Physicians and Patients/Caregivers Frequently Disagree on Medicare Resource Allocations for Patients With Advanced Head and Neck Cancer
In a study reported in JAMA Otolaryngology–Head & Neck Surgery, Rocke et al compared hypothetical resource allocation by otolaryngology–head and neck surgery physicians and patients with that by advanced cancer patients or their caregivers. They found significant differences in resource allocation between the two groups, with allocation being affected by patient/caregiver but not physician baseline health attitudes.
Study Details
In the study, physicians used an online tool to create a Medicare health plan for advanced cancer patients that allocated a limited pool of resources among 15 benefit categories: advice, cash ($360–$1,200 per month to help with living expenses), complementary services, cosmetic care, dental/vision, drugs, emotional support, home care, home improvement/equipment, house calls, nursing facility, other medical care, palliative care, primary care, and treatment for cancer. These data were compared with preliminary data from patients with cancer and their caregivers from a separate study using the same tool.
Attitudes toward quality vs quantity of life were assessed for both physicians and patients/caregivers using three questions: Would you rather have: (1) 1 year of life at 100% health or 10 years at 10% health; (2) 2 years of life at 50% health or 4 years at 25% health; and (3) 4 years of life at 25% health or 8 years at 12.5% health?
Of 9,120 otolaryngology–head and neck surgery physicians invited, 767 (8.4%) participated, and data were available for 146 patients and 114 caregivers (n = 240); patient and caregiver data were combined since there were no significant differences between allocations in the two groups in any of the benefit categories. For physicians vs patients/caregivers, health status was rated as poor by 0% vs 2%, fair by 1% vs 16%, good by 6% vs 40%, very good by 32% vs 33%, and excellent by 61% vs 10%.
Analysis of resource allocation by health status showed no significant associations for physicians, whereas patients/caregivers with worse health preferred more coverage in the cosmetic (P = .03), home care (P = .046), and nursing facility (P = .02) categories.
1 Year at 100% Health
Stratification by answer to the question of whether 1 year of life at 100% health (physicians = 73%, patients/caregivers = 75%) or 10 years of life at 10% health was preferred showed that physicians preferring 1 year at 100% health allocated more cash (P = .02) and that patients/caregivers with this response preferred less allocation to other medical care (P < .001) and palliative care (P = .008) and greater allocation to treatment for cancer (P < .001). Comparison between groups showed significant differences between physicians and patients/caregivers with regard to resource allocation for treatment for cancer (P = .01) and palliative care (P = .02).
2 Years at 50% Health
Stratification by answer to the question of whether 2 years of life at 50% health (physicians = 69%, patients/caregivers = 69%) or 4 years of life at 25% health was preferred showed that physicians preferring 2 years at 50% health allocated more to drugs (P = .03) and patients/caregivers with this response allocated less to other medical care (P = .005), palliative care (P = .006), and home improvement (P = .002) and more to treatment for cancer (P < .001). There were significant differences between physicians and patients/caretakers with regard to allocation of resources for home improvement (P = .003), other medical care (P = .02), palliative care (P = .002), and treatment for cancer (P = .01).
4 Years at 25% Health
Stratification by answer to the question of whether 4 years of life at 25% health (physicians = 76%, patients/caregivers = 77%) or 8 years of life at 12.5% health was preferred showed that physicians preferring 4 years at 25% health allocated more to home care (P = .048) and less to nursing facility (P = .02) categories and patients/caregivers giving this response allocated more to complementary care (P = .049) and less to palliative care (P = .009). There were significant differences between physicians and patients/caregivers with regard to allocation for the house calls category (P = .02).
The investigators concluded, “Patients with cancer and their caregivers have different preferences from physicians. These preferences are, for these patients and their caregivers, affected by their baseline health attitudes, but physician preferences are not. Understanding the effect of baseline attitudes is important for effective end-of-life discussions.”
Daniel J. Rocke, MD, JD, of Duke University Medical Center, is the corresponding author for the JAMA Otolaryngology–Head & Neck Surgery article.
The study was supported in part by a grant from the Agency for Healthcare Research and Quality. The study authors reported no potential conflicts of interest.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
