In a study published last month in JAMA Surgery, researchers from the Yale School of Medicine evaluated the risk of major surgery to older adults, providing experts with valuable data on "long-term surgical outcomes for older adults," Judith Graham writes for Kaiser Health News. 

Study details and key findings

For the study, the researchers analyzed claims data from Medicare beneficiaries ages 65 and older in the National Health and Aging Trends study from 2011 to 2017.

Overall, there were 1,193 major surgeries among 992 participants during the study period. The average age of participants was 79.2. In total, 55.7% were women, 2.5% were Hispanic, 16.6% were non-Hispanic Black, and 76.7% were non-Hispanic white.

According to Graham, the researchers classified major surgeries as "[i]nvasive procedures that take place in operating rooms with patients under general anesthesia," including procedures like hip replacement, gallbladder removal, or heart surgery.

During a one-year follow-up period, the overall mortality rate among participants was 13.4%. The mortality rate was 7.4% for elective surgeries and 22.3% for nonelective surgeries.

According to study author Thomas Gill, who is a professor of medicine, epidemiology, and investigative medicine at Yale, and his colleagues, older adults typically experience more problems after a major surgery if they have chronic conditions, are weak before surgery, struggle with mobility, are no longer able to care for themselves, or have cognitive issues.

For instance, older adults with probable dementia faced a high risk of death following a major surgery, with a mortality rate of 32.7% within a year. For those who were considered frail, there was a 27.8% mortality rate at a one-year follow-up..

In addition, patients who were at an advanced age of 90 years old or older were six times more likely to die than participants ages 65 to 69.

Commentary

While patients 65 years and older undergo almost 40% of all surgeries in the United States, national data on the outcomes of these surgeries was previously limited.

"As a field, we've been really remiss in not understanding long-term surgical outcomes for older adults," said Zara Cooper, a professor of surgery at Harvard Medical School and the director of the Center for Geriatric Surgery at Brigham and Women's Hospital.

"What older patients want to know is, 'What's my life going to look like?'" Cooper said. "But we haven't been able to answer with data of this quality before."

In a study published last year in the Annals of Surgery, Gill and his team found that roughly 1 million major surgeries occur in individuals 65 and older annually. "Remarkably, data documenting the extent of surgery in the older population has been lacking until now," Graham writes.

"This opens up all kinds of questions: Were these surgeries done for a good reason? How is appropriate surgery defined? Were the decisions to perform surgery made after eliciting the patient's priorities and determining whether surgery would achieve them?" said Clifford Ko, a professor of surgery at UCLA School of Medicine and director of the Division of Research and Optimal Patient Care at the American College of Surgeons.

Ultimately, most patients choose to have surgery. Marcia Russell, a staff surgeon at the Veterans Affairs Greater Los Angeles Healthcare System, recently treated a 90-year-old patient who had been diagnosed with colon cancer. "We talked with him about surgery, and his goals are to live as long as possible," said Russell. "He may need six to eight weeks to get ready for surgery, but he's motivated to improve."

As the population of older Americans increases, "covering surgery is going to be fiscally challenging for Medicare," noted Robert Becher, an assistant professor of surgery at Yale, who collaborates on research with Gill. According to a 2020 analysis, more than half of Medicare spending is allocated to inpatient and outpatient surgical care.

Meanwhile, "nearly every surgical subspecialty is going to experience workforce shortages in the coming years," Becher said, adding there will be almost 30,000 fewer surgeons than are required to meet the expected demand in 2033.

These trends underscore the importance of improving surgical outcomes among older adults—but progress has been slow, Graham writes. (Graham, Kaiser Health News, 11/28; Gill et al., JAMA Surgery, 10/19)