Some common surgeries for seniors should be considered “high risk” and preceded by careful conversations about the potential harms, according to a new study listing 227 operations with high mortality rates.
The risks of surgery for older adults are generally understood, but establishing a comprehensive list of the most problematic, for which the risks and benefits “should be carefully evaluated,” can be a helpful decisionmaking tool, the authors say.
Designation of a surgery as high risk presents an opportunity for patients to pause and consider the value of surgery over alternative treatments, or “prepare for the real potential of an unwanted outcome,” they write in a study published Wednesday in JAMA Surgery.
The team of researchers generated the list using admissions data of patients 65 years and older from two population-based cohorts dating between 2001 and 2007. They identified procedures using ICD-9-CM codes associated with a mean crude in-hospital mortality rate of at least 1%. They found a broad collection of high-risk cardiac, gastrointestinal, neurosurgical, thoracic, urological and vascular procedures.
Ten surgeries were the most problematic for older patients during emergency admissions: adrenal gland removal, removal of plaque buildup from the carotid arteries, arm blood-vessel replacement, abdominal vein resection or replacement, varicose vein removal, high gastric bypass, proctopexy, bile duct excision, a urinary reconstruction technique and ureter repair.
For both urgent and elective admissions, there were a total of 227 surgeries that were high risk (PDF) for patients 65 and older, compared with 154 for younger patients. At 6%, the pooled mortality was twice as high for older patients compared with their younger counterparts.
But the authors note the list was developed for the older patients. Although they examined the results in a younger cohort, the list of procedures common among those age groups may be incomplete.
The high-risk list includes coronary artery bypass grafting (CABG), heart valve procedures, small bowel resection and surgical removal of the lungs. Those procedures are also among the 20 most costly surgeries in the U.S., according to a 2014 report from the Agency for Healthcare Research and Quality (PDF).
The mean costs per hospital stay for those surgeries were $53,400 for heart valve procedures, $38,700 for CABG, $34,500 for small bowel resection, and $23,000 for the surgical removal of one or both lungs, the AHRQ report found.
The JAMA Surgery study authors (who work for the University of Wisconsin at Madison, the University of Pittsburgh, Beth Israel Deaconess Medical Center in Boston, and the University of Utah in Salt Lake City) say their list can be used to standardize the definition of high-risk surgery for older adults and to design targeted clinical interventions. “The risks and benefits of surgery should be carefully evaluated to assure that trade-offs between surgical treatment and nonsurgical options have been fully considered.”
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