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Patient Selection and Disclosure
Emily Finlayson, MD, MS
Department of Surgery
University of California, San Francisco
What we’re going to cover
• Mortality after surgery in the elderly
– Fact v Fantasy
• Recovery after surgery
– Longer than your surgeon said it was going to be
• What patients value
– Not always the same as your family or your surgeon
2
Context
• Population is aging
– 274 million 352 million
– 13% of population 20% of population
• An increasing number of very elderly patients will be candidates for major surgery
• Are these patients undergoing surgery?
3
It’s a cancer, so it has to come
out, right?
4
Some Decisions are Pretty Easy
5
Some Decisions Are Pretty Easy
6
Other Decisions Are Not So Easy
7
Are Older Patients with Cancer
Undergoing Surgery?
8
O’Connell et al, Ann Surg Oncol, 2004
Assumptions
• Surgery in the elderly is getting safer
• ‘Esophageal resection for carcinoma in patients older than 70 years old.’
Ann Surg Oncol. 2002;9(2):210-214.
• ‘Pancreaticoduodenectomy in the very elderly.’ Jour GI Surg. 2006;10(3):347-56.
Are These Results Generalizable?
• Selective submission, publication bias
• Consider the source
– Centers of Excellence
• Trial data
– Sick and elderly patients often excluded
• “Real world” mortality and survival data
– The ‘benefits’ side of the equation
11
National Benchmark Data: Mortality after Major Cancer Surgery
• Retrospective cohort study of patients 65+ undergoing major cancer resections (n=14,088)
– Lung
– Esophageal
– Pancreas
• SEER-Medicare (1992-2001)
• Outcomes
– Operative mortality
– 5-year survival
Finlayson et al, J Am Coll Surg, 2007
13
0
5
10
15
20
25
Lung Esophagus Pancreas
65-69
70-79
80+
14
If Elderly Cancer Patients
Make It Through Surgery,
Do They Survive Long Term?
15
5 year survival for age 80+ with cancer cohort - Lung, Pancreas and Esophagus
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60
Survival Time (Month)
Surv
ival
Dis
tribu
tion
Func
tion(
%)
Lung
Pancreas
Esophagus
16
Comorbidity Counts
Cancer 5 year survival (%)
Lung
<2 comorbidities 37
2+ comorbidities 28
Esophagus
<2 comorbidities 21
2+ comorbidities 17
Pancreas
<2 comorbidities 18
2+ comorbidities 5
17
National Benchmark Data: Discharge Disposition
• Retrospective cohort study of patients undergoing major cancer resections (N= 601,081)– Lung– Esophageal– Pancreas
• Nationwide Inpatient Sample (1994-2003)– Discharge disposition stratified by age
Finlayson et al, J Am Coll Surg, 2007
Discharge to SNF after Surgery, by age
18
Operation Age 65-69
Age 70-80
Age 80+
Lung resection 4% 8% 16%
Pancreatectomy 8% 16% 24%
Esophagectomy 6% 12% 30%
OK…but those are big operations.
What about the bread and butter stuff?
19
GI surgery in NH Residents
• NH residents 65+ undergoing GI surgery in the US
• Medicare inpatient file + MDS (1999-2006), N=70,719
– Bleeding DU
– Benign colon disease
– Cholecystitis
– Appendicitis
• Operative mortality compared to 1.1 million Medicare beneficiaries 65+
20Finlayson et al, Ann Surg, 2011
Outcomes of Interest
• Operative mortality
• Secondary interventions
– Mechanical ventilation > 96 hrs
– Central venous catheterization
– PA catheter placement
– IVC filter placement
– Bronchoscopy
– Feeding tube placement
– Tracheostomy placement
21Finlayson et al, Ann Surg, 2011
22
Operative Mortality
Finlayson et al, Ann Surg, 2011
23
Any invasive intervention(%)
DiagnosisNH Resident
General Population
Bleeding DU Survivors 42.2 36.2
Deaths 63.0 61.2
Benign colon
Survivors 40.7 22.4
Deaths 56.8 54.6
Cholecystitis Survivors 15.0 4.5
Deaths 40.7 36.0
Appendicitis Survivors 18.3 5.5
Deaths 40.343.2
Finlayson et al, Ann Surg, 2011
What other choice do we have?
• Life and death situations….
• Consider alternative therapies in patients with limited life expectancy
– Antibiotics
– Cholecystostomy tube
– Colonic stents
– IR for bleeding
24
What do we know about
the trajectory of recovery
after major surgery?
Functional Status after Surgery
• 372 patients age 60+
• Elective major abdominal operations (GS, GYN)
• Functional assessments
– Preoperative
– 1, 3, and 6 weeks, 3 and 6 months
Lawrence et al, J Am Coll Surg, 2004
2727
28
29
30
What about
functional recovery
in the very frail?
Functional Outcomes in NH Residents
• NH residents 65+ undergoing colectomy for cancer
• Medicare inpatient file + MDS (1999-2006), N=6822
• Functional trajectories after surgery
– MDS-ADL score (0-28)
• 1 year mortality
32Finlayson et al, JAGS, in press
Functional trajectories and 1 year morality
33Finlayson et al, JAGS, in press
Functional trajectories and 1 year morality, stratified by
baseline function
34Finlayson et al, JAGS, in press
ADL decline, maintenance of ADL, and death
35
36
Characteristic % declined RR, 95% CI
Age 80+ 52.81.53
(1.15-2.04)
Pre-op decline 59.91.21
(1.11-1.32)
Hospital readmission 51.81.15
(1.03-1.29)
Surgical complication 55.31.11
(1.02-1.21)
Urgent admission 52.51.10
(1.03-1.18)
Finlayson et al, Ann Surg, 2011
Predictors of Functional Decline
What outcomes are really valued by
older patients with limited life
expectancy?
Treatment Preferences in Patients with Limited Life Expectancy
• 226 subjects with limited LE given hypothetical scenarios
• Burden of treatment
– LOS, testing, invasive procedures
• Expected outcome
– Restoration of current health
– Death
– Functional impairment
– Cognitive impairment
Fried et al, N Engl J Med, 2002
39
Treatment Intensity
Health OutcomeWants
treatment
Low Burden Return to Current Health
98.7%
High Burden Return to Current Health
88.9%
Low Burden Functional Impairment
25.6%
Low Burden Cognitive Impairment
11.2%
There are Important Differences
Between Decisions Made by Elder Patients and
Their Surrogates
41
Patient-Surrogate Agreement about Acceptable Outcomes
• >80% for health states
– Current health, mild memory impairment
– Coma
• 61-65% for severe pain
– Patients/surrogates equally likely to rate as acceptable
• 58-62% for severe functional impairment
– Surrogates more likely to rate as acceptable
42Fried et al, Arch Intern Med, 2003
How Can We Improve Surgical Care
in Frail Elders?
43
Developing Quality Indicators for Elderly Surgical Patients
• RAND/UCLA project
– Expert panel from surgery, geriatrics, anesthesia, critical care, internal, and rehabilitation medicine
– Formally rated the indicators using a modification of the RAND/UCLA Appropriateness Methodology
– Identified 91 candidate indicators rated as valid
44McGory et al, Ann Surg, 2009
Developing Quality Indicators for Elderly Surgical Patients
• 6 Domains Unique to Elderly Patients
– Comorbidity assessment
– Evaluation of elderly issues
– Medication use
– Patient-to-provider discussions
– Postoperative management
– Discharge planning
45McGory et al, Ann Surg, 2009
Elderly-Specific Process Measures
• Patient-to-provider discussions
– Assess patient’s decision-making capacity
– Specific discussions on expected functional outcomes
– Advanced directives: life-sustaining preferences, surrogate decision maker
– Clarify goals of care
46McGory et al, Ann Surg, 2009
Summary
• Nationwide, operative mortality remains high and survival is low among the very elderly undergoing major cancer surgery
• Even for less complex procedures, mortality is very high in frail patients
• Functional recovery after major surgery is protracted in elders
• Patients with poor prognosis value function, cognition, and quality of life very highly
Implications
• Comprehensive assessment
– Medical
– Functional
– Cognitive
• Realistic expectations essential for true informed consent
• Need for multidisciplinary approach, care pathways for geriatric patients
48
