Older adults with serious illness face greater burdens after elective surgery

Older adults who have serious illness before undergoing elective surgery had hospital stays twice as long as similarly aged counterparts; were twice as likely to return to the hospital or the emergency department; and had almost double the yearly costs of health care, according to a study published in the Journal of the American College of Surgeons.

We were looking at the palliative care needs of this group of patients to see whether we could identify points to intervene. These needs were high in older adults with serious illness and who were going for major elective surgery."

Jolene Wong Si Min, MD, lead study author of the Center for Surgery and Public Health at Brigham and Women's Hospital in Boston and the National Cancer Center Singapore and Singapore General Hospital

The study used data from the Health and Retirement Survey linked to Medicare claims and analyzed data from 2,499 patients aged 66 and older who had major elective surgery between 2007 and 2019.

Key findings

• 79% of the study population had one of four clinical characteristics indicating a need for palliative care before undergoing elective surgery: moderate to severe pain; depression; functional dependence; and a need for a care partner.
• 63% of this population had serious illness.
• Seriously ill older adults with palliative care needs before surgery had higher rates of total hospital stays compared with patients who did not have serious illness before surgery.
• Adjusted one-year health care costs averaged $38,187 for this population compared with $20,129 for those without serious illness.

The study defined serious illness as any life-limiting condition that affects an individual's quality of life or causes excessive strain on care partners. Palliative care, according to the authors, focuses on improving the quality of life through the relief of pain and psychological symptoms, addressing functional needs, and providing care partner support, among others.

"Among the four characteristics that we looked at, depression had the highest significance when it comes to having an association with health care utilization and costs," Dr. Wong said. "If you were to choose any target to treat, it should be depression."

Patients with serious illness and depression had significantly higher rates of health care utilization than patients without serious illness.

"An important next step would be to see how we can successfully incorporate palliative care practices in the care of seriously ill patients going for routine elective surgery," Dr. Wong said.

While some health care advocates have held out a model of embedding palliative care specialists with surgical teams, Dr. Wong said the study authors believe training surgeons to be attentive to palliative care needs would be a more practical approach.

"Future research would be in a generalist palliative care model," Dr. Wong said. "We feel strongly that surgeons should be trained to understand how palliative care applies to surgical practice because these needs are so common."

Senior author of the study is Zara Cooper, MD, MSc, FACS, of the Center for Surgery and Public Health at Brigham and Women's Hospital in Boston. Study co-authors are Yihan Wang, PhD; Evan Bollens-Lund, MA; Amanda J. Reich, PhD, MPH; Hiba Dhanani, MD; Claire K. Ankuda, MD, MPH; Stuart Lipsitz, ScD; Tamryn F. Gray, PhD, RN, MPH, ScD; Christine S. Ritchie, MD, MSPH; and Masami Tabata-Kelly, MBA, MA.