News Release

A third of elderly Medicare beneficiaries undergo surgery during their last year of life but many procedures are likely to be unnecessary or unwanted

Peer-Reviewed Publication

The Lancet_DELETED

Almost a third of elderly American beneficiaries of fee-for-service Medicare undergo surgery during their last year of life, with most of these procedures being performed in the month before death. The likelihood of receiving surgery at the end of life varies substantially by patient age, where they live, and with the availability of hospital beds. These findings, published Online First in The Lancet, suggest that some operations could be discretionary or avoidable, financially motivated (surgical procedures are highly reimbursed), and at odds with the wishes of dying patients.

The aggressive medical care of patients at the end of life is well established. A fifth of elderly Americans die in intensive care, and about half undergo mechanical ventilation, and a quarter undergo pulmonary resuscitation in the days before death. However, little is known about surgical care during this time.

Ashish Jha from Harvard School of Public Health, Boston, USA, and colleagues analysed data from more than 1802 000 beneficiaries of fee-for-service Medicare in the USA, aged 65 years or older, who died in 2008. They assessed how often elderly Americans underwent surgery in the last year of life along with whether important regional factors such as number of hospital beds and supply of surgeons influenced the provision of surgical interventions to dying patients.

Nearly one in five beneficiaries of fee-for-service Medicare who died in 2008 underwent a surgical procedure in the last month of life and nearly 1 in 10 had a surgical procedure in their last week of life.

The proportion of patients undergoing end-of-life surgery was highest among younger patients -- 38.4% for people aged 65 years, 35.3% at age 80 years, and 23.6% in those between the ages of 80 and 90 years.

The rate of surgical intensity was three times greater in the highest intensity region of Munster, Illinois, compared with the lowest intensity region of Honolulu. Interestingly, the findings suggest that the availability of hospital heads per head (but not the number of surgeons) might increase the chance that a patient will receive surgery at the end of life, with high-intensity regions having nearly 40% more beds per head than low-intensity areas. Regions with high surgical intensity also had significantly higher Medicare spending.

The authors are concerned that the likelihood of elderly Americans receiving surgery at the end of life could be influenced by factors such as health-care provider practices and culture rather than what is medically appropriate or preferred by individual patients.

They say: "For clinicians, these data should prompt careful consideration of a patient's goals when assessing the need for surgical intervention at the end of life."

"Future research needs to focus on why these large variations exist. For policy makers seeking to reduce variation in care, focus could be directed to factors that lead to excess supply such as payment systems that reward quantity of care over the quality and appropriateness of care"*, concludes lead author Ashish Jha.

In a Comment, Amy Kelley from Mount Sinai School of Medicine, New York, USA, says: "The provision of appropriate, preference-guided treatment for patients with serious illness is the shared responsibility of all clinicians. Surgeons, like general practitioners, are obliged to work with patients and their families to identify appropriate goals of care and recommend treatment plans that help achieve those goals…Policymakers must align incentives for insurance plans, health-care institutions, and providers with individual patient goals."

Dr Ashish Jha, Harvard School of Public Health, Boston, USA. T) 1-617-432-5551 or 1-617-797-2177 (mobile) E) ajha@hsph.harvard.edu

Dr Amy Kelley, Mount Sinai School of Medicine, New York, USA. T) 1-917-414-7391 E) amy.kelley@mssm.edu

Notes to Editors: *Quote direct from author and cannot be found in text of article.

###

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.