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