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Reform Update: Timing of patient benefit should be weighed in value of preventive services, researchers say

By Melanie Evans
Posted: December 11, 2013 - 3:30 pm ET

The value of preventive services must be measured not just by how effective they are at reducing the risk of disease but also by how long before patients will benefit, a new online commentary in the Journal of the American Medical Association argues.

Elderly patients, particularly those already weakened by chronic disease, do not always live long enough to benefit from some clinically recommended interventions that carry an immediate risk, such as complications or side effects, the authors said in their commentary.

“For older adults, the question “When will it help?” is just as important as “How much will it help?” wrote Drs. Sei Lee and Louise Walter of the University of California and Dr. Rosanne Leipzig of the Icahn School of Medicine at Mount Sinai.

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The timing of the benefit is a critical consideration that is often overlooked in discussions of quality and overuse, commentary authors said

That question needs to be part of a shared decisionmaking process between patients and clinicians involving a frank discussion about the risks and benefits of care and patients' priorities. The authors wrote patients should dominate decisions when there's little difference between life expectancy and prevention benefits.

The Patient Protection and Affordable Care Act calls for the CMS Center for Medicare and Medicaid Innovation to develop and promote shared decisionmaking and use of tools that help patients make informed decisions about their care. There is evidence that shared decisionmaking and use of decision tools increases patient satisfaction, and there is some evidence that this can help reduce the use of inappropriate and unnecessary services.

Most Americans develop chronic illnesses as they age. Those ailments may be more likely to kill us than, say, a slow-growing prostate cancer, said Lee, an associate professor of medicine at the University of California San Francisco, in an interview. But “once we identify a prostate cancer it's very hard for doctors and patients to not do something about it,” even when the care is unnecessary and comes at a price. “There are costs in terms of healthcare dollars, but there are also significant human costs.”

That should give physicians pause, Lee said. Not all patients will live to see the cancer become life-threatening and they may have avoided the anxiety and decision of whether to treat the cancer if they had never been screened, he said.

Research on prevention and clinical guidelines could do more to better measure life expectancy and the lag time between intervention and benefit, the authors said. Guidelines often use age alone to calculate life expectancy, but health varies widely by age. “Although research will continue to improve the accuracy of life expectancy prediction and lag time to benefit, guidelines should move beyond age and explicitly encourage clinicians to juxtapose these two elements to improve the targeting of prevention,” they said.

Leipzig said she begins conversations by asking patients to estimate how many years they have left and describe what they want from those years. Informed decisions could help prevent overuse and waste but also prevent patients from unnecessary harm, he said. “There are opportunity costs both for medicine but more so for the individual patient.”

Eat well, pay more

Here's news that will surprise few but will nonetheless dismay healthcare providers with a growing financial stake in the health-related choices we make about what to eat, which can create serious complications for the chronically ill.

It is more expensive to eat healthy than it is to eat poorly. The difference, at its greatest, amounts to about $45 a month, researchers reported in the journal BMJ Open. The analysis was based on a review of 27 studies, including 14 from the U.S., which looked at the relative cost and health benefits of what we eat.

It's an obstacle that low-income households struggle to overcome. That issue is also of growing importance to hospitals and doctors as healthcare financing changes. States, Medicare and some private insurers are offering financial incentives to healthcare providers to curb the cost of healthcare, through accountable care contracts and other alternative payment models.

Hospitals and doctors have responded to these incentives with efforts to prevent hospitalization and better manage chronic disease, including initiatives that teach nutrition and weight loss.

Modern Healthcare recently looked at the role that money plays in the choices Americans make that affect their health, including diet. The cost barrier to eating healthy was highlighted by one North Carolina woman who struggled with a tight budget, diabetes and congestive heart failure.

“You just have to go low-budget on everything,” said Mary Lowery. “Staple stuff that will last for a while that you can stretch.” She bought macaroni and cheese, frozen breaded chicken, tomato sauce and spaghetti to feed herself and her family. “We'd eat a lot of processed foods,” she said. “Usually, I skipped the fresh produce aisle. One dollar and ninety-eight cents for tomatoes is ridiculous.”

Americans pay about $1.50 more a day to eat a healthy diet of fruit, vegetables, fish and nuts than they pay to eat processed foods, the researchers in the BMJ Open article said.

Follow Melanie Evans on Twitter: @MHmevans

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