity is too short. At 3 months patients may be undergoing adjuvant therapy, loco-regional radiotherapy and systemic chemotherapy, which add to their morbidity. It is essential that such studies are designed to assess psychological morbidity at completion of treatment to provide a more meaningful result. In this study, a further set of questionnaires to be completed at one year would have been necessary.
These issues are currently being addressed in a randomised trail in our institution, funded by the Scottish Office, which will complete recruitment at the end of 1998. Results from this study will hopefully clarify all the issues raised above.
Competing interests: No competing interests