One in three Medicare patients undergoes inpatient surgery in their last year of life, often during the final month, researcher found.
Of the 1.8 million Medicare patients who died in 2008, about one-third underwent a surgical procedure the year before their death, according to a new study published online in The Lancet. More than 18% underwent a procedure in the last month of life.
The researchers — led by Alvin Kwok, MD, of Harvard’s School of Public Health — used public records and 2007-2008 Medicare claims data to determine all patients who died during the 2008 calendar year who were 65 or older at time of death, and for whom there were Medicare claims 12 months prior to death.
The Medicare patients who underwent a surgical procedure in their last year of life were, on average, several years younger than those who did not undergo a procedure (P<0.0001), suggesting that surgeons are less likely to operate on patients over 80 because they worry they might have more complications from surgery.
Patients who underwent end-of-life surgeries were more often men and more often not white. Patient income had no impact on end-of-life surgeries.
But there were regional differences. Munster, Ind., for instance, had three times the amount of end-of-life surgeries as Honolulu, which had the lowest number.
The authors couldn’t explain the regional variation observed in the study, but said they suspect a variety of reasons, including “population health, practice patterns, culture, and potentially, availability of other end-of-life services such as hospices.”
Regions with a high number of hospital “beds per head” also had high end-of-life surgical intensity (P<0.001), as did regions with high total Medicare spending (P<0.001), suggesting that healthcare providers in areas that have ample hospital space for patients, and bring in a lot of Medicare money, are more likely to lean toward operating on an elderly Medicare patient.
Although the researchers didn’t determine which surgeries were appropriate and which weren’t, they nonetheless concluded that more surgery certainly doesn’t equate to improved quality of life.
“Although one might assume that more care results in better care, regions with high healthcare use at the end of life do not necessarily have better outcomes,” the study authors explained, adding that areas with high surgical intensity actually have high death rates, too.
Patients who underwent surgery typically had more hospital admissions, longer duration of stay, and a greater number of days spent in intensive care compared with Medicare beneficiaries who did not have a surgical procedure in the year before death, the found.
The authors concluded that the new data on how common end-of-life surgeries are among the elderly should should prompt clinicians to carefully consider a patient’s goals when determining whether to perform a surgical intervention near the end of a patient’s life.
The 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,” the study authors wrote.
In an accompanying comment in The Lancet, Amy Kelley, MD, of the Brookdale Department of Geriatrics and Palliative Medicine at Mount Sinai School of Medicine in New York, wrote that the fee-for-service model is a problem because it gives surgeons a financial incentive to operate on elderly Medicare patients.
Policymakers “must align incentives for insurance plans, healthcare institutions, and providers with individual patients’ goals,” she wrote.
Kelley also suggested that medical and nursing schools make sure all graduates have basic competencies in palliative care. Having more medical staff who are skilled in end-of-life care will help ensure that treatment matches the care the patient wants, she said.
The authors noted that one important limitation to their study was that they examined only inpatient procedures, although 44% of all medical procedures are done in an outpatient setting.
There was no funding for the study. The authors all reported they have no conflicts of interest.
Primary source: The Lancet
Source reference:
Kwok A, et al “The intensity and variation of surgical care at the end of life: a retrospective cohort study” Lancet 2011; DOI:
10.1016/S0140-6736(11)61268-3.
Additional source: The Lancet
Source reference:
Kelley A “Treatment intensity at end of life — time to act on the evidence” Lancet 2011; DOI:
10.1016/S0140-6736(11)61420-7.
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(Link last retrieved December 1, 2011)
