The British medical journal Lancet reported last month that 32 percent of elderly American patients undergo surgery in the year before they die, a statistic culled from Medicare data.
In an accompanying editorial, Dr. Amy Kelley of Mount Sinai School of Medicine labeled the 32 percent figure a “call to action” — to reduce costly surgeries, intensive-care stays, and other high-intensity care for the elderly.
Her call was parroted in hundreds of media outlets nationwide. But advocates for limiting healthcare spending on the elderly are distorting science to make their argument.
Don’t be bamboozled: The Lancet investigators looked only at patients who died, making surgery appear unsuccessful. That’s like saying Babe Ruth struck out 1,333 times so he must have been a poor ballplayer — even though he had a .342 lifetime batting average and 714 home runs.
Investigators should have considered how all surgery patients fared, including those who recovered, returned home from the hospital and resumed active lives.
Valid data show that surgeries on older patients are successful. A 2003 study in the Journal of the American College of Cardiology followed 220 patients age 65 and older who underwent heart-valve surgery. The study concluded that “age does not appear to limit the health-related quality of life benefits” of surgery.
Even patients over 75 had symptom relief and improvements in quality of life “on a par with improvements seen in younger patients.”
The decision to operate should be based on a patient’s ability to benefit, not age. Dr. Martin A. Makary of Johns Hopkins has developed a way to gauge readiness for surgery with his well-known, 10-minute frailty test. It identifies which older patients have the physical reserve to withstand the stress of surgery and resume an active life.
So should medical resources be reserved for younger patients? That’s an ethical issue. But research should not be rigged to prove that withholding care is harmless. Yet such flawed research is driving our political debate.
President Barack Obama’s former budget director, Peter Orszag, told reporters in June 2009 that the president’s plan to cut future Medicare funding would not be dangerous. He said that spending could be lowered by about 30 percent, to approximate what is spent in the lowest-cost regions of the country, without doing harm.
Mr. Orszag cited the Dartmouth Atlas of Healthcare 2008, which tried to prove that Medicare patients who got less care (fewer hospital days, doctor visits, and imaging tests) had the same outcomes as patients who received more care.
However, the Dartmouth investigators had pulled the same trick as the Lancet investigators: They examined only the records of patients who died. By definition, such patients — regardless of their level of care — ended up the same: dead.
Statewide studies in California and Pennsylvania have proven the opposite of what the Obama administration claims. They show that Medicare patients treated in hospitals that provide lower-intensity, lower-cost care have a higher risk of dying.
The California study, published in February in the Annals of Internal Medicine, found higher death rates from pneumonia, congestive heart failure, stroke, gastrointestinal hemorrhage, and hip fractures at low-spending hospitals.
The study’s authors calculated that 13,813 California patients treated for these conditions between 2004 and 2008 would have survived had they been treated at higher-spending hospitals rather than low-spending ones.
The Pennsylvania study produced similar results, showing higher survival rates at higher-spending hospitals.
Dr. Amber Barnato, lead author of the Pennsylvania study, explained that examining only the records of patients who died, as the Dartmouth and Lancet studies do, is Monday morning quarterbacking. Doctors often cannot tell when a patient is in the last year of life. When they can predict, they expend fewer resources.
Washington’s budget cutters should weigh these findings. Further slashing what hospitals are paid to care for the elderly — as the Obama health law and the Aug. 2 debt-ceiling deal both did — will not only reduce end-of-life care. It will also reduce care for patients who are capable of surviving their illness and going home.
Adjusting Medicare’s eligibility age and asking some patients to share more of the cost of care are safer budget options than cutting spending at the bedside.
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