Surgery in the last year of life

Lancet recently published a fascinating study of surgery in the last year of life in Medicare members.  During 2008, 1,802,029 Medicare beneficiaries over 65 years of age died; one of every three of those had a surgical procedure during his or her last year of life.  The study did not sort out the reasons the procedures were done, but there is a short list of possibilities. Some are likely valid, and some are less so.  Surgery in the elderly can be done to relieve pain, to improve function, or to prolong life.  You might point out that prolonging life or improving function in the last year of life doesn’t make much sense, but remember, no one actually knew at the time that it was the last year of life.  Other reasons for doing these procedures are harder to support and include doing things just because you know how to do them (the “everything looks like a nail if you are a hammer” argument), family pressure (“You have to do everything to save her.”), and money (“There is an opening in the surgery schedule and a bed in the ICU.”).
There was one other interesting part of the study—geographical variation.  These late life surgeries were 1/3 as common in Honolulu as in Gary, Indiana.  The rates were especially high around the southern end of Lake Michigan and in the Rio Grande Valley in south Texas. Geographic variations are much more consistent with decisions made for cultural and financial reasons than with decisions based on clinical factors.
Most of the rhetoric surrounding the Medicare financial crisis has concentrated on cutting plan profits and decreasing provider reimbursements. There has also been a push for preventive care with the tacit (and unproven) assumption that prevention will improve health and decrease expense in the elderly. There has been some discussion (albeit hesitant) of increasing the contribution from beneficiaries or increasing the age of eligibility.  What has not been emphasized is spending what is in the system more effectively.  The high rate of surgery in the last year of life is one of several examples of spending a great deal of money with questionable impact of either quality or length of life. Until we have the political and societal will to have those discussions, Medicare’s financial dilemma will remain unsolved.