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

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 χ(2) 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.