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Cost, Outcome, and Functional Status
in Octogenarians and Septuagenarians
After Cardiac Surgery*
Milo Engoren, MD, FCCP; Cynthia Arslanian-Engoren, PhD, RN, CNS;
Donna Steckel, BSN, RN; Julie Neihardt, BSN, RN; and
Nancy Fenn-Buderer, MS
Study objectives: To evaluate cost, outcome, and functional status of octogenarians and septuagenarians after cardiac surgery.
Design: Observational case control study. Retrospective analysis of hospital cost and outcome.
Prospective analysis of functional status at 1 to 2 years.
Patients: One hundred three consecutive octogenarians and 103 randomly selected septuagenarians who underwent cardiac surgery.
Setting: A university-affiliated tertiary care center.
Measurements and results: Compared to septuagenarians, octogenarians were more likely to be
widowed (p < 0.001) and to have had preoperative strokes (p < 0.05) but were less likely to have
diabetes mellitus (p < 0.001). They were less likely to have undergone mitral valve surgery
(p < 0.01) but were more likely to have undergone coronary artery bypass graft surgery without
cardiopulmonary bypass (p < 0.001). The hospital mortality rate was 6% in the younger group
and 9% in the older group (odds ratio, 1.5; 95% confidence interval [CI], 0.5 to 4.5; p > 0.05). In
patients undergoing isolated CABG, the mortality rate was 1.4% in the septuagenarians and 8.2%
in the octogenarians (odds ratio, 6.2; 95% CI, 0.7 to 52.7; p ⴝ 0.12). Despite similar ICU,
postoperative, and total lengths of stay, the median hospital direct variable cost was 35% higher
for the octogenarians. At late follow-up, octogenarians had lower levels of physical functioning
and general health but otherwise had levels of function that were similar to those of septuagenarians.
Conclusion: Cardiac surgery can be performed in the elderly with good hospital and late
functional results, but at a higher hospital cost than that for younger patients.
(CHEST 2002; 122:1309 –1315)
Key words: cardiac surgery; coronary artery bypass grafting; direct variable cost; functional outcome; octogenarians;
septuagenarians; survival
Abbreviations: CABG ⫽ coronary artery bypass graft; CI ⫽ confidence interval; CVA ⫽ cerebrovascular accident;
CVICU ⫽ cardiovascular ICU; ECF ⫽ extended care facility; RR ⫽ relative risk; SF-36 ⫽ 36-item short form;
TCU ⫽ transitional care unit
population is the fastest growing part
T heof elderly
the US population, with an estimated 10
million persons aged ⱖ 80 years. Other westernized
countries, including Japan, also have large and increasing elderly segments of their populations. Forty
percent of these elderly persons have symptomatic
*From the Departments of Anesthesiology (Dr. Engoren), Cardiovascular Nursing (Ms. Steckel and Ms. Neihardt), and Research (Ms. Fenn-Buderer), St. Vincent Mercy Medical Center,
Toledo, OH; and the Division of Acute, Critical, and Long-Term
Care (Dr. Arslanian-Engoren), School of Nursing, University of
Michigan, Ann Arbor, MI.
Received September 28, 2001; revision accepted April 23, 2002.
Correspondence to: Milo Engoren, MD, FCCP, Department of
Anesthesiology, St. Vincent Mercy Medical Center, 2213 Cherry
St, Toledo, OH 43608; e-mail: [email protected]
www.chestjournal.org
cardiac disease.1,2 Surgery, a well-accepted means of
increasing survival and improving quality of life in
patients ⬍ 70 years of age, is becoming more common in septuagenarians and even octogenarians.
However, perceptions by elderly patients, their families, and their physicians that they may have lower
functional reserve and more comorbidities than
younger patients, which are more likely to lead to
complications or death, may make cardiologists and
cardiac surgeons hesitant to offer elderly patients
life-saving or symptom-resolving cardiac surgery.
Yet, few studies exist to show the benefits, risks, and
costs of cardiac surgery in octogenarians. Previous
studies3– 6 have had small populations, are from the
1980s (improvements in perioperative techniques
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1309
and care may make these results obsolete), or have
not evaluated functional outcomes and costs in the
same population. Therefore, the purpose of this
study was twofold, as follows: (1) to determine hospital
outcomes and costs; and (2) to measure functional
outcomes at 1 to 2 years in octogenarians compared to
septuagenarians following cardiac surgery.
Materials and Methods
This study was approved by the institutional review board of a
university-affiliated, tertiary care medical center. The hospital’s
computerized medical information system was queried for all
patients 70 to 89 years of age who had undergone cardiac surgery
between January 1, 1998, and December 31, 1999. All patients
who were 80 to 89 years old (cases) and an equal number of
randomly selected patients who were 70 to 79 years old (control
subjects) from the same time period had their charts reviewed by
a single examiner. Because we wanted to see whether premorbid
conditions varied between the two groups, we used randomly
selected control subjects rather than matching control subjects
for any particular characteristic. Charts were reviewed for the
following: patient sex; marital status (ie, married, widowed,
divorced, or single); comorbidities (ie, hypertension, stroke,
cerebrovascular accident [CVA], myocardial infarction, diabetes
mellitus, and COPD); use of antidepressant, antipsychotic, or
anxiolytic medications (ie, CNS drug use); year of surgery (1998
or 1999); whether cardiac catheterization was performed during
the same hospital admission as was the cardiac surgery; type of
cardiac surgery (ie, coronary artery bypass grafts [CABGs], aortic
valve repair or replacement, mitral valve repair or replacement,
carotid artery endarterectomy performed simultaneously with the
cardiac surgery, or other surgery, such as ascending aortic
aneurysmectomy, left ventricular aneurysmectomy, tricuspid
valve repair, and femoral artery aneurysmectomy, performed
simultaneously with the primary cardiac surgery; use of cardiopulmonary bypass; transfusion; re-exploration for bleeding; the
development of a new focal central neurologic event (ie, CVA);
the development of a new global neurologic deficit not related to
anesthesia or medicines that lasted ⬎ 24 h (encephalopathy);
preoperative and peak postoperative serum creatinine levels; the
development of renal dysfunction (defined as a creatinine level of
ⱖ 2.0 mg/dL if the preoperative creatinine level was normal, or a
rise in the creatinine level of ⱖ 1.0 mg/dL if the preoperative
creatinine level was ⱖ 1.5 mg/dL); hemodialysis; prolonged
mechanical ventilation (defined as a requirement for mechanical
ventilation beyond 7 am the day after surgery; atrial fibrillation;
hospital outcome; and discharge to home, extended care facility
(ECF), transitional care unit (TCU), rehabilitation hospital, or
other location.
Direct variable cost was obtained from the hospital’s accounting department. All billed items and their associated costs were
assigned to 1 of the following 14 cost categories: preop (all costs
incurred before the morning of surgery); anesthesia (costs of
anesthetics, equipment, and disposables used by the anesthesiologist); perfusion (costs of cardiopulmonary bypass equipment,
cardioplegia, and disposables used by the perfusionist); surgery
(all other costs related to the use of the operating room, surgical
equipment, and disposables used by the surgeon); cardiovascular
ICU (CVICU) [costs related to nursing, equipment, and room in
the cardiovascular ICU]; postop room (costs related to nursing,
equipment, and room on the stepdown unit); respiratory (costs
related to respiratory equipment, treatments, and therapist time);
laboratory, blood bank (blood typing and transfusions); Ekg &
vasc lab (electrocardiograms and noninvasive vascular studies);
radiology, pharmacy, therapies (physical, occupational, and
speech therapy); and supplies.
Death was determined from the Social Security Death Index,
obituaries in The Toledo Blade, and hospital records. Three
trained registered nurses attempted to contact all survivors. If the
survivor gave oral informed consent, the 36-item short form
(SF-36) questionnaire7 was administered during the same telephone conversation.
Statistical Analysis
In addition to analyzing all patients who had undergone cardiac
surgery, patients who had undergone only CABG surgery (ie,
CABG-only group) were compared. Univariate comparisons between groups were made using ␹2 tests for categoric characteristics or Mann-Whitney-Wilcoxon tests for continuous characteristics. Linear regression analysis using forward, backward, and
stepwise selection was used to explain the variability in direct
variable cost.
Results
One hundred three patients in each group underwent cardiac surgery and were studied (Table 1).
Octogenarians were more likely to be widowed
(p ⱕ 0.001), while septuagenarians were more likely
to be married (p ⬍ 0.01). Octogenarians were more
likely to have had preoperative strokes (p ⫽ 0.05)
but were less likely to have diabetes mellitus
(p ⬍ 0.001). Other comorbidities were distributed
similarly. Octogenarians were less likely to have
undergone mitral valve surgery (p ⫽ 0.01) but were
more likely to have their CABGs performed without
cardiopulmonary bypass (p ⬍ 0.001). Postoperative
complications were similar between the two groups
(Table 2). The hospital mortality rate was 5.8% in the
younger group and 8.7% in the older group (relative
risk [RR], 1.5; 95% confidence interval [CI], 0.5 to
4.5; p ⬎ 0.05). Of the nine octogenarians who died,
two died of cardiac failure on the day of surgery.
Four of the remaining seven octogenarians required
re-exploration surgery for bleeding, one had a CVA,
two had encephalopathy, and six had sufficient renal
dysfunction to undergo dialysis. Of the six septuagenarians who died, one died of heart failure on the
first postoperative day. Two of the remaining five
septuagenarians required re-exploration surgery for
bleeding, three had encephalopathy, and four required hemodialysis. In patients undergoing isolated
CABGs, the mortality rate was 1.4% among septuagenarians and 8.2% among octogenarians (RR, 6.2;
95% CI, 0.7 to 52.7; p ⫽ 0.12). Older patients were
less likely to be discharged from the hospital directly
to home (RR, 0.3; 95% CI, 0.17 to 0.6; p ⱕ 0.01) and
were more likely to be discharged to a TCU or ECF
(RR, 3.0; 95% CI, 1.7 to 5.6; p ⱕ 0.01). Despite
similar ICU, postoperative, and total lengths of stays,
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Clinical Investigations
Table 1—Preoperative and Intraoperative Characteristics*
Septuagenarians
Characteristics
Male sex
Marital status
Married
Widowed
Divorced
Single
Hypertension
Preoperative CVA
Preoperative MI
Diabetes mellitus
COPD
CNS drug use
Renal dysfunction
Year of surgery, 1998
Cardiac catheter
Reoperation
CABG
AVR
MVR
CEA
Other#
Off-pump
Creatinine,** mg/dL
Hemoglobin,** g/dL
Octogenarians
No.
(n ⫽ 103)
%
(n ⫽ 100)
64
62
71†‡
20§㛳
5
7
84
11¶
55
39§
15
19
13
64
70
5
93
9
15†
10
4
3§
1.1
13.4
No.
(n ⫽ 103)
%
(n ⫽ 100)
53
69†‡
19§㛳
5
7
82
11¶
53
38§
15
18
13
62
68
5
90
9
15†
10
4
3§
(0.9–1.3)
(11.7–14.4)
49†‡
43§㛳
3
8
79
21¶
45
17§
14
18
10
51
70
5
95
16
4†
7
6
18§
1.1
13.3
51
48†‡
42§㛳
3
8
77
20¶
44
17§
14
17
10
50
68
5
92
16
4†
7
6
18§
(0.9–1.3)
(11.6–14.0)
*MI ⫽ myocardial infarction; CNS drug use ⫽ use of antidepressants, antipsychotics, or anxiolytics preoperatively; AVR ⫽ aortic valve
replacement or repair; MVR ⫽ mitral valve replacement or repair; CEA ⫽ carotid artery endarterectomy.
†p ⱕ 0.01.
‡Married vs all other marital statuses.
§p ⱕ 0.001.
㛳Widowed vs all other marital statuses.
¶p ⱕ 0.05.
#Septuagenarians: three ascending aortic aneursymectomies and one left ventricular aneursymectomy; octogenarians: four ascending aortic
aneursymectomies, one tricuspid valve repair, and one femoral artery aneursymectomy.
**Values given as median (interquartile range).
the median hospital cost was 35% higher for the
octogenarians (Table 3). By linear regression, higher
cost was associated with being an octogenarian,
having re-exploration surgery for bleeding, and longer
hospital length of stay. Having the surgery performed without cardiopulmonary bypass was associated with a lower cost (Table 4).
Survival was similar both in the all-patient groups
and the CABG-only groups. The 1-year survival rate
among the all-patient septuagenarians was 83% (95%
CI, 76 to 91%) compared to 85% (95% CI, 79 to
92%) among octogenarians. The 2-year survival rates
were 82% (95% CI, 75 to 90%) and 84% (95% CI, 77
to 91%), respectively (Fig 1, top) No patient in the
CABG-only groups died between 1 and 2 years after
surgery, giving 1-year and 2-year survival rates of
90% (95% CI, 83 to 97%) in septuagenarians and
88% (95% CI, 80 to 95%) in octogenarians (Fig 1,
bottom).
At the follow-up of the 97 septuagenarians who
www.chestjournal.org
survived hospitalization, 66 completed the interview, 13 were dead, 9 refused the interview,
5 were lost to follow-up, 3 were in ECFs, and
1 was hospitalized. The octogenarians had similar
outcomes and participation. Of the 94 who survived hospitalization, 59 completed the interview,
7 were dead, 9 refused the interview, 18 were lost
to follow-up, and 1 was in an ECF. The 45 living
patients who did not participate in the interview or
were lost to follow-up were slightly older (median,
81 years of age [interquartile range, 76 to 83 years]
vs 79 years of age [interquartile range, 74 to 81
years], respectively; p ⫽ 0.02), had higher preoperative creatinine levels (median, 1.2 mg/dL [interquartile range, 1.0 to 1.3 mg/dL] vs 1.0 mg/dL
[interquartile range, 0.9 to 1.2 mg/dL], respectively; p ⫽ 0.01), were more likely to have undergone aortic valve surgery (median, 21% vs 7%,
respectively; p ⫽ 0.01), were more likely to develop atrial fibrillation (median, 49% vs 32%;
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Table 2—Complications and Discharge Location*
Septuagenarians
Variables
Transfusion
Reexploration
New CVA
Encephalopathy
Renal dysfunction
Prolonged ventilation
Dialysis
Atrial fibrillation
Died
Discharged to
Home
ECF
TCU
Rehabilitation hospital
Other
Died
Peak creatinine, mg/dL
No.
64
5
5
17
25
18
10
36
6
48†
10
30
5
4
6
1.3
%
62
5
5
17
25
18
10
36
6
47†
10
29
5
4
6
(1.0–2.0)
Table 4 —Predictors of Cost*
Octogenarians
No.
75
8
4
19
18
19
7
41
9
22†
24
40
7
1
9
1.2
Predictors
Constant
Hospital LOS
Re-exploration
Octogenarian
Off-pump
%
73
8
4
19
18
19
7
41
9
Coefficient
$⫺5,403
$896
$21,865
$7,282
$⫺9,585
95% CI
p Value
$⫺13,356–$2,549
$744–$1,048
$11,682–$32,049
$2,340–$12,224
$⫺17,715–$1,455
⬍ 0.001
⬍ 0.001
0.004
0.021
*Coefficient ⫽ the amount that the occurrence of each categoric
variable (ie, re-exploration, octogenarian, off-pump) increases direct
variable cost.
21†
23
39
7
1
9
(0.9–1.6)
*New CVA ⫽ intraoperative or postoperative stroke.
†p ⱕ 0.01 (discharge to home vs all other locations).
p ⫽ 0.04), had spent a longer time in the hospital
(median, 10 days [interquartile range, 7 to 18 days]
vs 7 days [interquartile range, 6 to 11 days],
respectively; p ⬍ 0.01), and had higher hospital
costs (median, $12,853 [interquartile range,
$7,954 to $22,262] vs $9,412 [interquartile range,
$6,404 to 14,638]; p ⫽ 0.02) than the 125 who
were interviewed.
The interviews showed that both groups had excellent social functioning and role-emotional outcomes (Table 5). The values for the other SF-36
scales were similar between the two groups except
that the octogenarians had lower levels of physical
functioning and general health.
Discussion
Despite a higher prevalence of preoperative
stroke, which is a risk factor for hospital mortality
after cardiac surgery, we found that octogenarians
underwent cardiac surgery with hospital survival
rates and complication rates that were similar to
those of septuagenarians but at a higher hospital
cost. Our hospital mortality rate (8.2% in octogenarians) is similar to or lower (5.6 to 24.3%) than those
found in other studies evaluating CABG.6,8 Using
Medicare data, Peterson et al9 found a hospital
mortality rate of 11.5% in 24,461 patients aged ⱖ 80
years and had undergone isolated CABG surgery
between 1987 and 1990. The 1-year mortality rate for
those patients was 19%, compared to 12% in this study.
Our lower rate may be due to differences in patient
Table 3—Lengths of Stay and Direct Variable Costs*
Variables
Septuagenarians
Octogenarians
CVICU LOS, d
Postoperative LOS, d
Total LOS, d
Total costs, $
Pre-operative
Anesthesia
Perfusion
Surgery
CVICU
Postoperative room
Respiratory
Laboratory
Blood bank
ECG & vascular laboratory
Radiology
Pharmacy
Therapies
Supplies
1 (1–3)
6 (5–10)
8 (6–13)
9,383 (6,321–16,992)†
641 (410–1,284)
279 (217–532)
1,772 (1,216–2,540)
2,299 (1,773–3,780)
816 (433–1,867)
655 (1,094–2,212)
67 (30–196)
217 (111–442)
102 (34–254)
29 (67–120)
37 (11–134)
592 (343–1,226)
236 (106–439)
70 (39–149)
1 (1–3)
6 (5–9)
9 (6–13)
12,624 (7,836–22,124)†
743 (511–1,710)
356 (250–542)
2,224 (1,461–2,710)
3,041 (1,984–3,787)
1,154 (481–2,858)
761 (1,492–2,676)
146 (32–263)
258 (107–633)
91 (32–457)
31 (77–138)
90 (26–426)
702 (450–1,723)
221 (139–523)
95 (36–231)
*Values given as median (interquartile range). All p values are ⬎ 0.05 unless indicated. LOS ⫽ length of stay.
†p ⱕ 0.01.
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Clinical Investigations
Figure 1. Top: Kaplan-Meier plots of 2-year survival rates from
the time of surgery for septuagenarians (– – –) and octogenarians
(——) after all cardiac surgeries. Bottom: Kaplan-Meier plots of
2-year survival rates from the time of surgery for septuagenarians
(– – –) and octogenarians (——) after CABG-only surgery.
selection or to improvements in operative techniques
and perioperative care over the last decade.
Many factors have been found to be associated
with increased mortality among the octogenarians,
particularly emergency surgery, complexity of the
surgery, and the presence of comorbidities.5,10,11
Whether due to different criteria for patient selection or to improvements in stabilization in the catheterization laboratory, we, unlike Avery et al,5 had
few emergency patients with severe hemodynamic
instability. Where Glower et al11 noted an in-hospital
mortality rate of 23% in octogenarian patients with
any comorbidities, compared to 7% in patients without any comorbidities, we found that almost all of
our octogenarian patients (92.2%) had at least one
comorbidity. However, this high rate of comorbidities is similar to those cited in other studies.3,5
We found that the older group was more likely to
have had their CABG surgery performed without
cardiopulmonary bypass (ie, off-pump surgery).
While firm data are lacking, off-pump surgery is felt
to cause less postoperative neurologic and renal
dysfunction.12 This may have contributed to the
similar rates of cerebral and renal dysfunction in our
two groups. The occurrence of complications predicted a worse outcome, with dialysis being a prominent marker of hospital death. The survival rate
among patients initiating dialysis was 30% among
octogenarians and 57% among septuagenarians
(p ⬎ 0.05). This finding is similar to patients in a
general ICU. Octogenarians initiating hemodialysis
in the ICU had a survival rate (33.3%) that was
similar to that of nonoctogenarians (36.4%).13
Peterson et al9 attributed the 20% higher cost for
octogenarian patients to their longer average length
of hospital stay (3.9 days). Avery et al5 noted an
average 26.8% higher cost for their octogenarian
patients, which was explained on the basis of a 37%
longer average hospital length of stay and a higher
intensity of illness. In contrast, our study found
identical median ICU and postoperative lengths of
stays and similar total lengths of stays between the
younger and older groups. Despite this, the median
Table 5—Functional Outcome*
Septuagenarians
Octogenarians
Variables
No.
Median (IQ Range)
Mean ⫾ SD
No.
Median (IQ Range)
Mean ⫾ SD
Physical functioning
Role-physical
Bodily pain
General health
Vitality
Social functioning
Role-emotional
Mental health
66
66
66
66
66
66
65
66
75 (35–90)†
75 (25–100)
72 (61–100)
72 (50–84)‡
50 (35–75)
100 (75–100)
100 (67–100)
72 (60–80)
67 ⫾ 31
64 ⫾ 38
72 ⫾ 25
67 ⫾ 25
54 ⫾ 25
83 ⫾ 23
86 ⫾ 27
68 ⫾ 12
59
58
58
58
58
58
58
58
55 (28–80)†
50 (25–75)
73 (51–100)
64 (40–77)‡
50 (25–70)
100 (75–100)
100 (67–100)
72 (64–80)
54 ⫾ 30
53 ⫾ 36
69 ⫾ 29
58 ⫾ 24
47 ⫾ 29
82 ⫾ 26
79 ⫾ 36
69 ⫾ 17
*The No. of patients varies slightly because not all patients answered every question.
†p ⱕ 0.01.
‡p ⱕ 0.05.
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costs were 35% higher in the older group. While
costs were hundreds of dollars higher in the octogenarian group for the high-cost categories of surgery,
perfusion, and CVICU stay, these did not reach
statistical significance, probably because of inadequate power to detect subgroup differences.
Previous studies have found mean postoperative
lengths of stays of 10 to 16 days5,9,11,14 and mean total
hospital lengths of stays of 22 days3 for elderly
patients, which are considerably longer than the
median postoperative length of stay of 6 days and the
total hospital length of stay of 9 days in this study.
This probably relates to our fast-track cardiac program,15 the availability of a TCU contiguous to the
hospital, and nearby ECFs. Only 21% of our octogenarians were discharged to home, which is significantly less than the rate for the septuagenarians
(47%). The higher rate of octogenarians being discharged to places other than home was partially due
to octogenarians being less likely to be married. But,
even comparing married octogenarians to married
septuagenarians, married octogenarians were still
less likely to be discharged to home (33% vs 51%,
respectively; p ⬍ 0.05). Further evaluation is needed
to determine whether this is related to spousal
disability or other reasons. It was also significantly
less than the 64% reported elsewhere.3 A higher rate
of admission to the TCU or ECFs may be the
tradeoff for a short hospital length of stay.
We found that other than octogenarians having
lower levels of physical functioning and general
health, octogenarians and septuagenarians had similar functional outcomes. The octogenarians in our
study had similar scores or trends to better scores
than the general population that was ⱖ 75 years old,7
but they had lower scores than Canadian octogenarians after cardiac surgery.3 Fruitman et al3 administered the SF-36 to 99 of 103 octogenarian survivors at
15.7 ⫾ 6.9 months after their cardiac surgery in Halifax, NS, Canada. They found consistently higher scores
for five of the eight scales than we found (p ⬍ 0.01 for
Role-Physical, Bodily Pain, General Health Perceptions, and Mental Health; p ⬍ 0.05 for Vitality; and
p ⬎ 0.05 for Physical Functioning, Social Functioning,
and Role-Emotional). Whether this is due to different
patient characteristics, different versions of the SF-36,
or differences in the social services, medical care, and
prescription drug benefits between Canada and the
United States cannot be determined.
A limitation of this study is that it was conducted at
only one institution. Other hospitals may have different experiences. A multicenter study might also
provide sufficient statistical power to detect a difference in mortality. However, the population is similar
in size to those in most other studies evaluating
cardiac surgery in the elderly.3,14,16 –19 Given the
hospital mortality rates that we found (septuagenarians, 5.8%; octogenarians, 8.7%), it would take approximately 1,250 patients in each group to find a
statistically significant difference, with a type I error
of 0.05% and 80% power. The moderate number of
patients studied also precludes us from developing a
risk model for predicting death, complications, cost,
or functional outcome.
Another limitation is that one fourth of the survivors did not consent to be interviewed or could not
be located. Given that these 46 patients were slightly
older, were more likely to have renal dysfunction,
were more likely to have undergone aortic valve
surgery, were more likely to develop atrial fibrillation, and were more likely to cost more, they may not
have as good functional outcomes as those who
participated in the interview.
Conclusion
We found that cardiac surgery can be performed
in the elderly with good hospital and late functional
results, but at higher hospital costs than those for
younger patients.
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