Choosing a Surgeon
 

Your primary care doctor may recommend a surgeon to you. You also may want to identify another independent surgeon to get a second opinion.

One way to reduce the risk of surgery is to choose a surgeon who has been thoroughly trained to do the type of surgery you need and who has plenty of experience doing it. Be sure to ask about your surgeon's qualifications. For example, you may want to find out if your surgeon is certified by a surgical board that is approved by the American Board of Medical Specialties (such as the American Board of Orthopaedic Surgery, the American Board of Colon and Rectal Surgery, or other national surgical board). Surgeons who are board-certified have successfully completed training and passed exams for their specialty.

The letters "FACS" after a surgeon's name tell you that he or she is a Fellow of the American College of Surgeons. Fellows are almost always board-certified surgeons who have passed a test of their surgical training and skills; they also have shown their commitment to high standards of ethical conduct. Don't hesitate to call the doctor's office and ask for this information. Your State or local medical society and the hospital where the surgeon operates also should be able to verify his or her training. Try to choose an experienced surgeon who operates regularly (several times a week) and who has treated a problem like yours before.

Getting a Second Opinion
 

Getting a second opinion from another surgeon is a good way to make sure that having surgery is the best choice for you. Many people are uneasy about seeking another opinion. They worry that they might offend their doctor. However, getting a second opinion is a common medical practice. Most doctors encourage it.

Getting a second opinion is a good way to get additional expert advice from another doctor who knows a lot about treating your particular medical problem. In addition, a second opinion can reassure you that your decision to have surgery is the right one.

Don't be afraid to tell your surgeon that you want another opinion and that you would like your medical records sent to the second doctor. This can save time, money, and possible discomfort since tests that you've already had may not need to be repeated if the second doctor has the results.

When getting another opinion, tell the second doctor your symptoms, the type of surgery that has been recommended, and the results of any tests you've already had. Ask the second doctor the same questions you asked the first one about the benefits and risks of surgery.

Medicare and many private health insurance companies will help pay for a second opinion. Most Medicaid programs also pay for a second opinion. If the second doctor agrees that surgery is needed, he or she usually will refer you back to the first doctor for the surgery. If the second doctor disagrees with the first, you may feel you have enough information to decide what to do, you may wish to talk again with the first surgeon, or you may wish to see a third doctor. Your primary care doctor also may be able to help you decide what to do.

Informed Consent
 

Before having surgery, you'll be asked to give consent. It's important to discuss all of your concerns about your condition and the surgery with your surgeon before you sign this form. In most cases, your surgeon will volunteer a great deal of information, but don't hesitate to ask any questions you still have. Your doctor should be willing to take whatever time is necessary to make sure that you are fully informed.

Paying for Surgery
 

Before your surgery, ask about your surgeon's fees. Many surgeons volunteer this information; if yours doesn't, don't hesitate to ask. You can find out about hospital rates from the hospital business office. Your doctor should be able to tell you how long you can expect to be in the hospital. Today, many types of surgery can be performed without hospitalization. Your surgeon will be able to decide if that's possible in your case.

In addition to surgeons' fees and the costs of hospitalization, you also will be billed for the professional services of others involved in your care such as the anesthesiologist and medical consultants.

You may want to check your health insurance plan to see what portion of the costs you'll have to pay. You probably will need approval from your health insurance plan before surgery. If your insurance plan will not pay all of the anticipated costs and you cannot afford the difference, discuss this situation frankly with your surgeon.

Most people 65 and older have Medicare health insurance, which has two parts: Part A (hospital insurance) and Part B (medical insurance). Medicare Part A helps pay your hospital bill. It covers a semiprivate room, meals, general nursing, and other hospital services and supplies. It does not pay for private duty nursing, a television or telephone in your room, or a private room, unless medically necessary. For more information about Medicare coverage, call the toll-free helpline at 1-800-MEDICARE (1-800-633-4227).

For More Information
 

The American College of Surgeons (ACS) has information for the public. When You Need an Operation answers many questions that patients have about surgery. Frequently Performed Operations is a series of brochures on specific types of surgery such as hysterectomy, hernia repair, gall bladder surgery, and others. For free copies, contact the ACS at 633 North St. Clair, Chicago, IL 60611; telephone 312-202-5399.

Free booklets on what you should know about anesthesia are available from the American Society of Anesthesiologists at 520 Northwest Highway, Park Ridge, IL 60068-2573; telephone 847-825-5586. The website address is www.asahq.org .

 For more information about health and aging, contact the National Institute on Aging Information Center at 1-800-222-2225 or 1-800-222-4225 (TTY).   The NIA distributes a number of other free Age Pages, including "Hospital Hints" and "Choosing a Doctor."

Source: National Institute on Aging, U. S. Department of Health and Human Services, Public Health Service, National Institutes of Health, February 2000

3. Managing Osteoarthritis

Helping the Elderly Maintain Function and Mobility

Research shows how elderly patients with osteoarthritis can become more active and responsible for their own care, make more informed decisions, help to control the costs of health care, and improve their quality of life.

Osteoarthritis is the most prevalent form of arthritis in the United States, affecting over 20 million adults. More than half of all people age 65, and over have evidence of osteoarthritis. It is the leading cause of disability in this age group.

Research funded by the Agency for Healthcare Research and Quality (AHRQ) indicates that treatment involving patient self-management, occupational therapy, pharmaceutical therapy, and surgery can reduce pain, maintain or improve joint mobility, and limit functional disability. AHRQ's research shows how elderly patients with osteoarthritis can:

• Become more active and responsible for their own care.
• Make more informed decisions.
• Help to control the costs of health care.
• Improve their quality of life.

Background

Research funded by AHRQ shows that the effects of osteoarthritis accumulate as people age. The presence of osteoarthritis significantly predicts whether or not elderly people will become functionally limited in their ability to care for themselves^. According to AHRQ's Healthcare Cost and Utilization Project (HCUP), 250,000 people ages 65-79 were hospitalized in 1997 because of osteoarthritis.⁶ There is no known cure for osteoarthritis, and therapy becomes more and more complicated as people age.

Osteoarthritis of the knee and hip joints causes the most difficulty for the elderly because it significantly impacts their ability to conduct their normal activities of daily living, such as walking, cooking, bathing, dressing, using the toilet, and performing household chores^. Joints can become painful, stiff, and swollen.. The resulting pain causes limited motion, reduced physical capability, restriction of social activities, and compromised work capacity. The interaction of these factors—pain, loss of social contact, and diminished income—can create emotional distress, which further reduces physical activity. Increased disability results when the affected joints are exercised less, and the elderly begin to lose muscle tone, leading to reduced strength. Because there is no cure, the therapeutic goal of treatment for osteoarthritis is to minimize the effects of the disease and its consequences over time.

Knee Surgery Has Benefits and Risks

Surgical repair and replacement of the knee joints provide durable pain relief and functional improvement in patients with osteoarthritis.^7,17 However, the elderly need to consider certain factors, such as surgical complications and the pros and cons of having surgery performed on both knees at the same time.

Knee replacement surgery improves quality of life

The AHRQ total knee replacement Patient Outcomes Research Team (TKR PORT) showed that, despite the risk of complications, quality of life improves for the elderly after knee replacement surgery.Elderly patients reported less pain and better physical function.

Additional AHRQ-funded research confirmed the value of total knee replacement surgery in a study of patients whose average age was 65 years. After 4 years, nearly 90 percent of patients had a good to excellent outcome. After five years:

• 75 percent had no pain.
• 20 percent had mild pain.
• 3.7 percent had moderate pain.
• Only 1.3 percent had severe pain.

Complications from surgery increase with age

AHRQ research has indicated that the elderly face more risks of major or fatal complications when undergoing non-cardiac surgery, including orthopedic surgery, than younger patients. Specifically, older patients have a significantly higher risk of pulmonary edema, heart attack, abnormal heart rhythms, bacterial pneumonia, respiratory failure, and in-hospital mortality.

Patients ages 70-79 were twice as likely and patients 80 years and over were three times as likely to suffer postoperative complications or death when compared to patients ages 50-59. Older patients also had longer hospital stays  regardless of sex, ethnicity, preoperative clinical characteristics, functional status, and type of procedure.

AHRQ research showed that about 18 percent of patients undergoing knee replacement surgery, whose average age was 65, had complications. The mortality rate was 7.1 percent at 30 days but dropped to 1.5 percent after 1 year.

High Volume Hospitals and Surgeons Have Lower Complication Rates

AHRQ-funded studies conducted as a part of the TKR PORT indicated that patients generally have fewer complications when their surgeons perform more than 20 knee replacements per year or patients have their surgery in hospitals that perform at least 40 operations per year.³ One study showed that average surgical complication and mortality rates declined as the hospital performed more knee replacement surgeries.  These reductions were consistent in both medium- and large-size hospitals.   

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