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Ann Thorac Surg 1995;60:96-100
© 1995 The Society of Thoracic Surgeons

Cardiac Operations in Patients Aged 70 Years and Over: Mortality, Length of Stay, and Hospital Charge

Department of Surgery, Georgetown University Medical Center, Washington, DC

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. With emphasis today on cost containment in health care, the results and costs of cardiac operations in elderly patients are being scrutinized.

Methods. Our computerized database was used to obtain the characteristics of patients undergoing cardiac operations from January 1990 to July 1994. A study group of 628 patients aged 70 years and over was identified, and comparisons were made between them and adult patients less than 70 years of age.

Results. In the elderly group the 30-day mortality was 33 of 628 (5.3%), and the overall hospital mortality was 40 (6.4%). During this time the 30-day mortality for all adult patients less than 70 years old was 49 of 1787 (2.7%; p < 0.003) and the hospital mortality was 59 (3.3%; p < 0.001). The mean length of postoperative hospital stay (days ± standard error) in all surviving patients aged 70 years and over was 11.6 ± 0.4 days, compared with 8.5 ± 0.2 days in patients less than 70 years old (p < 0.001). Over the time of the study the length of stay in patients less than 70 years old declined from 9.6 ± 0.4 to 7.2 ± 0.6 days, whereas it stayed the same for elderly patients. The 30-day mortality and length of stay increased with the risk category of the Parsonnet model. The mean hospital charge for patients aged 70 and over was 114% of that for younger patients.

Conclusions. Although mortality, length of stay, and hospital charge are increased in patients 70 years of age and over, they are not excessively so. The results support the continued performance of cardiac surgical procedures in select elderly patients.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
See also page 100.

Changes in our health care system have been directed toward extending coverage and containing cost. The results and costs of open heart surgical procedures in elderly patients are being scrutinized because past studies have documented increased mortality, complications, and length of hospitalization in older patients [1–4]. New systems of health care may well involve some rationing of expensive treatments such as cardiac operations. With recent advances in myocardial preservation and intensive care, the risks and costs of cardiac operations in the elderly may in fact be less than those in the past. The purpose of this study was to determine our results in patients 70 years of age and over who underwent cardiac operations and to compare them with those in a concurrent group of patients younger than 70 years. To interpret better the results of the study, the risk stratification system described by Parsonnet and colleagues [5] was employed.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
The computerized Cardiovascular Surgery Database for Georgetown University Medical Center was used to obtain the characteristics of patients undergoing cardiac operations during January 1990 to July 1994. During that time 628 patients 70 years of age and over underwent cardiac operations at our center. The age distribution is shown in Table 1. The mean age of these patients was 75 ± 0.2 years (standard error). The types of operation were as follows: coronary artery bypass grafting (CABG), 427 (68%); combined CABG and valve procedure, 78 (12%); valve procedure, 118 (19%); and other, 5 (1%). There were 580 (92%) primary operations, 43 (7%) first reoperations, and 5 (1%) second reoperations. An emergency procedure was performed in 59 (9%) patients. In patients undergoing isolated CABG the mean number of grafts per patient was 3.0 ± 0.02, and 333 patients (78%) received at least one internal mammary artery graft.

Standard techniques of cardiopulmonary bypass were employed. Myocardial preservation was achieved by cold blood cardioplegia. The cardioplegia solution was given antegradely or retrogradely, or both, with or without warm solutions, depending on the surgeon's preference.

Of the 628 patients in the elderly study group, 522 patients were eligible for follow-up at 1 year (the hospital mortality was 40, and in 1994 less than 1 year had passed after operation in 66 patients). Follow-up information was obtained in all of these 522 patients. Information was obtained in 375 of the 377 (99.5%) patients eligible for 2-year follow-up.

Results are expressed as the mean ± standard error of the mean. The z-test for the difference in sample proportions, or an equivalent ² test, was used to compare mortalities. Student's t test was employed to compare mean lengths of hospitalization.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
The 30-day mortality for the entire series of patients 70 years of age and over was 33 of 628 (5.3%). Seven of the 628 patients who survived 30 days died in the hospital. The overall hospital mortality then for patients aged 70 and over was 40 of 628 (6.4%). Broken down by age group the 30-day mortality was 12 of 332 (3.6%) in those aged 70 to 74, 15 of 205 (7.3%) in those aged 75 to 79, 4 of 77 (5.2%) in those aged 80 to 84, and 2 of 14 (14%) in those 85 and older. The mortality in the 70 to 74 age group was significantly less than that for the remaining group of elderly patients (p < 0.03). The 30-day mortality for all patients aged 70 and over undergoing primary isolated CABG was 13 of 415 (3.1%), and the hospital mortality was 17 (4.1%).

The 30-day mortality for all adult patients less than 70 years old was 49 of 1787 (2.7%; p < 0.003 compared with patients 70 and older) and the hospital mortality was 59 (3.3%; p < 0.001 compared with the elderly group). The 30-day mortality in these younger patients who underwent primary isolated CABG was 14 of 1203 (1.2%), and the hospital mortality was 19 (1.6%) (p < 0.01 for both mortalities compared with the elderly group). The 30-day mortalities observed for each category of the Parsonnet model of risk stratification for all patients are shown in Table 3. In both the elderly and younger patients, mortality increased according to risk stratification. No patients aged 70 and over were in the good-risk category because of the minimum weight of 7 assigned by the Parsonnet model [5].

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

This effect of age on cardiac surgical results is reflected in models for risk stratification. In the system described by Parsonnet and colleagues [5] in 1989, operative risk was weighted by age when the patient was 70 years and over. In this model a weight of 7 (equivalent to a 7% operative risk) was added to the patient's weighted score if he or she was 70 to 74 years old. A weight of 12 was given to patients 75 to 79 years old, and patients 80 years and over were assigned a weight of 20. These data were based on the results of a retrospective analysis of 3500 consecutive operations performed from 1982 to 1987 and tested prospectively in three centers in more than two thousand patients. More recently Higgins and colleagues [10] weighted age 65 to 74 with 1 point and age greater than 75 with 2 points in a system in which the risk significantly increased when the clinical score was 6 or more. In reviewing the results of adult open heart surgical procedures in New York State, Hannan and colleagues [11] noted a steady rise in hospital mortality rates with advancing age. Recognizing that technical advances and improvements in perioperative care have occurred in the past few years, the present study was undertaken to determine whether age is still an important determinant of surgical results.

Internal mammary artery grafting has become part of most CABG operations, but until recently the internal mammary artery seems to have been used less in elderly patients than in younger ones [12, 13]. Recent analyses [14, 15] have indicated results from internal mammary artery grafting are improved even in elderly patients. Edwards and colleagues [14], reporting on a patient population taken from the Society of Thoracic Surgeons National Cardiac Surgery Database, noted a significant improvement in the operative mortality in patients aged 70 years and over who received an internal mammary artery graft, unless the patient was undergoing a reoperation. We, like others, have been impressed by the fact that the internal mammary artery in elderly patients is frequently a good size and only minimally affected by atherosclerosis. In the present study population 78% of the elderly patients undergoing isolated CABG received at least one internal mammary artery graft.

The mortality in the elderly patients in this study was somewhat higher than that in the younger patients (5.3% versus 2.7%). However, the mortality was less than that predicted by the Parsonnet model described in 1989 and that cited in other reports from the 1980s. It is likely that continuing refinements in myocardial preservation, perioperative care, and patient selection are responsible for the favorable results we observed. When weight for age is entirely removed from the Parsonnet model (see Table 2), it is apparent that age greater than 70 is still an incremental risk factor for mortality. Accordingly some weight for age still seems appropriate in risk stratification models. Current studies reported on in the literature have revealed that mortality is particularly increased in patients aged 80 and over [8, 17].

Length of postoperative stay was selected as a variable in this study as we thought it reflected the resilience of patients and the occurrence of complications. Elderly age has been recognized as a predictor of increased length of hospitalization after cardiac operations [16–19]. Models that have been developed to predict length of stay include age as an important factor [17, 20]. In our study the mean length of postoperative stay in patients aged 70 and over was approximately 3 days longer than that in patients less than 70 years of age (11.6 versus 8.5 days). This increased length of stay is a reflection of the higher incidence of major complications in the elderly patients (see Table 5). The mean length of postoperative stay increased from 8.5 to 13.1 days as risk increased.

The analyses of cost revealed that the hospital charges in elderly patients were 10% to 20% higher than those in the younger patients. The hospital charge ratio increased over the time of the study as the length of hospitalization in the younger patients declined; that in the elderly patients remained about the same. Length of stay is an important determinant of the costs for cardiac surgical procedures, and the development of rapid recovery protocols [21] are important for cost containment. As these protocols can be applied to older patients, the differential in hospital charges should be lessened.

Although follow-up data for the patients in this study are limited, favorable early results of cardiac operations in elderly patients are reported in the literature. Gersh and colleagues [22] in an extensive nonrandomized study of patients aged 65 and older from the Coronary Artery Surgery Study registry have documented a cumulative survival rate of 79% at 6 years in the surgical group. At 5 years 62% of the patients in the surgical group were free of chest pain. In comparison, the cumulative survival rate at 6 years was 64% in the medical group, and at 5 years only 29% of them had no chest pain. Salomon and colleagues [12] reported a 5-year survival rate of 80% for patients older than 75 years of age undergoing CABG. Rahimtoola and colleagues [23] have documented 5- and 10-year survival rates of 81% and 65%, respectively, in patients aged 65 years and older who underwent CABG. Jaeger and colleagues [24] have reported that most elderly patients experience a meaningful improvement in their functional capacity after cardiac operations.

The changing results of cardiac operations over time emphasize the importance of flexibility in risk analysis systems so that they can accommodate new data. The Society of Thoracic Surgeons National Database [25, 26] is such a system and should be of considerable value in the future for predicting risk in individual patients. Risk stratification models such as those described by Parsonnet [5] and Higgins [10] and their associates can clearly be modified to accommodate changes in surgical results. These risk analysis systems are important when deciding whether to operate and when counseling patients and their families. Risk analysis models are becoming important as well in estimating costs as health care systems change from a fee for service to capitation method.

Based on our study findings we conclude that (1) although mortality was higher in patients aged 70 years and over, it was not excessively so, being about 6% versus 3% in those patients less than 70; (2) the mean length of hospitalization in the elderly patients was approximately 12 days and increased with increased risk categories; (3) the hospital charges in patients aged 70 and over were about 10% to 20% higher than those in the younger patients; and (4) the Parsonnet model predicted relative risk correctly, but the current actual risk may be less. Our data suggest the magnitude of the weights for age should be reduced.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We thank Gary A. Chase, PhD, for statistical consultation and Kerry Murphy, RN, and Evelyn Naranjo, MA, for assistance with the statistical analyses and manuscript preparation.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Katz, Department of Surgery, Georgetown University Medical Center, 3800 Reservoir Rd, NW, Washington, DC 20007.

Presented at the Thirty-first Annual Meeting of The Society of Thoracic Surgeons, Palm Springs, CA, Jan 29–Feb 1, 1995.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Nevin M. Katz Robert L. Hannan Richard A. Hopkins Robert B. Wallace Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Katz, N. M. Articles by Wallace, R. B. Search for Related Content PubMed PubMed Citation Articles by Katz, N. M. Articles by Wallace, R. B. Related Collections Related Article