Older Age, Aggressiveness of Care, and Survival for Seriously Ill, Hospitalized Adults

16 November 1999 | Volume 131 Issue 10 | Pages 721-728

Background: Older age is associated with less aggressive treatment and higher short-term mortality due to serious illness. It is not known whether less aggressive care contributes to this survival disadvantage in elderly persons.

Objective: To determine the effect of age on short-term survival, independent of baseline patient characteristics and aggressiveness of care.

Design: Secondary analysis of data from a prospective cohort study.

Setting: Five academic medical centers participating in SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments).

Patients: 9105 adults hospitalized with one of nine serious illnesses associated with an average 6-month mortality rate of 50%.

Measurements: Survival through 180 days of follow-up. In Cox proportional-hazards modeling, adjustment was made for patient sex; ethnicity; income; baseline physical function; severity of illness; intensity of hospital resource use; presence of do-not-resuscitate orders on study day 1; and presence and timing of decisions to withhold transfer to the intensive care unit, major surgery, dialysis, blood transfusion, vasopressors, and tube feeding.

Results: The mean (± SD) patient age was 63 ± 16 years, 44% of patients were female, and 16% were black. Overall survival to 6 months was 53%. In analyses that adjusted for sex, ethnicity, income, baseline functional status, severity of illness, and aggressiveness of care, each additional year of age increased the hazard of death by 1.0% (hazard ratio, 1.010 [95% CI, 1.007 to 1.013]) for patients 18 to 70 years of age and by 2.0% (hazard ratio, 1.020 [CI, 1.013 to 1.026]) for patients older than 70 years of age. Adjusted estimates of age-specific 6-month mortality rates were 44% for 55-year-old patients, 48% for 65-year-old patients, 53% for 75-year-old patients, and 60% for 85-year-old patients. Similar results were obtained in analyses that did not adjust for aggressiveness of care. Acute physiology and diagnosis had much larger relative contributions to prognosis than age.

Conclusions: We found a modest independent association between patient age and short-term survival of serious illness. This age effect was not explained by the current practice of providing less aggressive care to elderly patients.

Author and Article Information

From Beth Israel Deaconess Medical Center, Boston, Massachusetts; Brown University, Providence, Rhode Island; University of Virginia School of Medicine, Charlottesville, Virginia; Center to Improve Care of the Dying, George Washington University, Washington, D.C.; Duke University Medical Center, Durham, North Carolina; and Johns Hopkins University, Baltimore, Maryland.

Presented in part at the National Meeting of the Society of General Internal Medicine, Washington, D.C., April 1994.

Grant Support: By the Robert Wood Johnson Foundation. The opinions and findings contained in this manuscript are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or their Board of Trustees. Dr. Hamel is supported by a Career Development Award from the National Institute on Aging (K08 AG0075-02).

Requests for Reprints: Mary Beth Hamel, MD, MPH, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215. For reprint orders in quantities exceeding 100, please contact the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints{at}mail.acponline.org.

Current Author Addresses: Drs. Hamel, Davis, and Phillips: Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.

Dr. Teno: Center for Gerontology and Health Care Research, Brown University, Box GB-219, 171 Meeting Street, Providence, RI 02912.

Drs. Knaus and Harrell: Department of Health Evaluation Sciences, University of Virginia School of Medicine, Box 600, Charlottesville, VA 22908.

Dr. Lynn: Center to Improve Care for the Dying, 2175 K Street NW, Suite 820, Washington, DC 20037.

Dr. Galanos: Division of Geriatrics, Duke University Medical Center, 353—Blue Zone, Durham, NC 27710.

Dr. Wu: Health Service Research and Development Center, Johns Hopkins University, 624 North Broadway, Baltimore, MD 21205.