Elsevier

The Lancet

Volume 378, Issue 9800, 15–21 October 2011, Pages 1408-1413
The Lancet

Articles
The intensity and variation of surgical care at the end of life: a retrospective cohort study

https://doi.org/10.1016/S0140-6736(11)61268-3Get rights and content

Summary

Background

Although the extent of hospital and intensive-care use at the end of life is well known, patterns of surgical care during this period are poorly understood. We examined national patterns of surgical care in the USA among elderly fee-for-service Medicare beneficiaries in their last year of life.

Methods

We did a retrospective cohort study of elderly beneficiaries of fee-for-service Medicare in the USA, aged 65 years or older, who died in 2008. We identified claims for inpatient surgical procedures in the year before death and examined the relation between receipt of an inpatient procedure and both age and geographical region. We calculated an end-of-life surgical intensity (EOLSI) score for each hospital referral region defined as proportion of decedents who underwent a surgical procedure during the year before their death, adjusted for age, sex, race, and income. We compared patient characteristics with Rao-Scott χ2 tests, resource use with generalised estimating equations, regional differences with generalised estimating equations Wald tests, and end-of-life surgical intensity scores with Spearman's partial-rank-order correlation coefficients.

Findings

Of 1 802 029 elderly beneficiaries of fee-for-service Medicare who died in 2008, 31·9% (95% CI 31·9–32·0; 575 596 of 1 802 029) underwent an inpatient surgical procedure during the year before death, 18·3% (18·2–18·4; 329 771 of 1 802 029) underwent a procedure in their last month of life, and 8·0% (8·0–8·1; 144 162 of 1 802 029) underwent a procedure during their last week of life. Between the ages of 80 and 90 years, the percentage of decedents undergoing a surgical procedure in the last year of life decreased by 33% (35·3% [95% CI 34·7–35·9; 8858 of 25 094] to 23·6% [22·9–24·3; 3340 of 14 152]). EOLSI score in the highest intensity region (Munster, IN) was 34·4 (95% CI 33·7–35·1) and in the lowest intensity region (Honolulu, HI) was 11·5 (11·3–11·7). Regions with a high number of hospital beds per head had high end-of-life surgical intensity (r=0·37, 95% CI 0·27–0·46; p<0·0001), as did regions with high total Medicare spending (r=0·50, 0·41–0·58; p<0·0001).

Interpretation

Many elderly people in the USA undergo surgery in the year before their death. The rate at which they undergo surgery varies substantially with age and region and might suggest discretion in health-care providers' decisions to intervene surgically at the end of life.

Funding

None.

Introduction

The intensity of medical care at the end of life is well known.1, 2 A fifth of elderly Americans die in intensive-care services and of these patients, about half undergo mechanical ventilation and a quarter undergo cardiopulmonary resuscitation in the days before death.3, 4, 5 Furthermore, the intensity of end-of-life care varies substantially on the basis of where patients receive care.6, 7 Although one might assume that more care results in better care, regions with high health-care use at the end of life do not necessarily have better outcomes.8 Areas of high use have been associated with lower quality and lower perceptions of quality of dying among bereaved families than in areas with fewer health-care resources.8, 9 These large variations lead many clinical leaders and policy makers to believe that there is substantial room to improve end-of-life care.

Despite increasing attention on improving care at the end of life, substantial gaps exist in our knowledge about surgical care at the end of life. We are aware of only one study that examined trends in surgical care at the end of life,10 although others have examined patterns of non-surgical care at the end of life.3, 5, 11 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. If the proportion of dying patients who receive surgical care is substantial, and if it varies significantly on the basis of patient characteristics or across regions, it would provide an important new focus area for clinical leaders and policy makers hoping to optimise care during this vulnerable period.

We aimed to understand how often elderly Americans undergo surgical interventions in the last year of life and to what degree such interventions vary by age and across health-care markets. We also sought to understand whether key regional factors, such as the number of hospital beds and supply of surgeons, influences the degree to which dying patients receive surgical interventions.

Section snippets

Study design and patients

We did a retrospective cohort study of 2008 Medicare fee-for-service enrollees with Medicare data from 2007–08. These data contained diagnosis and procedure codes for all beneficiaries of Medicare enrolled in the fee-for-service programme who were admitted to an acute-care hospital or skilled nursing facility. Data included International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes for comorbidities and procedures undertaken in the hospitals.12 We also

Results

1 802 029 beneficiaries of fee-for-service Medicare aged 65 years or older died in 2008. Nearly a third of these decedents (31·9% [95% CI 31·9–32·0; 575 596 of 1 802 029]) underwent an inpatient surgical procedure during their last year of life (median 2 [IQR 1–3]), compared with 13·9% (13·90–13·91; 4 893 241 of 35 185 017) of survivors during 2008. During the last 3 months of life, more than a quarter (25·1% [95% CI 25·0–25·2; 452 309 of 1 802 029]) of decedents underwent a procedure, whereas

Discussion

Nearly a third of elderly Americans had a surgical intervention during the last year of life and most of these procedures occurred in the month before death. Beneficiaries who underwent surgery typically had more hospital admissions, longer duration of stay, and a greater number of days spent in intensive care than did those who did not have a surgical procedure in the year before death. The likelihood of receiving surgery at the end of life varied substantially with patients' age and where

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