A new paper published on February 20, 2020, in the The New England Journal of Medicine found that people who had experienced a heart attack within a week or two after they turned 80 were less likely to get treated with coronary artery bypass surgery (CABG) than someone who was still 79 — even if that person was going to turn 80 within the next two weeks. Although there aren’t clinical guidelines that instruct surgeons to reduce the use of CABG after any set age, the authors suspected that because of the complexity, risk of short-term complications, and long recovery period, that doctors might be more hesitant to perform this procedure on patients they perceived as being older. “I think this idea of the left-digit bias is very real. It manifests from our desire to group individuals constantly, whether it’s generations — boomers and Gen X and millennials — or decades when it comes to ages,” says Christopher Ryan Burke, MD, a cardiovascular surgeon and assistant professor of cardiac surgery at UW Medicine in Seattle. “At the end of the day there’s really no difference between a person who is 79 years and 50 weeks old and someone who is 80 years and two weeks old,” says Dr. Burke, was not involved in this research. For the study, investigators used the data from Medicare records of approximately 70,000 patients from 2006 to 2012 and a found a total of 9,462 people who were 79 or 80 years old. Within that population, investigators focused on the group born within a four-week window — 308 people who were still 79 and about to turn 80, and those who had turned 80 within the last two weeks. They discovered that whereas 7 percent of the people who were still technically 79 were given bypass surgery, only 5.3 percent of those who just turned 80 had the operation. To see if the trend existed across other ages, authors made various comparisons, such as 77 versus 79 and 81 versus 83, and didn’t find any difference in surgery rates, which strengthens the theory that the threshold between 79 and 80 was a factor in the decision. Although authors of the study agree that it’s unrealistic to expect doctors to completely eliminate every bias, the research is a start to improving care. “The main thing that they can do is simply be aware that this bias exists,” notes study coauthor Anupam B. Jena, MD, PhD, an associate professor at Harvard Medical School and a physician at Massachusetts General Hospital in Boston.
How Bias Impacts Medical Care
For Burke, this was a timely paper as it reminded him of a similar situation he faced a few months ago. “There was a patient that I saw in clinic who needed a fairly complex open-heart operation; he was 79 and had a birthday coming up in the next month or so,” Burke recalls. “I made a joke to him that we needed to schedule his surgery sooner rather than later because my colleagues might look at me funny if I was performing this surgery on someone who was 80 years old,” he says. “I think that for heart surgery specifically, that transition from someone in their seventies to their eighties impacts — probably subconsciously — the way we view some of these patients,” adds Burke. Another influencing factor could be that results about the efficacy of a drug or procedure can be grouped in terms of ages or decades as well. “It’s rarely random; we love grouping people in some kind of organized fashion,” says Burke. It’s not just the bias itself that can create inequities in healthcare, but also a lack of understanding that these biases do exist. A recent study, published in June 2019 in Neurology, found that more than half of American neurologists believe that a person’s gender identity has no significance in how their neurologic disease should be treated. This lack of awareness could lead to significant medical consequences. There are many forces at play that factor into our decision making when evaluating patients, says Burke. “A paper like this can serve as a ‘light bulb’ moment to make us understand how we make decisions and evaluate patients that can help prevent us from making poor judgements,” he says.
