Skip to main content

Three times higher rates of surgery before death in Munster, Indiana than Honolulu, Hawaii

A McMansion in Munster, IN, from Wikimedia Commons
Honolulu, HI, from Wikimedia Commons
Following up on our previous post about study that hinted at substantial regional variation in the effectiveness of advance directives, a new study in the Lancet describes considerable regional variation in surgical procedures right before death.  The authors examined claims for nearly 2 million Medicare recipients over age 65.  They found:

  • 32% had surgery in the last year of life
  • 18% had surgery in the last month of life
  • 8% had surgery in the last week of life
  • The good news is that rates of surgery before death varied by age, with the lowest rates among the oldest patients, suggesting some discretion on the part of surgeons
  • The bad news is the tremendous regional variation in rates of surgery before death.  Rates of surgery before death were 3 times higher in the highest region (Munster, IN) than the lowest region (Honolulu, HI).  As a Hawaiian who was transplanted to the midwest for my formative years, can I say this is just one more reason that Hawaii is superior?
Amy Kelley writes in a nice editorial that it's unfortunate that the likelihood of having potentially burdensome and futile surgery before death appears to vary not so much by medical appropriateness or patient preferences, but the arbitrariness of the local culture and financial incentive structure of your hospital.  She writes:
Surgeons, like general practitioners, are obliged to work with patients and their families to identify appropriate goals of care and recommend treatment plans that help achieve those goals. The personal commitment of thoughtful and well-trained practitioners, if supported by proper incentives and well designed health-care systems and programmes, will help to improve alignment of patients' preferences and treatment plans. 
 Well said.  Surgeons need to join the conversation.  Nice to see that Atul Gawande was a co-author on the study: if any surgeon has the power to lead surgeons toward improved communication skills, it's him.

by: Alex Smith

Comments

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Length of Stay in Nursing Homes at the End of Life

One out of every four of us will die while residing in a nursing home. For most of us, that stay in a nursing home will be brief, although this may depend upon social and demographic variables like our gender, net worth, and marital status. These are the conclusions of an important new study published in JAGS by Kelly and colleagues (many of whom are geripal contributors, including Alex Smith and Ken Covinsky).

The study authors used data from the Health and Retirement Study (HRS) to describe the lengths of stay of older adults who resided in nursing homes at the end of life. What they found was that out of the 8,433 study participants who died between 1992 and 2006, 27.3% of resided in a nursing home prior to their death. Most of these patients (70%) actually died in the nursing home without being transferred to another setting like a hospital.

 The length of stay data were striking:

the median length of stay in a nursing home before death was 5 months the average length of stay was l…

Palliative Care in Nursing Homes: Discussion of a Multinational Trial with Lieve Van den Block

Nursing homes are a tough place to do palliative care.  There is extremely high staff turnover, physicians are often not present except for the occasional monthly visit, many residents die with untreated symptoms usually after multiple hospitalizations and burdensome life-prolonging treatments, and specialty palliative care - well that is nowhere to be found in most nursing homes outside of hospice.  So what can we do to improve the palliative care outlook in nursing homes?

On todays podcast we talk with Lieve Van den Block about her recent palliative care intervention that was published in JAMA IM this week.  Lieve led a multicomponent intervention to integrate basic nonspecialist palliative care in in 78 nursing homes located in 7 different European countries.  Just take a moment to grasp the size of this study - 7 counties, 78 nursing homes.  I struggle with just trying to improve palliative care in one site!

We discuss with Lieve the results of the study, her take on why they got…