The Incidence and Cumulative Risk of Major Surgery in Older Persons in the United States

Abstract

ImportanceAs the population of the United States (US) ages, there is considerable interest in ensuring safe and high-quality surgical care for older persons. Yet, valid, generalizable data on the occurrence of major surgery in the geriatric population are sparse.ObjectiveTo estimate the incidence and cumulative risk of major surgery in older persons over a 5-year period and evaluate how these estimates differ according to demographic and geriatric characteristics.DesignProspective longitudinal study.SettingContinental US from 2011 to 2016.Participants5,571 community-living fee-for-service Medicare beneficiaries, aged 65+, from the National Health and Aging Trends Study (NHATS).Main Outcomes and MeasuresMajor surgeries were identified through linkages with data from the Centers for Medicare & Medicaid Services. Data on frailty and dementia were obtained from the baseline NHATS assessment.ResultsThe nationally-representative incidence of major surgery per 100 person-years was 8.8 (95% confidence interval [CI], 8.2-9.5), with estimates of 5.2 (95% CI, 4.7-5.7) and 3.7 (95% CI, 3.3-4.1) for elective and non-elective surgeries. The adjusted incidence of major surgery peaked at 10.8 (95% CI, 9.4-12.4) in persons 75-79 years, increased from 6.6 (95% CI, 5.8-7.5) in the non-frail group to 10.3 (95% CI, 8.9-11.9) in the frail group, and was similar by sex (males 8.6 [95% CI, 7.7-9.6]; females 8.3 [95% CI, 7.5-9.1]) and dementia (no 8.6 [95% CI, 7.9-9.3]; possible 7.8 [95% CI, 6.3-9.6]; probable 8.1 [95% CI, 6.7-9.9]). The 5-year cumulative risk of major surgery was 13.8% (95% CI, 12.2%-15.5%), representing nearly 5 million unique older persons (4,958,048 [95% CI, 4,345,342-5,570,755]), including 12.1% (95% CI, 9.5%-14.6%) in persons 85-89 years, 9.1% (95% CI, 7.2%-11.0%) in those ≥90 years, 12.1% (95% CI, 9.9%-14.4%) in those with frailty, and 12.4% (95% CI, 9.8%-15.0%) in those with probable dementia.Conclusions and RelevanceMajor surgery is a common event in the lives of community-living older persons, including high-risk vulnerable subgroups such as the oldest old, those with frailty or dementia, and those undergoing non-elective surgery. The burden of major surgery in older Americans will add to the challenges ahead for the US health care system in our aging society.KEY POINTSQuestionWhat is the incidence and cumulative risk of major surgery in older persons in the United States?FindingsIn this prospective longitudinal study, data from 5,571 community-living fee-for-service Medicare beneficiaries were used to calculate nationally-representative estimates for the incidence and cumulative risk of major surgery over a 5-year period. Nearly 9 major surgeries were performed annually for every 100 older persons, and more than 1 in 7 Medicare beneficiaries underwent a major surgery over 5 years, representing nearly 5 million unique older persons.MeaningMajor surgery is a common event in the lives of community-living older persons.