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Academia and the Profession |

Health Values of the Seriously Ill

Joel Tsevat, MD, MPH; E. Francis Cook, ScD; Michael L. Green, MD, MS; David B. Matchar, MD; Neal V. Dawson, MD; Steven K. Broste, MS; Albert W. Wu, MD, MPH; Russell S. Phillips, MD; Robert K. Oye, MD; and Lee Goldman, MD, MPH
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From Harvard Medical School and Harvard School of Public Health, Boston, Massachusetts. Duke University Medical Center, Durham, North Carolina. MetroHealth Medical Center and Case Western Reserve University, Cleveland, Ohio. Marshfield Clinic, Marshfield, Wisconsin. Johns Hopkins University, Baltimore, Maryland. University of California, Los Angeles, Medical Center, Los Angeles, California. For The SUPPORT Investigators. Requests for Reprints: Joel Tsevat, MD, MPH, Section of Outcomes Research, Division of General Internal Medicine, University of Cincinnati Medical Center, 231 Bethesda Avenue, Cincinnati OH 45267-0535. Acknowledgments: The authors thank the late Marilyn Bergner, PhD, for her contributions and dedication to this project and the members of the SUPPORT Publications Committee for helpful comments. Grant Support: By the Robert Wood Johnson Foundation's Program on the Care of Critically Ill Hospitalized Adults.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1995;122(7):514-520. doi:10.7326/0003-4819-122-7-199504010-00007
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Objective: To assess 1) the health values and health ratings of seriously ill hospitalized patients, their surrogate decision makers, and their physicians; 2) the determinants of health values; and 3) whether health values change over time.

Design: Prospective, longitudinal, multicenter study.

Setting: 5 academic medical centers.

Participants: 1438 seriously ill patients with at least one of nine diseases who had a projected overall 6-month mortality rate of 50%; their surrogates; and their physicians.

Measurements: Time-tradeoff utilities (reflecting preferences for a shorter but healthy life) and health ratings.

Results: At study day 3, patients had a mean time-tradeoff utility of 0.73 ±0.32 (median [25th, 75th percentile], 0.92 [0.63, 1.0]), indicating that they equated living 1 year in their current state of health with living 8.8 months in excellent health. However, scores varied widely; 34.8% of patients were unwilling to exchange any time in their current state of health for a shorter life in excellent health (utility, 1.0), and 9.0% were willing to live 2 weeks or less in excellent health rather than 1 year in their current state of health (utility, 0.04). Health rating scores averaged 57.8 ±24.0 (median [25th percentile, 75th percentile], 60 (50, 75) on a scale of 0 (death) to 100 (perfect health). The patients' mean time-tradeoff score exceeded that of their paired surrogates (n = 1041) by 0.08 (P < 0.0001). Time-tradeoff scores were related to psychosocial well-being; health ratings; desire for resuscitation and extension of life rather than relief of pain and discomfort; degree of willingness to live with constant pain; and perceived prognosis for survival and independent functioning. Scores of surviving patients increased by an average of 0.06 after 2 months (P < 0.0001) and 0.08 after 6 months (P < 0.0001).

Conclusions: Health values of seriously ill patients vary widely, are higher than patients' surrogates believe, are related to few other preference and health status measures, and increase over time.

Figures

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Figure 1.
Histogram of patients' time-tradeoff scores at day 3 (n = 1438).
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Figure 2.
Histogram of differences between the time-tradeoff scores of patients and those of their surrogates at day 3 (n = 1041).

Differences are expressed as the fraction of a year of excellent health that the patient equated with 1 year in his or her current state of health minus the corresponding value estimated by the surrogate. A difference of zero indicates exact agreement between patient and surrogate. Positive values indicate that patients' time-tradeoff scores were higher; negative values indicate that they were lower.

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Figure 3.
Comparison of the mean time-tradeoff scores of patients and their matched surrogates, overall and by disease category (n = 1041).P

An asterisk indicates a statistically significant difference ( < 0.05) between the scores of patients and their surrogates. ARF = acute respiratory failure; MOSF = multiorgan system failure; COPD = chronic obstructive pulmonary disease; CHF = congestive heart failure; Ca = cancer.

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