Surgery at the End of Life Common, Associated With Location

Ricki Lewis, PhD

October 05, 2011

October 5, 2011 — The frequency of inpatient surgical intervention in the last year of life is high and reflects patient age and bed availability, according to a new study published online October 6 in The Lancet. Although this is not the first study to suggest that patients are receiving too much care at the end of life, it focuses on surgery and adds important information about geographic variation.

Alvin C. Kwok, MD, from Harvard School of Public Health, Boston, Massachusetts, and colleagues conducted a retrospective cohort study of more than 1,802,000 beneficiaries of fee-for-service Medicare in the United States using medical records. The patients, who were aged 65 years or older, died in 2008. The study compared them with decedents who were hospitalized but did not have surgery and with decedents who experienced neither hospitalization nor surgery.

Nearly a third of the patients had surgery during the final year (31.9%; 95% confidence interval [CI], 31.9% - 32.0%). For the last 3 months the proportion was 25.1% (95% CI, 25.0% - 25.2%); for the last month, 18.3% (95% CI, 18.2% - 18.4%); and for the last week, 8.0% (95% CI, 8.0% - 8.1%).

Likelihood of surgery fell with increasing age. Among patients over 65 years of age, 38.4% had surgery during their last year. That proportion was 35.5% for those up to 80 years of age, but it fell to 23.6% for those between 80 and 90 years.

The average age of patients undergoing surgery was 79.8 years compared with 82.5 among those not having surgery. These results suggest that perhaps family wishes to stop aggressive care are more common for the older old, the researchers write.

The team evaluated hospital referral regions using a metric called end-of-life surgical intensity (EOLSI), which is the rate of undergoing at least 1 surgical procedure during the last year of life, adjusted for age, sex, race, and income.

A significant factor in likelihood of surgery was the number of hospital beds in a region. On the other hand, there was no statistically significant association between the likelihood of surgery and the number of surgeons in a region. The region with the highest surgical intensity was Munster, Illinois, and the lowest, Honolulu, Hawaii — these regions varied 3-fold in EOLSI scores.

The investigators acknowledged several limitations of their study. For example, they considered only inpatient surgeries, they made no assessment of the role of surgery in contributing to death, and they were unable to assess whether the procedures were palliative.

They pointed out, however, that the data for surgery are consistent with those for aggressive care in general, confirming the overtreatment of the elderly and pointing to external factors in deciding end-of-life care, writes Amy S. Kelley of Mount Sinai School of Medicine, New York City, New York, in an accompanying comment. The rationale for the high frequency of surgery in people over age 65 at high risk for death, not assessed in the study, includes high reimbursement for inpatient surgery and inability of families to provide home care, contributing to soaring health care costs, Kelley suggests.

Conclude the researchers, "These findings should lead to a renewed effort to identify the optimum care for dying patients, taking their wishes into account, to ensure that interventions help extend life and reduce suffering."

Lancet. Published online October 6, 2011. Full text

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