Caveats to “letting go”

A recent NYTimes article comes at the heels of Dr. Gawande's compelling essay on end of life care. The matter at hand is that legislators are realizing the economic value of palliative care options for terminally ill patients. Recently, Gov. David A. Paterson signed into law a bill — the New York Palliative Care Information Act — requiring physicians who treat patients with a terminal illness to have frank discussions about prognosis and options for end-of-life care, including aggressive pain management and hospice care as well as the possibilities for further life-sustaining treatment. A similar law in California seeks to overcome physician resistance to talking openly with terminally ill patients about end of life care options. As part of the original federal healthcare overhaul, a similar provision would have reimbursed doctors for the time it takes to have such conversations – which however did not make through it given the traction gained by "death panels". Overall, even commercial insurers have financial incentive to steer patients with a poor prognosis away from costly health care services.

The point is that there is a cost advantage, in addition to the better quality of life argument. Several studies reveal that palliative care and hospice services can reduce costs of can-do-aggressive medicine anywhere from 20 to 35 %. Given that end-of-life costs make up a quarter of the Medicare budget, steering patients away from the ICU makes for good economics right? If that is the case then shouldn't all states follow suit? There are caveats however - that are well brought to our attention in this write up, on the Disease Care Management Blog.

Doctors cannot predict the end of life: "When confronted with a critically ill cancer patient, popular culture would have you think the physicians can predict the likelihood of not making it out of the ICU alive and can therefore treat accordingly. The problem is that the prediction is far from perfect with an ROC, according to this study, of about 0.8 (where 1 is perfect). In other words, there are enough false positives to give physicians pause before recommending pulling the plug." Further, "for non-cancer patients, the prognostic tools are even worse".

Research on hospice is on shaky ground: "given our national manic compulsion for "evidence-based" science to guide treatment decisions, that the research supporting the benefits of hospice is decidedly shaky. Dr. Gawande only quoted some studies that happened to support his point of view"

Having said that, what could change is a physician's perspective on palliative care – not as an option after all else fails.

Behavioral Biases in Medical Testing

As evidence continues to mount that established models of rational decision-making are dangerously out of date, behavioral science has embraced human irrationality in all of its deceptively predictable forms. At the forefront of the field is Duke University professor Dan Ariely, whose simple experiments into human bias have shed light on everything from the fallacy of supply and demand to the problem of procrastination.

In a recent interview with NPR, he turned his gaze toward the growing debate about rampant health care costs and their potentially behavioral origins. To contextualize the issue, he describes an experiment in which different groups are asked to order pizzas. One group is presented a menu where the default is an all-dressed pizza and toppings have to be taken off if they aren't wanted. Another group is presented with a menu featuring a cheese-only pizza where any preferred toppings have to be added. It turns out that those presented with the all-dressed pizza menu were more inclined to order more toppings, and those with the cheese-only menu were more likely to order fewer toppings.

If this outcome is truly representative of a natural human bias, the implications for ordering medical tests is painfully obvious and potentially quite costly. As Ariely confirms:

If you go to the hospital these days, or to visit your physician, you will see that they have these electronic order forms. And they basically use those to order tests for you. And sometimes these order forms are empty, nothing is selected for them. The default is nothing, and they have to pick what they want to order. And sometimes some tests are preselected for them.

So we created scenarios in which we described to physicians some patients who arrived at the ER, and we asked them to decide what test to give them. And to half of the physicians we gave the fully-loaded options, like the pizza. And for the other half we gave them one that were empty, and they had to check which one they wanted to do.

The basic result was that in the empty set, physicians chose an average of five tests. And in the full set, they chose an average of 13 tests....the difference was about $1,300 per patient. So now if you think about it, these information systems are going to roll out into hospitals in all kinds of ways and I think they have tremendous influence on what the physicians will decide.

The experiment didn't use actual patients but the intuition should be fairly obvious: given a natural human bias to anchor to a default selection when presented with a menu of options, more attention should be paid to what that "default" set of tests will be for a particular set of symptoms, and how that decision will ultimately impact both the quality and the costs of care.