A recent study has found that nearly one out of every seven older people die within a year of undergoing major surgery, shedding much-needed light on the risks faced by seniors, particularly the more vulnerable, during invasive procedures.
Most at risk are older patients with probable dementia (33% die within a year) and frailty (28%), as well as those having emergency surgeries (22%), reports KHN. Advanced age also amplifies risk, said the research, with those 90 or older six times as likely to die than those aged 65 to 69.
The study in JAMA Surgery, published by researchers at Yale School of Medicine, addresses a notable gap in research: Though patients 65 and older undergo nearly 40% of all surgeries in the US, detailed national data about the outcomes of these procedures has been largely missing.
“As a field, we’ve been really remiss in not understanding long-term surgical outcomes for older adults,” said Dr Zara Cooper, a professor of surgery at Harvard Medical School and the director of the Centre for Geriatric Surgery at Brigham and Women’s Hospital in Boston.
Of particular importance is information about how many seniors die, develop disabilities, can no longer live independently, or have a significantly worsened quality of life after major surgery.
“What older patients want to know is, ‘What’s my life going to look like?’” Cooper said. “But we haven’t been able to answer with data of this quality before.”
In the latest study, Dr Thomas Gill and Yale colleagues examined claims data from traditional Medicare and survey data from the National Health and Aging Trends study spanning the years from 2011 to 2017.
Invasive procedures in operating rooms with patients under general anaesthesia were counted as major surgeries. Examples include procedures to replace broken hips, improve blood flow in the heart, excise cancer from the colon, remove gallbladders, fix leaky heart valves, and repair hernias, among many more.
Older adults tend to experience more problems after surgery if they have chronic conditions like heart or kidney disease; if they are already weak or have difficulty moving around; if their ability to care for themselves is compromised; and if they have cognitive problems, noted Gill, a professor of medicine, epidemiology, and investigative medicine at Yale.
Two years ago, Gill’s team conducted research that showed one in three older adults had not returned to their baseline level of functioning six months after major surgery. Most likely to recover were seniors who had elective surgeries for which they could prepare in advance.
In another study, published last year in the Annals of Surgery, his team found that about 1m major surgeries occur in individuals 65 and older each year, including a significant number near the end of life. Remarkably, data documenting the extent of surgery in the older population have been lacking until now.
“This opens up all kinds of questions: Were these surgeries done for a good reason? How is appropriate surgery defined? Were the decisions to perform surgery made after eliciting the patient’s priorities and determining whether surgery would achieve them?” said Dr Clifford Ko, a professor of surgery at UCLA School of Medicine and director of the Division of Research and Optimal Patient Care at the American College of Surgeons.
As an example of this kind of decision-making, Ko described a patient who, at 93, learned he had early-stage colon cancer on top of pre-existing liver, heart, and lung disease. After an in-depth discussion and being told that the risk of poor results was high, the patient decided against invasive treatment.
“He decided he would rather take the risk of a slow-growing cancer than deal with a major operation and the risk of complications,” Ko said.
Still, most patients choose surgery. Dr Marcia Russell, a staff surgeon at the Veterans Affairs Greater Los Angeles Healthcare System, described a 90-year-old patient who recently learned he had colon cancer during a prolonged hospital stay for pneumonia.
“We talked to him about surgery, and his goals are to live as long as possible,” said Russell. To help prepare the patient, now recovering at home, for future surgery, she recommended he undertake physical therapy and eat more high-protein foods, measures that should help him get stronger.
“He may need six to eight weeks to get ready for surgery, but he’s motivated to improve,” Russell said.
The choices older Americans make about undergoing major surgery will have broad societal implications. As the 65-plus population expands, “covering surgery is going to be fiscally challenging for Medicare”, noted Dr Robert Becher, an assistant professor of surgery at Yale and a research collaborator with Gill. Just over half of Medicare spending is devoted to inpatient and outpatient surgical care, according to a 2020 analysis.
What’s more, “nearly every surgical subspecialty is going to experience workforce shortages in the coming years”, Becher said, noting that in 2033, there will be nearly 30 000 fewer surgeons than needed to meet expected demand.
Study 1 details
Population-Based Estimates of 1-Year Mortality After Major Surgery Among Community-Living Older US Adults
Thomas Gill, Brent Vander Wyk, Linda Leo-Summers et al.
Published in JAMA Surgery on 19 October 2022
Key Points
Question What are the population-based estimates of 1-year mortality after major surgery among community-living older US adults?
Findings In this cohort study of 1193 major surgeries identified from 992 community-living participants, overall 1-year mortality was 13.4%. More than 1 of 4 community-living older US adults who were frail and nearly 1 of 3 who had probable dementia died in the year after major surgery.
Meaning In this study, mortality after major surgery was found to be elevated among older persons who are frail or who have probable dementia, highlighting the potential prognostic value of geriatric conditions.
Abstract
Importance
Despite their importance to guiding public health decision-making and policies and to establishing programs aimed at improving surgical care, contemporary nationally representative mortality data for geriatric surgery are lacking.
Objective
To calculate population-based estimates of mortality after major surgery in community-living older US adults and to determine how these estimates differ according to key demographic, surgical, and geriatric characteristics.
Design, Setting, and Participants
Prospective longitudinal cohort study with 1 year of follow-up in the continental US from 2011 to 2018. Participants included 5590 community-living fee-for-service Medicare beneficiaries, aged 65 years or older, from the National Health and Aging Trends Study (NHATS). Data analysis was conducted from February 22, 2021, to March 16, 2022.
Main Outcomes and Measures
Major surgeries and mortality over 1 year were identified through linkages with data from the Centers for Medicare & Medicaid Services. Data on frailty and dementia were obtained from the annual NHATS assessments.
Results
From 2011 to 2017, of the 1193 major surgeries (from 992 community-living participants), the mean (SD) age was 79.2 (7.1) years; 665 were women (55.7%), and 30 were Hispanic (2.5%), 198 non-Hispanic black (16.6%), and 915 non-Hispanic white (76.7%). Over the 1-year follow-up period, there were 206 deaths representing 872 096 survey-weighted deaths and 13.4% (95% CI, 10.9%-15.9%) mortality. Mortality rates were 7.4% (95% CI, 4.9%-9.9%) for elective surgeries and 22.3% (95% CI, 17.4%-27.1%) for nonelective surgeries. For geriatric subgroups, 1-year mortality was 6.0% (95% CI, 2.6%-9.4%) for persons who were nonfrail, 27.8% (95% CI, 21.2%-34.3%) for those who were frail, 11.6% (95% CI, 8.8%-14.4%) for persons without dementia, and 32.7% (95% CI, 24.3%-41.0%) for those with probable dementia. The age- and sex-adjusted hazard ratios for 1-year mortality were 4.41 (95% CI, 2.53-7.69) for frailty with a reduction in restricted mean survival time of 48.8 days and 2.18 (95% CI, 1.40-3.40) for probable dementia with a reduction in restricted mean survival time of 44.9 days.
Conclusions and Relevance
In this study, the population-based estimate of 1-year mortality after major surgery among community-living older adults in the US was 13.4% but was 3-fold higher for nonelective than elective procedures. Mortality was considerably elevated among older persons who were frail or who had probable dementia, highlighting the potential prognostic value of geriatric conditions after major surgery.
Study 2 details
The Incidence and Cumulative Risk of Major Surgery in Older Persons in the United States
Robert Becher , Brent Vander Wyk, Linda Leo-Summers, Mayur Desai, Thomas Gill.
Published in the Annals of Surgery on 14 July 2021
Abstract
Objective
The objective of this study was to estimate the incidence and cumulative risk of major surgery in older persons over a 5-year period and evaluate how these estimates differ according to key demographic and geriatric characteristics.
Background
As the population of the United States ages, there is considerable interest in ensuring safe, high-quality surgical care for older persons. Yet, valid, generalizable data on the occurrence of major surgery in the geriatric population are sparse.
Methods
We evaluated data from a prospective longitudinal study of 5,571 community-living fee-for-service Medicare beneficiaries, aged 65 or older, from the National Health and Aging Trends Study (NHATS) from 2011 to 2016. Major surgeries were identified through linkages with Centers for Medicare & Medicaid Services data. Population-based incidence and cumulative risk estimates incorporated NHATS analytic sampling weights and cluster and strata variables.
Results
The nationally-representative incidence of major surgery per 100 person-years was 8.8, with estimates of 5.2 and 3.7 for elective and non-elective surgeries. The adjusted incidence of major surgery peaked at 10.8 in persons 75-79 years, increased from 6.6 in the non-frail group to 10.3 in the frail group, and was similar by sex and dementia. The 5-year cumulative risk of major surgery was 13.8%, representing nearly 5 million unique older persons, including 12.1% in persons 85-89 years, 9.1% in those ≥90 years, 12.1% in those with frailty, and 12.4% in those with probable dementia.
Conclusions
Major surgery is a common event in the lives of community-living older persons, including high-risk vulnerable subgroups.
KHN article – Should Older Seniors Risk Major Surgery? New Research Offers Guidance
See more from MedicalBrief archives:
Elderly may benefit from more invasive treatment — large 7-year study
Longer life for elderly from TAVR
UK elderly denied life-saving operations
Hidden toll of delirium on hip fracture patients – 2022 report
Less aggressive treatment for the oldest