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11-10-2011 | Article

Surgical care at the end of life varies widely across the USA


Free abstract

MedWire News: Variation in surgical care suggests treatment intensity at end of life may be at the discretion of individual healthcare providers, says US study.

By conducting a retrospective study of elderly fee-for-service Medicare beneficiaries, Alvin Kwok (Harvard School of Public Health, Boston, USA) and colleagues were able to discern the pattern of surgical care in the last year of life across the USA.

"Because of the high cost and invasiveness of surgical interventions, improved understanding of how much surgical care we provide and how this varies would be potentially helpful," they write.

The study, published in The Lancet, identified and evaluated 1,802,029 patients over the age of 65 years who died in 2008. The researchers found that 31.9% of decedents underwent an inpatient surgical procedure in their final year, and 18.3% in their last month of life. The percentage of surgical procedures at end of life was 33% lower in 90-year-old compared with 80-year-old patients.

Speculating over the reasons for this decline in rate of surgery with age, the authors suggest that "healthcare providers might have a high threshold to undertake surgery for elderly patients or a perception that these patients are more likely to have complications or less likely to benefit from such interventions than might younger patients."

"Some of these age-related differences could also be due to the preferences of patients and their families," they add.

The team calculated an end-of-life surgical intensity (EOLSI) score for each hospital referral region adjusted for age, gender, race, and income, which showed Munster, Indiana, to be the highest intensity region (EOLSI score of 34.4) and Honolulu, Hawaii, to be the area with the lowest intensity of surgery (11.5).

Analysis of EOLSI data showed that regions with a higher number of hospital beds per head had a significantly higher EOLSI score, as did areas with higher overall Medicare spending. These results are in line with past research on general end-of-life care in elderly people.

"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 a fee-for-service payment system," conclude the authors.

The retrospective study design limited available information and analysis: for example, the data could not be adjusted for patient risk factors, such as health and economic status.

Nevertheless, in an accompanying commentary, Amy Kelley (Mount Sinai School of Medicine, New York, USA) wrote: "Although some might continue to critique such study methods, including those used by Kwok and colleagues, the weight of evidence supports the need for action on many levels."

By Chloe McIvor