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

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...

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Bibliographic Details
Published in:The Lancet (British edition) 2011-10, Vol.378 (9800), p.1408-1413
Main Authors: Kwok, Alvin C, MD, Semel, Marcus E, MD, Lipsitz, Stuart R, ScD, Bader, Angela M, MD, Barnato, Amber E, MD, Gawande, Atul A, MD, Jha, Ashish K, Dr
Format: Article
Language:English
Subjects:
Aged
Aged, 80 and over
Beneficiaries
Biological and medical sciences
Codes
cohort studies
correlation
death
elderly
equations
Ethics
Fee-for-Service Plans
Female
General aspects
Hospitalization - statistics & numerical data
Hospitals
Humans
Income
Intensive Care Units - utilization
Internal Medicine
Male
Medical sciences
Medicare
Palliative care
patients
Payment systems
people
Public health. Hygiene
Public health. Hygiene-occupational medicine
Sensitivity analysis
Studies
Surgery
Surgical Procedures, Operative - statistics & numerical data
Teaching. Deontology. Ethics. Legislation
Terminal Care
United States
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Summary: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
ISSN:0140-6736
1474-547X
DOI:10.1016/S0140-6736(11)61268-3