• Reflex: October 11, 2011

    Many Medicare patients get surgeries in their last year of life, reports Amanda Gardner. She cites a new study in the Lancet that reports that, “in a group of almost 2 million elderly beneficiaries, all of whom died in 2008, almost one-third had inpatient surgery in the year before they died, almost one in five in the last month of their lives and almost one in 10 in the week before they took their last breath.”Aaron’s comment: I’m not saying that all of these surgeries are unnecessary, but some of the 10% that occurred in the last week of life and some of the 20% that occurred in the last month of life could likely have been avoided. We simply have to find a way to address end-of-life care better.

    The trouble with Prostate screening tests is that it is common and often leads to overtreatment, writes Madison ParkThe U.S. Preventive Services Task Force, an independent panel of experts, reviewed the existing evidence and has released draft recommendations about the use of a screening test, the PSA, that would recommend that it be done far less often. Don’s comment: this is an unsettling development for many who have received the PSA and undergone treatment, as well as for those who must decide along with their doctor whether they should get the test or not. Addressing such controversies head on by asking 3 questions about such a test (does it extend life, does it improve quality of life, how much does it cost?) is a step toward a sustainable health care system. We have to learn how to talk about these difficult issues.This is part of what cost control will look like.

    Liberals are exploring backup options if the individual mandate is declared unconstitutional, reports Jennifer Haberkorn (Politico). “If the mandate fell and Republicans retain control of the House in 2013, it would be difficult for supporters of the national health care law to get much through Congress. States, especially those with Democratic-controlled legislatures, would be able to move more quickly.” Austin’s comment: There are plenty of state-based ideas to replace the national mandate.

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    • The Gardner piece makes me wonder about the following scenario. Take a patient on Medicare. Let’s say – a 75 year old with stage 2 ovarian cancer.

      Take their vital and demographic statistics. Feed them to a robot programmed to make decisions in strict accordance with NICE’s QALY algorithm, and a doctor who believes that you can make reliable determinations about whether or not care was worth giving based upon how soon it was administered before death.

      Will the patient be able to tell the difference, and which will seem more human? The answer is not clear to me.

    • Honestly, I was really disappointed in the Gardner article and other coverage of the Lancet study. I feel like the coverage makes it sound like big unnecessary surgery is being done on terminal patients, when really many of the things they count are diagnostic, very minor procedures, or in some cases even palliative and within the realm of hospice and other end of life care regimens…
      Not sure if others saw this as it was in the article appendix, but here were the top ten procedures (I’ll only list those for people having surgery in the last year), these procedures make up 31% of all procedures being done for folks in the last year of life (out of thousands of ICD-9 codes…)

      EGD w/ biopsy
      Small bowel endoscopy
      PEG tube placement
      Left heart cardiac cath
      Wound debridement
      Colonoscopy
      PTCA or Coronary Atherectomy
      IVC filter placement
      Open reduction and internal fixation of femur
      Temporary Tracheostomy

      From EGD to Colonoscopy is almost 25% of all procedures done in the last year of life…
      I guess my question is, of those procedures which one’s should we be doing less of?