Patient Selection and Disclosure Emily Finlayson, MD, MS Department of Surgery University of California, San Francisco.

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

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