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. Author manuscript; available in PMC: 2024 Jan 1.
Published in final edited form as: Ann Surg. 2021 Jul 14;277(1):87–92. doi: 10.1097/SLA.0000000000005077

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

Robert D Becher 1, Brent Vander Wyk 2, Linda Leo-Summers 2, Mayur M Desai 3, Thomas M Gill 2
PMCID: PMC8758792  NIHMSID: NIHMS1723310  PMID: 34261884

STRUCTURED ABSTRACT

Objective:

The objective of this study was to 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 key demographic and geriatric characteristics.

Background:

As the population of the United States ages, there is considerable interest in ensuring safe, high-quality surgical care for older persons. Yet, valid, generalizable data on the occurrence of major surgery in the geriatric population are sparse.

Methods:

We evaluated data from a prospective longitudinal study of 5,571 community-living fee-for-service Medicare beneficiaries, aged 65 or older, from the National Health and Aging Trends Study (NHATS) from 2011 to 2016. Major surgeries were identified through linkages with Centers for Medicare & Medicaid Services data. Population-based incidence and cumulative risk estimates incorporated NHATS analytic sampling weights and cluster and strata variables.

Results:

The nationally-representative incidence of major surgery per 100 person-years was 8.8, with estimates of 5.2 and 3.7 for elective and non-elective surgeries. The adjusted incidence of major surgery peaked at 10.8 in persons 75–79 years, increased from 6.6 in the non-frail group to 10.3 in the frail group, and was similar by sex and dementia. The 5-year cumulative risk of major surgery was 13.8%, representing nearly 5 million unique older persons, including 12.1% in persons 85–89 years, 9.1% in those ≥90 years, 12.1% in those with frailty, and 12.4% in those with probable dementia.

Conclusions:

Major surgery is a common event in the lives of community-living older persons, including high-risk vulnerable subgroups.

MINI-ABSTRACT

Valid, nationally-representative data on the occurrence of major surgery in the United States’ geriatric population are needed. This prospective longitudinal study estimated the incidence and cumulative risk of major surgery in older persons over a 5-year period, and evaluated how these estimates differ according to key demographic and geriatric characteristics.

INTRODUCTION

The projected growth of the geriatric population has been called the most significant demographic trend in the history of the United States (US).1,2 The number of persons aged 65 years or older is expected to double between now and 2060, from 46 to 98 million.1,3 While the expanding geriatric population will affect all areas of medicine, one field that will be especially impacted is surgery.4

As the US population ages, the number of older persons who will require surgical intervention will increase substantially.4,5 Because advancing age, frailty, dementia, and other geriatric-specific conditions are risk factors for adverse outcomes after surgery,6–10 there is considerable interest in ensuring safe and high-quality surgical care for older persons.11 Despite this demographic imperative, valid and generalizable data on the epidemiology of major surgery in older Americans are lacking. Estimates of surgery in the geriatric population are outdated, based on administrative discharge data, employ an overly broad definition of an operation, and/or do not include values for clinically relevant subgroups, such as those who are frail or cognitively impaired.12–19 Reliable, up-to-date national estimates of the occurrence of major surgery in older persons are needed to inform public health policy and planning, enhance the accuracy of medical and surgical needs assessments by academic, health care, and commercial institutions, and identify opportunities to intervene in clinical practice.

The objectives of the current study were two-fold: first, to estimate the incidence and cumulative risk of major surgery in older persons in the US, across the spectrum of surgical disciplines, including both elective and non-elective operations; and second, to evaluate how these estimates differ according to key demographic and geriatric characteristics, including frailty and dementia. To accomplish these objectives, we used data from the National Health and Aging Trends Study20 (NHATS), linked to data from the Centers for Medicare & Medicaid Services (CMS).

METHODS

Data Sources

NHATS is an ongoing, prospective, nationally-representative longitudinal study of Medicare beneficiaries.20 On September 30, 2010, NHATS drew a random sample of persons 65 years or older living in the contiguous US (excluding Alaska, Hawaii, and Puerto Rico) from the Medicare enrollment file, with oversampling of non-Hispanic Blacks and those 90 years or older. Baseline (Round 1) interviews, completed from May through November 2011, yielded a sample of 8,245 persons with a 71% weighted response rate. Proxy respondents were interviewed when the participant could not respond (5.8% [weighted]). The annual, in-home, face-to-face NHATS interviews attempt to fully characterize disability in older Americans by collecting an extensive array of detailed information on patient-related and geriatric factors that can predict the disablement process and its consequences; such data are not available in administrative datasets. The NHATS protocol was approved by the Johns Hopkins Institutional Review Board, and all NHATS participants provided informed consent. Our study was approved by the Yale Human Investigation Committee.

CMS records of fee-for-service Medicare claims, cross-linked to NHATS data, were used to identify participants who underwent major surgery. Comparable data are not available in NHATS from Medicare Advantage. Major surgery was defined as any procedure in an operating room requiring the use of general anesthesia for a non-endoscopic, invasive operation. This definition, which has been previously implemented by our group,8,21 is consistent with other definitions of major surgery in older persons.22 We categorized each procedure into one of six subtypes: 1. Musculoskeletal; 2. Abdominal/Gastrointestinal; 3. Vascular (including endovascular, non-coronary bypass grafts, and amputations); 4. Neurologic (including brain and spine); 5. Cardiothoracic; and 6. Other (including major endocrine, gynecologic, urologic, breast, plastic, otolaryngologic, and transplant surgery). The “other” category includes a heterogenous group of surgical specialties because none of these individual specialties had a sufficient number of cases to stand on its own. Major surgeries were categorized as elective (planned) or non-elective (unplanned) based on a CMS indicator variable.8,21

Study Population

Among the 7,609 NHATS participants who were living in settings other than nursing homes (community-living) at the time of their Round 1 interview, we identified those who were enrolled for at least 1 month in fee-for-service Medicare during the subsequent 5-year surveillance period from 2011 to 2016. The number of participants with continuous fee-for-service Medicare, a combination of fee-for-service Medicare and Medicare Advantage, and Medicare Advantage only were 4,559 (61.1%), 1,012 (13.1%), and 2,038 (25.8%), respectively. As such, 5,571 community-living NHATS participants (7609 – 2038 = 5571) were included in the study.

During Round 1 of NHATS, information was collected on demographic characteristics, including age, sex, race/ethnicity, education, living situation; and ten self-reported, physician diagnosed chronic conditions, including heart attack, high blood pressure, arthritis, osteoporosis, diabetes, lung disease, stroke, dementia or Alzheimer’s disease, cancer, hip fracture since age 50; and two geriatric characteristics: frailty and dementia.20 Participants were categorized as non-frail, pre-frail, and frail according to the Fried phenotype23 and as having no dementia, possible dementia, or probable dementia based on a validated assessment strategy.24 Data on frailty and dementia were 100% complete.23,24 Medicaid eligibility was obtained from CMS data.

Statistical Analysis

To generate nationally-representative incidence and cumulative risk estimates, all analyses incorporated both the NHATS Round 1 analytic sampling weights20,25,26 and the cluster and strata variables, thereby accounting for the complex sample survey design.20 All analyses were performed using SAS 9.4 (SAS Institute, Cary, North Carolina, US).

Incidence Rates

We calculated nationally-representative incidence rates of major surgery over the 5-year follow-up period using Poisson regression; the variance associated with the survey sampling was estimated using general estimating equations (GEE). All eligible surgeries were included in the numerator; to account for differences in time at risk for surgery, we used participants’ time (in months) with fee-for-service Medicare coverage as the offset term. We calculated overall (unadjusted) incidence rates per 100 person-years for all major surgeries and separately by timing (elective and non-elective) and subtype of surgery. In addition, for all major surgeries, elective surgeries, and non-elective surgeries, we calculated both unadjusted and age- and sex-adjusted incidence rates stratified by four demographic and geriatric characteristics: age, sex, frailty, and dementia.

Cumulative Risk

We calculated the proportion (cumulative risk) and incidence count of individuals who underwent at least one major surgery during the 5-year follow-up period using data from NHATS participants who were continuously enrolled in fee-for-service Medicare, including decedents. Employing the empirical survivor function for the 2011 NHATS cohort, cumulative risk estimates were calculated for all major surgery, elective and non-elective major surgery, and subgroups defined by age, sex, frailty, and dementia.

RESULTS

Among the 5,571 community-living NHATS participants who were enrolled in fee-for-service Medicare for at least 1 month between May 2011 and November 2016 (Supplemental Table S1), the mean age was 75.3 (Standard Error, 0.1) years, more than half were female (55.9%), and 4 out of 5 (81.5%) were non-Hispanic White. More than 1 in 8 (13.4%) were Medicaid eligible, and nearly 1 in 2 (43.4%) had 3 or more chronic conditions. Almost half (46.7%) of the participants were pre-frail, and 17.2% were frail, while more than 1 in 5 were cognitively impaired, with either possible (10.7%) or probable (10.7%) dementia. Differences between NHATS participants with at least 1 month of fee-for-service Medicare and those in fee-for-service only or Medicare Advantage only were relatively small, with the latter group having a slightly lower percentage of males, living alone, Medicaid eligible, frailty, and probable dementia.

Incidence Rates

Based on a total estimated time at risk of 97,049,615 person-years, the nationally-representative incidence rate of major surgery was 8.8 per 100 person-years (95% confidence interval [CI] 8.2–9.5), indicating that for every 100 community-living older Americans, an average of 8.8 major surgeries were performed per year in the US. The national rates of elective and non-elective surgery were 5.2 (95% CI, 4.7–5.7) and 3.7 (95% CI, 3.3–4.1), respectively.

The adjusted incidence rate per 100 person-years of all major surgeries varied by age group (Figure 1), peaking at 10.8 (95% CI, 9.4–12.4) in persons 75–79 years and declining to a low of 6.4 (95% CI, 5.0–8.2) in those ≥90 years. Rates of elective surgery were highest in the youngest three age groups (65–69; 70–74; 75–79), while rates of non-elective surgery were highest in the oldest three age groups (80–84; 85–89; ≥90). Rates were similar between males and females for both elective and non-elective surgeries. The incidence of major surgery increased with worsening frailty, 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. This increase was driven largely by an increase in non-elective surgery with worsening frailty, from 2.6 (95% CI, 2.1–3.2) in the non-frail group to 5.5 (95% CI, 4.5–6.6) in the frail group. Although there was relatively little difference in the rate of major surgery across the three dementia groups, the rate of elective surgery was considerably higher in the no dementia (4.2 [95% CI, 3.7–4.7]) than the probable dementia group (2.4 [95% CI, 1.6–3.6]), while the rate of non-elective surgery was considerably higher in the probable dementia (5.3 [95% CI, 4.2–6.7)]) than no dementia group (3.9 [95% CI, 3.4–4.4]). The unadjusted and adjusted rates by age, sex, frailty, and dementia are shown in Supplemental Table S2, which also provides unadjusted rates by subtype of surgery. The most frequent per 100 person-years were musculoskeletal (3.6 [95% CI, 3.2–4.0]) and abdominal/gastrointestinal (1.7 [95% CI, 1.4–2.0]), while the least frequent was cardiothoracic (0.7 [95% CI, 0.6–0.9]).

FIGURE 1. Age- and sex-adjusted incidence rates per 100 person-years of major surgery by age (A), sex (B), frailty (C), and dementia (D).

FIGURE 1.

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All plots are shown by timing of surgery (elective vs non-elective). Major surgery subtypes are aggregated. Error bars represent 95% confidence intervals. The plot of age was adjusted by sex (and not age), while the plot of sex was adjusted by age (and not sex). Exact incidence rates are provided in Supplemental Table S2.

Cumulative Risk

The weighted 5-year cumulative risk of major surgery, based on participants who were continuously enrolled in fee-for-service Medicare, 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]). The cumulative risks were 8.6% (95% CI, 7.3%−9.2%) for elective surgery, yielding nearly 3.1 million older persons (3,088,809; [95% CI, 2,600,831–3,576,187]) and 6.8% (95% CI, 6.0%−7.6%) for non-elective surgery, yielding nearly 2.5 million older persons (2,439,253; [95% CI, 2,157,235–2,721,272]).

Figure 2 shows the 5-year cumulative risk of major surgery by the four demographic and geriatric characteristics. Values ranged from more than 9% in persons ≥90 years to more than 16% in the 74–79 and 80–84 age groups. The cumulative risk was not evenly distributed between elective and non-elective surgeries by age: the younger age groups (65–69; 70–74; 75–79) had higher risk for elective surgery, while the older age groups (80–84; 85–89; ≥90) had higher risk for non-elective surgery. The cumulative risk of major surgery was nearly identical for males and females, for both elective and non-elective surgeries. Values for cumulative risk were 15.6% (95% CI, 13.6%−17.5%) and 12.1% (95% CI, 9.9%−14.4%) in the pre-frail and frail groups. For both groups, risk was about equally divided between elective and non-elective major surgery, although the frail group had a slightly higher cumulative risk of non-elective surgery. In contrast, the cumulative risk of elective surgery (9.2% [95% CI, 7.3%−11.1%]) was much greater than that of non-elective surgery (4.5% [95% CI, 3.5%−5.5%]) in the non-frail group, yielding an overall risk of 12.6% (95% CI, 10.6%−14.5%). Although the cumulative risk of all major surgeries differed little by dementia status, the risk of elective surgery was highest in the no dementia group (9.4% [95% CI, 7.9%−10.8%]), while the risk of non-elective surgery was highest in the dementia group (8.9% [95% CI, 6.5%−11.4%]).

FIGURE 2: Cumulative risk of any major surgery over 5 years by age (A), sex (B), frailty (C), and dementia (D).

FIGURE 2:

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Plots are shown by all major surgery as well as elective and non-elective major surgery. Major surgery subtypes are aggregated. Exact weighted cumulative risk proportions, with 95% confidence intervals, are provided in Supplemental Table S3.

More detailed information about the cumulative risk of major surgery is provided in Supplemental Table S3.

DISCUSSION

In this nationally-representative sample of community-living older persons, we estimated the incidence and cumulative risk of major surgery in the US over a 5-year period and evaluated how these estimates differ by demographic and geriatric characteristics for both elective and non-elective surgeries. Our findings demonstrate that major surgery is a common event in the lives of community-living older persons, including high-risk vulnerable subgroups such as the oldest-old (≥85 years), those with frailty or dementia, and those undergoing non-elective surgery. As the US prepares to meet the challenges of an aging society,2,27 the burden of major surgery in older Americans warrants attention from policy makers and others committed to a high-functioning national health care system.

We found that an average of nearly 9 major surgeries were performed per year for every 100 community-living persons aged 65 years or older. During the 5-year surveillance window, more than 1 in 7 Medicare beneficiaries underwent at least one major surgery, representing nearly 5 million unique older persons. Two in 5 of these major surgeries were unplanned. Vulnerable subgroups had amongst the highest incidence rates and cumulative risks of major surgery in general and non-elective surgery in particular.

Our findings have important implications for the US health care system in terms of costs, caregivers, and care. First, the growing number of Medicare beneficiaries requiring major surgery in the coming years will further stress an already expensive Medicare program. In 2018, Medicare spending was $605 billion, representing 20% of total national health spending, 15% of the entire federal budget, and 3% of gross domestic product (GDP).28 During the next 30 years, Medicare spending is projected to grow considerably – to 6% of GDP.29 As over half of fee-for-service Medicare expenditures are for surgical care, and nearly 50% of hospitalization costs are related to operating room-based procedures,30,31 continuing to cover all major surgeries will pose fiscal challenges to Medicare.

Second, there will be increased demand for surgeons and a perioperative workforce with competency in geriatric care. The US is already experiencing shortages in nine of 10 surgical specialties, with orthopedic surgery, general surgery, and urology having the largest surgeon-deficits for specialties performing major surgery.32 Based on current projections suggesting that the supply of surgeons will remain constant for the next 15 years, the US will lack as many as 28,700 surgeons by 2033.33 Furthermore, as highlighted in an Institute of Medicine report, the elder care workforce to manage geriatric patients is inadequate.34 Given the multidisciplinary nature of perioperative management, the predicted shortfall of up to 139,000 physicians within the next 13 years may adversely affect the ability to perform timely, safe, high-quality major surgery.33

Third, innovative strategies will be required to better address and prioritize the unique needs and wishes of older surgical patients in the perioperative period, especially those in high-risk vulnerable subgroups. Major surgery is inherently invasive and may be unnecessary, harmful, and even potentially inappropriate in some older persons. Nearly one-third of fee-for-service Medicare beneficiaries have at least one major surgery in the year before death, including 20% in the last month of life.22 While studies of decedents must be interpreted carefully, a large proportion of major surgeries are performed near the end-of-life. When surgery is being considered, the outcomes that matter most to older persons are symptom burden, functional independence, and health-related quality of life.35,36 To reduce non-patient-centered, non-beneficial surgical care, developing new approaches to perioperative decision making, risk stratification, outcome metrics, and goals of care will be needed. Future efforts should build on ongoing work by the Coalition for Quality in Geriatric Surgery (CQGS), a partnership between the American College of Surgeons (ACS) and the John A. Hartford Foundation.11

The data from the current manuscript can be used by the CQGS and others to support and encourage geriatric surgery research targeting the highest incidence and cumulative risk groups for major surgery, including high-risk vulnerable subgroups. This would help to ensure that future research and funding target groups who are the most likely to benefit. For example, one key finding from our study is that the incidence and cumulative risk of major surgery increase with worsening frailty, dementia, and old age – especially for non-elective surgery. To better address this high level of non-elective surgery among patients who are likely to have the worst outcomes, one starting point is the investigation of major surgery in these vulnerable subgroups. The entire spectrum of care could potentially be improved in an evidence-based manner, from peri-operative decision-making and defining goals of care, to postoperative management and enhanced systems of care.

Measuring the current and future population-based burden of conditions that have a large-scale impact on public health is a fundamental feature of a mature, high-performance health care system.37 Despite its importance to public health and policy, up-to-date and reliable data on the occurrence of major surgery in the US are not readily available. The present analysis addresses this knowledge gap.

Three unique strengths enhance the generalizability, validity, and applicability of our findings. First, by linking CMS data to NHATS, a population-based cohort, we were able to generate nationally-representative estimates of major surgery in Medicare beneficiaries. Second, we used a definition of major surgery in older persons that is clearly defined, clinically relevant, and encompasses the spectrum of surgical disciplines.8,21,22 Prior studies that have estimated rates of geriatric surgery employed either an overly-broad14–18 or narrowly-restrictive12,13,19 definition of an operation. These definitions could lead to erroneous conclusions about the rates and risks of major surgery in older persons and contribute to misleading population-based estimates. Third, we provide estimates for subgroups defined on the basis of frailty and dementia, two key determinants of health and well-being in older persons.8,21,38,39

Our findings should be interpreted in the context of limitations. First, our results are limited to fee-for-service Medicare beneficiaries since Medicare Advantage CMS data were not available. The penetrance of Medicare Advantage was around 25% in the current study but is projected to increase to 42% by 2028.40 With the recent decision by CMS to make Medicare Advantage claims data more broadly available, it should be possible to base future estimates on all Medicare beneficiaries. Second, because information on the geriatric conditions was not updated beyond NHATS Round 1, our findings may underestimate the occurrence of major surgeries in older persons who are frail or have dementia since the prevalence of these conditions increases over time. Third, for the incidence rate analysis, our choice of the Poisson with GEE represents a tradeoff between the ability to provide national estimates using the NHATS survey design and a potentially more appropriate distribution with other models. To assess this, we completed a set of sensitivity analyses that estimated the rates of surgeries across several different distributions and model parameterizations. These included: Poisson with and without GEE; negative binomial with and without GEE; zero-inflated Poisson without GEE; zero-inflated negative binomial without GEE. We found that the estimates were not notably different (all fell within the confidence intervals of the Poisson with GEE). Importantly, the Poisson with GEE was able to converge in all cases whereas the other models did not. Forth, we focused solely on the incidence and cumulative risk of major surgery in older persons. Future studies using nationally-representative data sources should focus on other high-priority areas, such as evaluating functional outcomes, mortality, and quality of life after major surgery.

In conclusion, major surgery is a defining health issue for community-living older persons, including high-risk vulnerable subgroups such as the oldest-old, those with frailty or dementia, and those having non-elective major surgery. Our findings provide generalizable data on the occurrence of major surgery in older Americans and highlight potential challenges for the US health care system in the context of an aging population needing major surgery.

Supplementary Material

Supplemental Table S1
Supplemental Table S2
Supplemental Table S3

Source of Funding:

The study was conducted at the Yale Claude D. Pepper Older Americans Independence Center (P30AG21342). Dr. Gill is the recipient of an Academic Leadership Award (K07AG043587) from the National Institute on Aging.

Footnotes

Conflicts of Interest

No conflicts of interest were declared.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Table S1
NIHMS1723310-supplement-Supplemental_Table_S1.docx (39.5KB, docx)
Supplemental Table S2
NIHMS1723310-supplement-Supplemental_Table_S2.docx (38.4KB, docx)
Supplemental Table S3
NIHMS1723310-supplement-Supplemental_Table_S3.docx (99KB, docx)

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