The implications of using patient preferences (utilities) vs. health status on decision making and policy recommendations for patients with ulcerative colitis

Abstract

Q THE IMPLICATIONS OF USING PATIENT PREFERENCES (UTILITIES1 VS. HEALTH STATUS ON DECISION MAKING AND POLICY RECOMMENDATIONS FOR PATIE~S WITH ULCERATIVE COLITIS. D. Provenzale, M. Shearin, W. Tillinger, B. Phillips-Bute, F.S. Sherman R. Bollmger, M. Koruda, D. Drossman, J.B. Wong, Di~sion of Gastro'enterotogy: Epidemimogy, ~ecision Analysis, Outcomes t~esearch Grotto, Duke Umv~sltL¢, Durham., N=C., Universit3/of N.C., Chapel Hill N.C. Tufts-New tmgtand Meaical ~Str. ~oston, MA. ,~ , ' ' f o r patients wire pancotitis or more man 7-1u years auration, most authorines recommend surveillance colonoscopy with biopsies, but others advocate prophylactic colectomy after 10 years of disease to minimize cancer risk. Health status and quality of life arter colectomy are important outcomes, in decisions for surveillance and colectomy. Health status measures evaluate physical, social .and emotional function, while quality of life measures examine patient preferences for health states. Both measures provide valuable information about the patient-specific outcomes of surveillance programs. In an earlier report, we measured quality of life values ofpost-cotectomy patients using tlae time trade-off tecfinique (TTO) and, in a decision analysis, examined their effect on management decisions for patients with ulcerative colitis. In this study, we measured the health status of 21 patients who had undergone proctocolectomy with ileal pouchanal anastomosis. Health status was measured with the SF-36, a general measure of health status and well being, which has been validated m postcolectomy patients. We incorporated these results into the decision model to determine the effect of post-operative physical functioning on decisions for surveillance and colectomy. We compared these results with the results obtained using the measured quality o f life values. The decision model compares strategies of prophylactic proctocolectomy and ileal pouch-anal anastomosis with surveillance every 1-5 years and surveillance at variable intervals based on the duration of the disease, with no surveillance. The details of the model are published in an earlier report. TrO SF-36 Quality adjustment for colectomy 0.97 (perfect health=l.0) 0.81 (perfect health=l.0) Preferred strategy Prophylactic colectomy Surveillance very 5 years Using the TTO results, prophylactic colectomy would increase qualityadjusted life expectancy by 7months compared to no surveillance and b y up to 6 months compared to surveillance strategies. Using the results ot~tained with the SF-36, surveillance every 5 years would increase quality-adjusted life expectancy by up to 5.3 years compared to prophylactac colectomy, and by 4.6 years compared to surveillance with co[ectomy for low grade dysplasia. The optimalmanagement strategy depends upon the perspective of the decision maker. The individual patient and physician who might consider the quality of life post-colectomy as most important, would adopt the optimal management strategy based on the TTO results. Individuals Who consider physical functioning most important, and those who make health policy, might base their recommendations on management strategies that incorporate the physical functioning score. Quality of life and health status are unportant outcomes for post-colectomypatients. Their measurement should be incorporated into all individualdecisions and policy recommendations for patients with ulcerative colitis. ETHICALLY JUSTIFIED, CLINICALLY COMPREHENSIVE GUIDELINES FOR PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBE PLACEMENT. L. Rabaneck. L. B. McCullough, N.P. Wray. VA Medical Center HSRD persistent vegetative state; uncomplicated dysphagia; and complicated dysphagia. We then developed an algorithm to guide physicians in deciding when to offer and recommend PEG tube placement for patients in each category. In the past, the decision to place a PEG tube has mainly centered on the patient's inability to take food by mouth. We contend that PEG tube placement is a medical intervention no different from any other. In deciding whether to offer PEG tube placement, beneficence-based clinical judgment must be complete, and take into account the patient's overall quality of life. The patient's autonomy must also be respected. By placing the decision in the context of this ethical framework, we have developed clinically sensible and ethically sound guidelines for the procedure.