Cost and Needing Time off Work Prevent Some Older Adults from Undergoing Surgery


Regarding elective surgery, more than half of older adults in a survey study expressed concerns about pain and discomfort, as well as difficulty in recovery. Common concerns included costs, COVID-19 exposure, and time needed to be off work.

Cost and Needing Time off Work Prevent Some Older Adults from Undergoing Surgery

Nicholas L. Berlin, MD, MPH, MS

Credit: Michigan Medicine, University of Michigan

A study surveying older adults’ concerns about elective surgery found more than half of the respondents expressed concerns about pain, discomfort, and recovery, with other common concerns being out-of-pocket costs, COVID-19 exposure, and time needed to take off from work.1 In total, 64.3% of respondents reported being very concerned or somewhat concerned about pain and discomfort.

With approximately 200,000 patients undergoing elective surgery each year, investigators believe results could help improve the management of patients who may be considering elective surgeries.2

“The financial burden of surgery has been the focus of recent federal initiatives to improve price transparency and eliminate out-of-network surprise billing,” said investigators, led by Nicholas L. Berlin, MD, MPH, MS, from the department of surgery at the University of Michigan. “Whether these initiatives will reduce the financial implications of surgery remains unknown.”

Berlin and colleagues’ cross-sectional study sought to characterize preoperative concerns among older US adults who considered elective surgery and whether concerns were linked to self-reported decisions to have surgery. From this, they can determine whether concerns potentially deter respondents from having the operation.

The investigators surveyed a nationally representative sample of US adults aged 50 – 80 years through the University of Michigan National Poll on Healthy Aging using the National Opinion Research Center AmeriSpeak panel. The panel is intended to be representative of the US household population. Overall, 64% of respondents completed the survey, and the sample had 52.7% of females with a mean age of 63.7 years.

The survey included questions on whether they considered having elective surgery in the past 5 years, to rate how concerned they were about surgery-related factors including pain, discomfort, recovery, out-of-pocket costs, and employment. The survey also asked questions on sociodemographic information, physical health, mental health, and COVID-19 vaccination status.

The investigators used multivariable logistic regression models to evaluate associations between concerns and decisions to have the surgery. Data was analyzed from July – August 2023 and November 2023.

Only 32% (n = 676) of older US adults reported they had considered having an elective surgery in the prior 5 years, and 66.6% (n = 450) of these individuals underwent surgery. The most common elective surgeries were major joint surgery such as hip or knee replacement (18.1%), eye surgery (12.4%), abdominal surgery including hernia repair, gall bladder removal, hysterectomy (10.2%), cosmetic surgery (8.8%), and foot or leg surgery (6.8%).

Most concerns were about pain or discomfort (64.3% of participants, n = 417), as well as recovery (57.2%, n = 57.2%), but older adults were also concerned about out-of-pocket costs (22.9%, n = 144), COVID-19 exposure (18.9%, n = 48), and time needed to be off work (20.2%; n = 41). Multivariable models showed individuals with concerns about out-of-pocket costs, COVID-19 exposure, and time needed to be off work were less likely to have surgery.

“Our data provide further evidence that concerns about exposure to COVID-19 may have exacerbated issues of access and contributed to pent up demand for care and preventable morbidity associated with surgical disease,” investigators wrote.

The team also stated how the number of adults employed aged ≥ 60 years has doubled from 2000 and 2020. They highlighted how future studies should assess whether job employment affects time off for recovery.

The investigators also pointed out limitations, including how the concerns are retrospective and may not take into consideration all concerns for patients who consider elective surgery. Additionally, the study did not plan for multiple testing. Moreover, some variables remain unknown, such as whether patients received estimates for out-of-pocket costs, COVID-19 risks, and if they received necessary time off from work.

“Overall, these findings highlight opportunities to support older adults who consider elective surgery so that these decisions can be based on clinical benefits, risks, and each patient’s goals and preferences,” investigators concluded.


  1. Berlin, N, Kirch, M, Singer, D, et al. Preoperative Concerns of Older US Adults and Decisions About Elective Surgery. JAMA Network Open. 2024;7(1):e2353857. doi:10.1001/jamanetworkopen.2023.53857
  2. Elective Surgery Data. NSW Health. Accessed January 30, 2024.
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