Transcript Slide 1

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
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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?
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Some Decisions are Pretty Easy
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Some Decisions Are Pretty Easy
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Other Decisions Are Not So Easy
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Are Older Patients with Cancer
Undergoing Surgery?
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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
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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
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20
15
65-69
70-79
80+
10
5
0
Lung
Esophagus
Pancreas
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If Elderly Cancer Patients
Make It Through Surgery,
Do They Survive Long Term?
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5 year survival for age 80+ with cancer cohort - Lung, Pancreas and Esophagus
100
Lung
90
Pancreas
Esophagus
Survival Distribution Function(%)
80
70
60
50
40
30
20
10
0
0
10
20
30
40
50
60
Survival Time (Month)
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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
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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
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Discharge to SNF after Surgery,
by age
Operation
Age 6569
Age 7080
Age 80+
Lung resection
4%
8%
16%
Pancreatectomy
8%
16%
24%
Esophagectomy
6%
12%
30%
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OK…but those are big
operations.
What about the bread and
butter stuff?
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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+
Finlayson et al, Ann Surg, 2011
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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
Finlayson et al, Ann Surg, 2011
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Operative Mortality
Finlayson et al, Ann Surg, 2011
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Any invasive intervention
(%)
NH Resident
General
Population
Survivors
42.2
36.2
Deaths
63.0
61.2
Survivors
40.7
22.4
Deaths
56.8
54.6
Survivors
15.0
4.5
Deaths
40.7
36.0
Survivors
18.3
5.5
Deaths
40.3
Diagnosis
Bleeding DU
Benign colon
Cholecystitis
Appendicitis
43.2
Finlayson et al, Ann Surg, 2011
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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
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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
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28
29
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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
Finlayson et al, JAGS, in press
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Functional trajectories and
1 year morality
Finlayson et al, JAGS, in press
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Functional trajectories and
1 year morality, stratified by
baseline function
Finlayson et al, JAGS, in press
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ADL decline, maintenance of ADL,
and death
100%
90%
80%
70%
60%
ADL maintained
50%
ADL decline
Dead
40%
30%
20%
10%
0%
3 months
6 months
9 months
12 months
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Predictors of Functional Decline
Characteristic
% declined
RR, 95% CI
1.53
(1.15-2.04)
1.21
(1.11-1.32)
1.15
(1.03-1.29)
Age 80+
52.8
Pre-op decline
59.9
Hospital readmission
51.8
Surgical complication
55.3
1.11
(1.02-1.21)
Urgent admission
52.5
1.10
(1.03-1.18)
Finlayson et al, Ann Surg, 2011
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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
Treatment
Intensity
Health Outcome
Wants
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%
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There are
Important Differences
Between Decisions Made
by Elder Patients and
Their Surrogates
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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
Fried et al, Arch Intern Med, 2003
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How Can We
Improve Surgical Care
in Frail Elders?
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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
McGory et al, Ann Surg, 2009
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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
McGory et al, Ann Surg, 2009
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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
McGory et al, Ann Surg, 2009
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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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