One in three people on Medicare have surgery in the final year of their lives, and many have surgery in their last month, according to a new study published in The Lancet.
Of the 1.8 million Medicare patients over age 65 who died in 2008, researchers found that a third had undergone surgery in the year before death and that 18% of those surgeries had occurred in the month before death. Nearly 1 in 10 had surgery in their final week. The numbers were surprisingly high, researchers said.
To some extent, the finding makes sense: sick people have surgery and sick people also die. But while the researchers did not examine whether individual surgeries were necessary or whether they improved patients’ quality of life — many surely did — the data suggested they did not improve outcomes overall. Areas of the country that had high rates of surgery also had high rates of death.
Geography had a lot to do with a Medicare patient’s likelihood of having surgery in the last year of life. Muncie, Ind., had the highest rate, at 34%, while Honolulu had the lowest, at 12%. Why that’s so isn’t clear, but the authors suggested several possible contributing factors, including population health, patterns of medical practice, culture and availability of end-of-life services such as hospice care.
Rates of surgery also differed by age. About 38% of 65-year-old Medicare patients had surgery in the year they died, compared with 35% of 80-year-olds — not a very vast difference. But rates of surgery dropped off more sharply in patients older than 80, with fewer than 24% of patients between 80 and 90 having surgery, suggesting that surgeons had greater concerns about the risk of complications in this age group.
Given the patterns in surgery rates across the country, the authors suggest that medical need is not the only factor driving doctors’ desire to operate. Many surgeries may be done to avoid difficult discussions about patients’ prognosis, or to fix problems that wouldn’t necessarily prolong life or improve its quality, the authors said. Doctors are also failing to figure out exactly how dying patients wish to spend their final days.
“In a lot of places, we’re doing a lot of these surgeries I think unnecessarily,” lead author Ashish Jha, a professor of health policy and management at the Harvard School of Public Health, told Bloomberg. “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.”
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.
In an accompanying comment in The Lancet, Kelley wrote that doctors’, insurance companies’ and hospitals’ incentives must be aligned with the wishes of the patient. She also suggested that another to way to increase the likelihood that patients get the care they want is to ensure that all medical and nursing school students receive basic education in end-of-life care
The study is not without its limitations, however. For example, researchers looked only at surgery patients who died; it’s not known how many patients who had the same procedure survived.