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<DIV class=timestamp>October 5, 2011</DIV>
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<H1><NYT_HEADLINE version="1.0" type=" ">Surgery Rate Late in Life Surprises
Researchers</NYT_HEADLINE></H1><NYT_BYLINE>
<H6 class=byline>By <A class=meta-per title="More Articles by Gina Kolata"
href="http://topics.nytimes.com/top/reference/timestopics/people/k/gina_kolata/index.html?inline=nyt-per"
rel=author>GINA KOLATA</A></H6></NYT_BYLINE><NYT_TEXT>
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<P>Surgery is surprisingly common in older people during the last year, month
and even week of life, researchers reported Wednesday, a finding that is likely
to stoke, but not resolve, the debate over whether medical care is overused and
needlessly driving up medical costs. </P>
<P>The most comprehensive examination of operations performed on <A
class=meta-classifier title="Recent and archival health news about Medicare."
href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/medicare/index.html?inline=nyt-classifier">Medicare</A>
recipients in the final year of life found that nationally in 2008, nearly one
recipient in three had surgery in the last year of life. Nearly one in five had
surgery in the last month of life. Nearly one in 10 had surgery in the last week
of life. </P>
<P>The very oldest patients were less likely to have surgery. Those who were 65
had a 38.4 percent chance of having surgery in the last year of life. For
80-year-olds, the chance was 35.3 percent, but the rates fell off more sharply
from there, declining by a third by age 90. </P>
<P>But such analyses are controversial. By looking only at people who died,
researchers can get a skewed picture of what is taking place, critics say. </P>
<P>“Because the patient died, you can’t assume that the treatment and therapies
were not of value,” said Dr. Peter B. Bach of Memorial Sloan-Kettering Cancer
Center. “Although in that individual, things may not have worked out, you have
no insight into whether the decision to operate was appropriate.” Nor is it
known how many similar patients who had that same surgery did not die. </P>
<P>But the sheer number of operations at the end of life was unexpected, said
the researchers, at Harvard School of Public Health. They added that they did
not know why the operations had been done. Some undoubtedly were necessary to
relieve pain and suffering or to prolong life. But, they said, they know from
experience that doctors often operate to repair something that can be fixed but
that will not save a dying patient, avoiding the difficult discussions with
patients about their prognosis and whether the surgery will improve or
compromise their quality of life. </P>
<P>In their study, published Wednesday in The Lancet, the investigators analyzed
data for all the 1,802,029 Medicare recipients 65 and older who died in 2008. In
addition to the number of operations nationally, they reported marked regional
variations in the use of surgery at the end of life. For example, the rate of
surgery in Honolulu was a third of that in Gary, Ind. </P>
<P>“Honolulu and Gary, Ind., can’t both be doing it right,” said Dr. Ashish Jha,
an associate professor of health policy at Harvard and the lead author of the
study. </P>
<P>But regional variations in health care have been controversial because it is
not clear whether they reflect true differences in patient needs or in health
care practices or regional differences in health care payment rules, Dr. Bach
said. </P>
<P>Dr. Scott Ramsey, an economist and a physician who is director of <A
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href="http://health.nytimes.com/health/guides/disease/cancer/overview.html?inline=nyt-classifier">cancer</A>
outcomes research at the Fred Hutchinson Cancer Research Center in Seattle,
faulted the researchers for citing regional differences but then suggesting a
long list of factors that might be causing them, including the health of the
population, the patterns of medical practice, and the availability of <A
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title="Recent and archival health news about hospice care."
href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/hospice_care/index.html?inline=nyt-classifier">hospice
care</A> and other end-of-life services. </P>
<P>Their list of potential explanations “covers about everything and says
absolutely nothing,” Dr. Ramsey said. </P>
<P>But the researchers said their study — done from public records and with no
financing — probably pointed to a real problem in American medicine: surgery,
which can be painful, expensive and debilitating, is tempting for doctors and
patients alike. </P>
<P>“I will admit to being guilty of this,” Dr. Jha said. “Often we say, ‘If you
have this intervention, we will be able to fix that problem. You have an
intestinal blockage. Surgery will fix it.’ But will it let you walk out of the
hospital alive? Will it let you return to your old life?” </P>
<P>Dr. Mark McClellan, a former commissioner of the Centers for Medicare and
Medicaid Services, who directs the Engelberg Center for Health Care Reform at
the Brookings Institution, said, “Evidence like this — and a lot of previous
evidence, directly from patients and their families — shows that we need much
better support for patients and their families when they have serious illnesses
and may need intensive treatments.” </P>
<P>Dr. Jha said he and his colleagues were continuing to study the causes and
consequences of surgery at the end of life, adding, “It is hard to take these
data and make clear policy recommendations about what is appropriate and what is
not.” </P>
<P>But he said he had no doubt that the difficult conversations that should
precede a decision to operate all too often never occurred. </P>
<P>“As clinicians, we often end up focusing on something narrow and small that
we think we can fix,” Dr. Jha said. “That leads us down the path of surgical
intervention. But what the patient cares about is not going to get fixed.” </P>
<P>Dr. Jha provided a recent example from his hospital. A man had metastatic <A
class=meta-classifier
title="In-depth reference and news articles about Pancreatic carcinoma."
href="http://health.nytimes.com/health/guides/disease/pancreatic-carcinoma/overview.html?inline=nyt-classifier">pancreatic
cancer</A> and was dying. A month earlier, he had been working and looked fine.
</P>
<P>“No one had talked to him about how close he was to death,” Dr. Jha said.
“It’s the worst kind of conversation to have.” </P>
<P>Instead, doctors did an <A class=meta-classifier
title="In-depth reference and news articles about Endoscopy."
href="http://health.nytimes.com/health/guides/test/endoscopy/overview.html?inline=nyt-classifier">endoscopy</A>
and a <A class=meta-classifier
title="In-depth reference and news articles about Colonoscopy."
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because the man had internal bleeding. Then they did abdominal surgery. “We did
all of this because we were trying desperately to find something we could fix,”
Dr. Jha said. </P>
<P>The man died of a complication from the surgery. </P>
<P>“The tragedy is what we should have done for him but didn’t,” Dr. Jha said.
“We should have given him time to have the conversation he wanted to have with
his family. You can’t do that when you are in pain from surgery, groggy from <A
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title="Recent and archival health news about anesthesia and anesthetics."
href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/anesthesiaandanesthetics/index.html?inline=nyt-classifier">anesthesia</A>.
We should have controlled his pain. We should have controlled his nausea.” </P>
<P>Instead, Dr. Jha said, “we sent him to the O.R.” </P><NYT_CORRECTION_BOTTOM>
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<DIV><FONT size=2 face=Verdana>____________________________________</FONT></DIV>
<DIV><FONT size=2 face=Verdana>Wayne A. Fox<BR><A
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