Chicago—About 30,000 elderly nursing home residents undergo major gastrointestinal (GI) operations each year, and their risk for death is more than three times higher than community-dwelling seniors, according to a study presented at the 2009 Clinical Congress of the American College of Surgeons.

“Mortality after surgery in this population is extremely high,” said senior author Emily Finlayson, MD, MS, an assistant professor of surgery at the University of California, San Francisco.

Dr. Finlayson said that although she expected nursing home patients would experience higher than average mortality rates after major procedures, “the differences are even more dramatic than what [she] anticipated.”

The study found that nursing home residents who underwent six types of GI operations had mortality rates ranging from 30.1% after surgery for a bleeding gastroduodenal ulcer (GDU) to 8.5% for cholecystitis. The same procedures were associated with an average operative mortality of 10.3% and 1.5% among all Medicare beneficiaries.

The findings were based on an assessment of the Medicare Inpatient Files and the Medicare Minimum Data Set for the years 1999 and 2007. The researchers looked at mortality rates after surgery for bleeding GDUs, benign colon disease, colon cancer, cholecystitis and appendicitis, and compared the outcomes of 30,721 nursing home residents with 1.18 million Medicare beneficiaries.

Nursing home residents experienced significantly higher mortality for all types of surgery. Compared with the other seniors and depending on the procedure, mortality rates among nursing home residents ranged from three to eight times higher. Operative mortality among nursing home residents was 22.5% for benign colon disease compared with 6.5% for other seniors, 16% for colon cancer compared with 3.8%, and 8.7% for appendicitis compared with 0.9%.

However, study authors and practicing surgeons stress that nursing home residents should not be ruled out as surgical candidates for treatment of the serious GI conditions that, when untreated, are associated with mortality rates of near 100%.

“This study should not be viewed as an excuse to deny even definitive operative care for elderly nursing home patients,” cautioned Travis Webb, MD, an associate professor of surgery and a specialist in geriatric surgery at the Medical College of Wisconsin in Milwaukee.

Seniors requiring nursing home care are more likely to be deconditioned and malnourished and suffer cognitive impairments compared with other seniors, and they also tend to have worse preprocedural functional status—factors known to contribute to poorer surgical outcomes, he said.

“The study provides validation to concerns regarding performing major abdominal operations on elderly patients currently residing in nursing homes. As general surgeons, we must be aware of the high potential for complications and death in this frail patient population,” Dr. Webb said.

Experts said surgeons must provide patients and their families the realistic figures and recommendations needed for true informed consent.

The researchers plan to look next at the factors that increase mortality risks for nursing home residents. “If we can tease these things out, that’s when we can try to design interventions that would optimize outcomes in terms of preparing these patients for surgery and developing pathways and interventions postoperatively,” Dr. Finlayson said.

Dr. Finlayson said the study highlights the need for strategies to reduce mortality, suggesting consideration of steps such as alternative treatment strategies, advance directives and dedicated geriatric surgery protocols.

The study also showed that nursing home residents were more likely to undergo mechanical ventilation and receive a feeding tube than the general Medicare population. Of nursing home residents, 33% were mechanically ventilated following bleeding GDU, whereas only 15.7% of the general population required ventilation. For the same procedure, 15.7% of nursing home residents and 7.5% of the general Medicare population had a feeding tube placed.

As well, tracheostomy placement after surgery was shown to be rare among nursing home residents. It is used in 1.3% of elderly patients who undergo surgery for bleeding GDU, marginally higher than the 1.1% of the general population with tracheostomy placement after the same operation.

Nearly half of Americans older than 60 years will spend time in a nursing home and, increasingly, this population is considered eligible candidates for surgery.