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