Many older adults worry about costs, time off work and COVID-19 risk when considering surgery

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When it comes to surgery, older adults don’t base their decisions on how much pain they’ll experience and how quickly they’ll recover, a new study finds.

Many also have serious concerns about how much they will have to pay out of pocket, how much work they will miss, and whether they will catch COVID-19 in a hospital or surgery center.

And most of those who said they were very worried about these things didn’t have an operation they’d considered, the study found. The percentage who did not undergo surgery was much lower among those who said they were very concerned about pain or the recovery process.

New information, published JAMA Network Open A team at the University of Michigan’s Institute for Healthcare Policy and Innovation can inform policymakers, surgical teams and employers.

The findings come from further analysis of data from the National Poll on Healthy Aging, which showed in 2022 that nearly half of seniors who considered surgery had concerns about cost, time off work or Covid risk. IHPI conducted the poll with funding from AARP and the Academic Medical Center of Michigan Medicine, UM.

Surgeon Nicholas Berlin, MD, MPH, MS, says the new findings have affected his own interactions with patients.

When I counsel patients in my clinic who are considering elective surgery, I now also spend a lot of time discussing the financial and employment implications of surgery with them. Unfortunately, I have seen many uninsured patients not need surgery because they are unable to afford the out-of-pocket costs or take time off work to recover.”

Nicholas Berlin, MD, MPH, MS

Cost considerations

The new survey shows that nearly half of those who said they were very concerned about the cost, and more than half of those who were very concerned about taking time off work, did not have the surgery they considered.

In contrast, those who said they were very concerned about surgery-related pain were just as likely to proceed with the operation as those who had no concern about pain.

He noted that federal policymakers have tried to address the issue by making hospitals more transparent about prices for operations and reducing “surprise” billing for services by providers who don’t participate in a patient’s insurance network.

But, he adds, these policies don’t address financial concerns about lost wages from employment that don’t come with paid time off, or the costs associated with the way a person’s health insurance is structured. Over the past two decades, the percentage of people over 60 has doubled, and enrollment in Medicare Advantage plans with limited networks and high-deductible health plans has increased.

Berlin is an associate in microsurgery and plastic surgery in the Department of Surgery at the UM Medical School and an alumnus of the National Clinician Scholars Program of the IHPI.

Considering COVID-19

The COVID-19 concerns found in the study reflect the fact that the original survey was conducted in August 2021 and asked respondents to reflect on surgery-related concerns and decisions over the previous five years.

At that time, two-thirds of those who said they were very concerned about COVID-19 exposure during surgery and the recovery process considered no surgery.

At the start of the pandemic in early 2020, elective operations such as those asked in the survey were canceled for several months and only emergency operations proceeded. This affects the surgery schedule after resuming elective operations.

Even today, for patients who are especially vulnerable to, or wary of, severe COVID-19, the recent surge in COVID-19 cases and the rollback of infection-prevention requirements by hospitals and surgery centers may influence decision-making, Berlin said.

Poll director and senior author of the new paper Jeffrey Kullgren, MD, MS, MPH, said more research is needed to understand what influences a person’s decision to proceed with the operation so that health care providers can best advise their patients. Kullgren is a primary care physician at the VA Ann Arbor Healthcare System and an associate professor of internal medicine at UM and a member of IHPI and the VA Center for Clinical Management Research.

The most common elective operations considered by poll respondents were hip or knee replacement, cataract surgery, hernia repair, gallbladder removal, and hysterectomy, all of which are medically necessary and may be covered by insurance. But some respondents also considered or had cosmetic surgery, which is paid for entirely out of pocket.

“More research is needed to understand and address caregiver input, which was a reason for some people in the study not to have surgery,” Kullgren said. “This includes both those who are concerned about the surgery being temporarily unable to care for someone else and those who are concerned about being cared for after their operation.”

The survey involved 2,110 adults aged 50 to 80, of whom 32% said they had considered an elective operation in the previous five years. Two-thirds of those who said they had considered having an operation actually had one.

For more on NPHA’s procedures, see

In addition to Berlin and Kullgren, the study’s authors are NPHA poll team members Matthias Kirch, MS, Diane Singer, MPH, Erica Solway, PhD, and Preeti Malani, MD.


Journal Reference:

Berlin, NL, etc. (2024). Preoperative anxiety and decisions about elective surgery in older US adults. JAMA Network Open.

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