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 Researchers found that while 7.0% of 4,426 heart attack patients who
were age 79 and only two weeks from their 80th birthday got bypass
surgery, the rate dropped significantly to only 5.3% for 5,036
people who were just 2 weeks past their 80th birthday - even though
the health of people in both groups was essentially the same.
That, in turn, translated to a higher death rate among the
80-year-olds over the 30 and 60 days following their heart attacks,
according to the report in The New England Journal of Medicine.
Doctors "are arbitrarily classifying the two groups of patients as
young versus old instead of treating them as two groups who are
basically the same age," coauthor Dr. Anupam Jena, an associate
professor of healthcare policy and medicine at Harvard University
Medical School in Boston, told Reuters Health in a telephone
interview.
"It's an important observation," said Dr Richard Becker, director of
the Heart, Lung and Vascular Institute at the University of
Cincinnati College of Medicine, in Ohio, who was not involved in the
study. "We don't want to exclude someone from a procedure that could
be potentially life-saving."
Becker told Reuters Health by phone that doctors should be relying
on decision making tools that help predict the success of such
surgery, such as the scoring system developed by the Society for
Thoracic Surgeons, in which age is not a factor.
Jena said patients and families need to be aware of the bias when
doctors are recommending treatment options, and encourage doctors to
look beyond patients' chronological age "because their biological
age may be very different."
The decision to exclude more 80-year-olds from bypass surgery
appears to stem from an unconscious habit, Jena's team concludes.
The moment the first digit of a person's age changes from a 7 to an
8, doctors start to lump them in with patients who are well into
their 80s.
Such bias reflects the natural but irrational tendency to inflate
the importance of the first digit of a number, Jena explained, such
as when consumers are drawn to an item priced at $4.99 instead of
the same item priced at $5.00. That extra penny takes on a
disproportionate importance, one not seen when consumers compared
two items priced, for example, at $4.98 and $4.99.
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"It's something that affects people's decisions in a subconscious
way," Jena said. But when applied to the age of a heart attack
victim who might benefit from bypass surgery, "this is shifting
doctor's decisions on a serious medical decision."
This is not the first study to demonstrate that type of bias in
medicine.
Research published in 2017 by another of the current study's
authors, Stephen Coussens of Columbia University's Mailman School of
Public Health in New York City, found that if you arrived at the
emergency department just after your 40th birthday, you were roughly
10% more likely to be tested for heart disease and 20% more likely
to be diagnosed with heart disease than if you were only a few weeks
away from your 40th.
The bypass findings are based on seven years of Medicare data, which
also showed that turning 80 didn't reduce a person's chances of
successful bypass surgery.
But it did have an impact on death rates. The 30-day mortality rate
after hospitalization for heart attack was 17.7% for those just shy
of their 80th and 19.8% for patients admitted within two weeks after
their 80th.
A similar increase was seen at 60 days, but after one year the
effect had faded.
To double-check their findings, the Jena team compared the odds of
getting bypass two weeks before and after other birthdays. They
found no similar dropoff for ages 77, 78, 79, 81, 82 or 83.
Bypass surgery is not the only way to re-open coronary arteries
after a heart attack. In a procedure known as stenting, doctors
unclog the artery and place a small metal tube, or stent, to hold it
open. The current study didn't look at whether patients who didn't
get surgery got stents instead.
SOURCE: https://bit.ly/2SQMaSd The New England Journal of Medicine,
online February 19, 2020.
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