The Case for Conservative Care for Seniors

A study published recently in The Lancet¹ should be causing surgeons and hospital administrators some serious concerns. The study examined the percentage of Medicare beneficiaries who undergo surgery in their last year of life. Here is what the study found:

"Of 1,802,029 elderly beneficiaries of fee-for-service Medicare who died in 2008, 31.9% underwent an inpatient surgical procedure during the year before death, 18.3% underwent a procedure in their last month of life, and 8.0% underwent a procedure during their last week of life."

Imagine that: Almost one out of every three Medicare beneficiaries will have surgery during their last year of life, many in the last month of their life. Is this really what elderly patients want? (Keep in mind that I recognize the sensitive nature of this topic; after all, when a loved one is approaching the end of their life and surgery offers the possibility of extending life for even a little longer, the decision of whether to pursue surgery is certainly a personal one involving the patient and their family.)

This data initially brings up the obvious question of patient safety. How many of the almost 330,000 seniors who died within a month after surgery died due to "complications?" This study did not address that issue.

Estimating the cost of these surgeries is a little challenging. One way to get close is to take the average cost of the most popular Medicare surgeries. According to the Centers for Medicare and Medicaid Services, the average cost of the "Top 31" elective inpatient surgeries is $45,290.² If we multiply that cost by the number of surgeries in the last year of life (574,847), we see that in the U.S, more than $26 billion is spent each year for surgeries during the last year of life for almost a third of our seniors.

According to the 2011 Medicare Trustee Report,³ "in 2010, 47.5 million people were covered by Medicare. ... [The] total benefits paid in 2010 were $516 billion" for those 47.5 million beneficiaries, or about $10,863 per beneficiary per year.

Sadly, $26 billion in last-year-of-life surgeries may only be part of the cost. According to the Lancet study, "Decedents who underwent a surgical procedure had higher adjusted mean number of hospital admissions than did those who were admitted to [the] hospital without a surgical procedure, spent nearly 50% more days in [the] hospital, and had almost twice as many days in intensive care." This could easily represent as much as 10 percent of the total annual Medicare expenditures.

An interesting correlation found in the study is that "regions with a high number of hospital beds per head had higher surgical intensity at the end of life than did those with fewer beds. Fisher and colleagues⁴ reported that residents of areas with a high number of hospital beds per head were up to 30 percent more likely to be admitted to [the] hospital than in those in areas with fewer beds per head, suggesting substantial discretion of health-care providers in deciding which patients to admit to [the] hospital." This was most pronounced in a comparison between Munster, Ind., which has a surgical intensity rate "three times higher" than Honolulu, Hawaii.

What is perhaps most interesting are the comments made by one of the investigators in an interview with ABC News.⁵ Dr. Ashish Jha, one of the authors of the Lancet study and an associate professor of health policy at Harvard School of Public Health, said, "[T]his level of surgical intensity doesn't seem to be having much in the way of benefit for the population. Our sense is that there are probably lots of unnecessary procedures that go on at end of life."

Ken Thorpe, a professor of health policy at Emory University, was also quoted in the ABC News article. He noted that "researchers are finding that these aggressive procedures have the same outcomes as less invasive, less expensive treatments. This study shows us there's an enormous opportunity to basically save money and provide less intervention, and still have the same quality of care and life expectancy."

As my mother is currently 79 years old, I can relate to the concerns about life expectancy and quality of life. If there were ever a time to be less aggressive and less invasive in health care, it is at this stage of her life. Many of these half-million surgeries are probably successful. But if the patient is forced to spend much of their last year, last month or last week sedated and in a hospital room, then the surgeons have forgotten that they are operating on real people.

Chiropractic, nutrition and other conservative forms of care should be the standard when caring for seniors. End-of-life surgeries are clearly a big business for surgeons and hospitals, but one wonders how much place they have in American health care. In the past, common sense has not led Medicare to the conclusion that conservative care is more beneficial in the last years of life. Perhaps our current economic trauma will help them see the light.

References

1. Kwok AC, Semel ME, Lipsitz SR, Bader AM, Barnato AE, Gawande AA, Jha AK. The intensity and variation of surgical care at the end of life: a retrospective cohort study. Lancet, Oct 5, 2011. [Epub ahead of print]
2. Top 31 Elective Inpatient Hospital DRGs. Fiscal Year 2006 Data. Updated: June 20, 2007.
3. 2011 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. May 13, 2011.
4. Fisher ES, Wennberg JE, Stukel TA, et al. Associations among hospital capacity, utilization, and mortality of US Medicare beneficiaries, controlling for sociodemographic factors. Health Serv Res, 2000;34:1351-62.
5. "Medicare Patients Get Costly Surgery Before Death." ABC News, Oct. 6, 2011.

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