Is Surgery at the End of Life Overused?

Thursday, 06 October 2011 12:40 PM

Age and where they live may have more to do with whether elderly Americans undergo surgery in the last year of their lives than their medical need or desire for the procedures, a Harvard study found.

Almost one-third of the 1.8 million Medicare recipients who were at least 65 years old and died in 2008 had surgery in the year before their deaths, researchers at the Harvard School of Public Health reported in a study published online in the medical journal The Lancet.

Many of the procedures probably failed to improve dying patients’ lives, said Ashish Jha, a professor of health policy and management at Harvard and the study’s lead author. Medicare is the U.S. health program for the elderly and disabled.

“In a lot of places, we’re doing a lot of these surgeries I think unnecessarily,” Jha said in an interview. “We’re not having the kinds of conversations with patients that we need to have, about what they want out of their last few days and how we help them achieve those goals.”

End-of-life surgeries were most common in Muncie, Indiana, where more than 34 percent of elderly Medicare recipients had operations in the year before they died, according to the report released Wednesday. Honolulu had the lowest rate, with less than 12 percent undergoing surgery in that period. High rates of surgery among dying elderly patients drive up overall Medicare spending, the research showed.

Disparities by Age
The likelihood of undergoing end-of-life surgery declines as patients age, the study found. More than 38 percent of Medicare recipients who died in 2008 at age 65, and 35 percent of those who died at age 80, had surgery in their last year of life. Fewer than 24 percent of those who died from the ages of 80 to 90 underwent such procedures.

“My sense is that a lot of surgeons are still uncomfortable with doing surgery on the very elderly, and that’s why they back off,” Jha said.

Many physicians also shy away from frank discussions about how dying patients want to spend their final days, Jha said.

“We need a much more concerted effort to encourage and train physicians to talk to their patients about their wishes at the end of life,” he said.

Doctors and hospitals may have a financial incentive to operate on dying seniors “regardless of the patient’s preferences or goals,” because Medicare is guaranteed to pay for the procedures, said Amy Kelley, an assistant professor of Geriatrics and Palliative Medicine at Mount Sinai School of Medicine in New York.

“Policy makers must align incentives for insurance plans, healthcare institutions, and providers with individual patients’ goals,” Kelley said in a commentary that accompanied the Harvard study.

Copyright Bloomberg News

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