Underinvestigation and undertreatment of carotid disease in elderly patients with transient ischaemic attack and stroke: comparative population based study
I have misgivings about this paper and about the suggestions of ageism in the accompanying editorial. In the introduction, we learn that lower rates of treatment in older people “might legitimately reflect … patients’ choice”. However, the conclusions of the abstract assert “a willingness to have surgery” on the part of elderly patients and in the discussion section of the main paper we are told that the low rate of endarterectomy in patients of 80 and above is ”unlikely to have been due … to patient choice”. Neither of these statements is supported by a reference. In the methods section, we are told that “all patients were interviewed and examined so that the potential appropriateness of carotid surgery could be determined”. However, we are not told how appropriateness was determined and from whose perspective.
When research findings contradict clinical experience, they demand careful scrutiny. My experience of talking to older people over many years is that many, although certainly not all, begin to lose their enthusiasm for hospital treatment of any sort after the age of 80, let alone for invasive surgery with a significant, albeit small, risk of harm. I note that in this study the gold standard was a decision made by the patient after discussions with surgeons who were not involved in the study. Ageism is undoubtedly operating in the distribution of healthcare resources in the UK but we should not forget that it can also occur when patients are persuaded to accept treatments that do not accord with their own values and aspirations. There is a real danger that locating ageism within rates of prophylactic surgery will distract attention from the much more pervasive expressions of ageism which are to be found in the lack of funding for the care of frail older people in England and particularly those suffering from dementia.
Rapid Response:
Whose ageism?
I have misgivings about this paper and about the suggestions of ageism in the accompanying editorial. In the introduction, we learn that lower rates of treatment in older people “might legitimately reflect … patients’ choice”. However, the conclusions of the abstract assert “a willingness to have surgery” on the part of elderly patients and in the discussion section of the main paper we are told that the low rate of endarterectomy in patients of 80 and above is ”unlikely to have been due … to patient choice”. Neither of these statements is supported by a reference. In the methods section, we are told that “all patients were interviewed and examined so that the potential appropriateness of carotid surgery could be determined”. However, we are not told how appropriateness was determined and from whose perspective.
When research findings contradict clinical experience, they demand careful scrutiny. My experience of talking to older people over many years is that many, although certainly not all, begin to lose their enthusiasm for hospital treatment of any sort after the age of 80, let alone for invasive surgery with a significant, albeit small, risk of harm. I note that in this study the gold standard was a decision made by the patient after discussions with surgeons who were not involved in the study. Ageism is undoubtedly operating in the distribution of healthcare resources in the UK but we should not forget that it can also occur when patients are persuaded to accept treatments that do not accord with their own values and aspirations. There is a real danger that locating ageism within rates of prophylactic surgery will distract attention from the much more pervasive expressions of ageism which are to be found in the lack of funding for the care of frail older people in England and particularly those suffering from dementia.
Competing interests:
None declared
Competing interests: No competing interests