Peter A. Ubel

American Society of Clinical Oncology Guidance Statement: The Cost of Cancer Care

Advances in early detection, prevention, and treatment have resulted in consistently falling cancer death rates in the United States. In parallel with these advances have come significant increases in the cost of cancer care. It is well established that the cost of health care (including cancer care) in the United States is growing more rapidly than the overall economy. In part, this is a result of the prices and rapid uptake of new agents and other technologies, including advances in imaging and therapeutic radiology. Conventional understanding suggests that high prices may reflect the costs and risks associated with the development, production, and marketing of new drugs and technologies, many of which are valued highly by physicians, patients, and payers. The increasing cost of cancer care impacts many stakeholders who play a role in a complex health care system. Our patients are the most vulnerable because they often experience uneven insurance coverage, leading to financial strain or even ruin. Other key groups include pharmaceutical manufacturers that pass along research, development, and marketing costs to the consumer; providers of cancer care who dispense increasingly expensive drugs and technologies; and the insurance industry, which ultimately passes costs to consumers. Increasingly, the economic burden of health care in general, and high-quality cancer care in particular, will be less and less affordable for an increasing number of Americans unless steps are taken to curb current trends. The American Society of Clinical Oncology (ASCO) is committed to improving cancer prevention, diagnosis, and treatment and eliminating disparities in cancer care through support of evidence-based and cost-effective practices. To address this goal, ASCO established a Cost of Care Task Force, which has developed this Guidance Statement on the Cost of Cancer Care. This Guidance Statement provides a concise overview of the economic issues facing stakeholders in the cancer community. It also recommends that the following steps be taken to address immediate needs: recognition that patient-physician discussions regarding the cost of care are an important component of high-quality care; the design of educational and support tools for oncology providers to promote effective communication about costs with patients; and the development of resources to help educate patients about the high cost of cancer care to help guide their decision making regarding treatment options. Looking to the future, this Guidance Statement also recommends that ASCO develop policy positions to address the underlying factors contributing to the increased cost of cancer care. Doing so will require a clear understanding of the factors that drive these costs, as well as potential modifications to the current cancer care system to ensure that all Americans have access to high-quality, cost-effective care.

Whose quality of life? A commentary exploring discrepancies between health state evaluations of patients and the general public

There is often a discrepancy between quality of life estimates from patients and the general public. These discrepancies are of concern to the disability community, who worry that the public does not understand how valuable life can be for people with disabilities; policy planners, who must decide whose quality of life estimates to use in economic analysis; and practitioners and patients facing difficult medical decisions, who may have to worry that people have difficulty imagining unfamiliar health states. We outline several factors that may contribute to these discrepancies. Discrepancies might occur because patients and the public interpret health state descriptions differently – for example, making different assumptions about the recency of onset of the health state, or about the presence of comorbidities. Discrepancies might also arise if patients adapt to illness and the public does not predict this adaptation; because of response shift in how people use quality of life scales; because of a focusing illusion whereby people forget to consider obvious aspects of unfamiliar health states; because of contrast effects, whereby negative life events make people less bothered by less severe negative life events; and because of different vantage points, with patients viewing their illness in terms of the benefits that would result from regaining health, while the public views the illness in terms of the costs associated with losing good health. Decisions about whose values to measure for the purposes of economic analyses, and how to measure discrepancies, should take these potential contributing factors into account.

Reducing the Influence of Anecdotal Reasoning on People’s Health Care Decisions: Is a Picture Worth a Thousand Statistics?:

Background . People’s treatment decisions are often influenced by anecdotal rather than statistical information. This can lead to patients making decisions based on others’ experiences rather than on evidence-based medicine. Objective . To test whether the use of a quiz or pictograph decreases people’s reliance on anecdotal information. Design . Two cross-sectional survey studies using hypothetical scenarios. Participants read a scenario describing angina and indicated a preference for either bypass surgery or balloon angioplasty. The cure rate of both treatments was presented using prose, a pictograph, a quiz, or a pictograph and quiz combination. Participants read anecdotes from hypothetical patients who described the outcome of their treatment; the number of successful anecdotes was either representative or unrepresentative of the cure rates. Setting and Participants . Prospective jurors at the Philadelphia County Courthouse and travelers at the Detroit-Wayne County Metropolitan Airport. Measurements . Proportion of respondents preferring bypass over balloon angioplasty. Results . In study 1, when statistical information was presented in prose, treatment choices were influenced by anecdotes, with 41% of participants choosing bypass when the anecdotes were representative and only 20% choosing it when the anecdotes were unrepresentative (x2 = 14.40, P < 0.001). When statistics were reinforced with the pictograph and quiz, anecdotes had no significant influence on treatment decisions (38% choosing bypass when anecdotes were representative v. 44% when unrepresentative, x2 = 1.08, P > 0.20). In study 2, the tradeoff quiz did not reduce the impact of the anecdotes (27% v. 28% choosing bypass after receiving or not receiving the quiz, x2 < 1, P > 0.20). However, the pictograph significantly reduced the impact of anecdotes, with 27% choosing bypass after receiving no pictograph and 40% choosing bypass after receiving a pictograph (x2 = 6.44, P < 0.001). Conclusions . Presenting statistical information using a pictograph can reduce the undue influence of anecdotal reasoning on treatment choices.

Between two worlds: Medical student perceptions of humor and slang in the hospital setting

AbstractOBJECTIVE: Residents frequently use humor and slang at the expense of patients on the clinical wards. We studied how medical students react to and interpret the “appropriateness” of derogatory and cynical humor and slang in a clinical setting. DESIGN: Semistructured, in-depth interviews. SETTING: Informal meeting spaces. PARTICIPANTS: Thirty-three medical students. MEASUREMENTS: Qualitative content analysis of interview transcriptions. MAIN RESULTS: Students’ descriptions of the humorous stories and their responses reveal that students are able to take the perspective of both outsiders and insiders in the medical culture. Students’ responses to these stories show that they can identify the outsider’s perspective both by seeing themselves in the outsider’s role and by identifying with patients. Students can also see the insider’s perspective, in that they identify with residents’ frustrations and disappointments and therefore try to explain why residents use this kind of humor. Their participation in the humor and slang—often with reservations—further reveals their ability to identify with the perspective of an insider. CONCLUSIONS: Medical students describe a number of conflicting reactions to hospital humor that may enhance and exacerbate tensions that are already an inevitable part of training for many students. This phenomenon requires greater attention by medical educators.

When Do Patients and Their Physicians Agree on Diabetes Treatment Goals and Strategies, and What Difference Does It Make?

BACKGROUND: For patients with chronic illnesses, it is hypothesized that effective patient-provider collaboration contributes to improved patient self-care by promoting greater agreement on patient-specific treatment goals and strategies. However, this hypothesis has not been tested in actual encounters of patients with their own physicians.OBJECTIVE: To assess the extent to which patients with type 2 diabetes agree with their primary care providers (PCPs) on diabetes treatment goals and strategies, the factors that predict agreement, and whether greater agreement is associated with better patient self-management of diabetes.DESIGN: One hundred twenty-seven pairs of patients and their PCPs in two health systems were surveyed about their top 3 diabetes treatment goals (desired outcomes) and strategies to meet those goals. Using several measures to evaluate agreement, we explored whether patient characteristics, such as education and attitudes toward treatment, and patient-provider interaction styles, such as shared decision making, were associated with greater agreement on treatment goals and strategies. We then examined whether agreement was associated with higher patient assessments of their diabetes care self-efficacy and self-management.RESULTS: Overall, agreement on top treatment goals and strategies was low (all κ were less than 0.40). In multivariable analyses, however, patients with more education, greater belief in the efficacy of their diabetes treatment, and who shared in treatment decision making with their providers were more likely to agree with their providers on treatment goals or strategies. Similarly, physician reports of having discussed more content areas of diabetes self-care were associated with greater agreement on treatment strategies. In turn, greater agreement on treatment goals and strategies was associated both with higher patient diabetes care self-efficacy and assessments of their diabetes self-management.CONCLUSION: Although patients and their PCPs in general had poor agreement on goals and strategies for managing diabetes, agreement was associated with higher patient self-efficacy and assessments of their diabetes self-management. This supports the hypothesis that enhancing patient-provider agreement on both overall treatment goals and specific strategies to meet these goals may lead to improved patient outcomes.

The impact of the format of graphical presentation on health-related knowledge and treatment choices.

OBJECTIVE To evaluate the ability of six graph formats to impart knowledge about treatment risks/benefits to low and high numeracy individuals. METHODS Participants were randomized to receive numerical information about the risks and benefits of a hypothetical medical treatment in one of six graph formats. Each described the benefits of taking one of two drugs, as well as the risks of experiencing side effects. Main outcome variables were verbatim (specific numerical) and gist (general impression) knowledge. Participants were also asked to rate their perceptions of the graphical format and to choose a treatment. RESULTS 2412 participants completed the survey. Viewing a pictograph was associated with adequate levels of both types of knowledge, especially for lower numeracy individuals. Viewing tables was associated with a higher likelihood of having adequate verbatim knowledge vs. other formats (p<0.001) but lower likelihood of having adequate gist knowledge (p<0.05). All formats were positively received, but pictograph was trusted by both high and low numeracy respondents. Verbatim and gist knowledge were significantly (p<0.01) associated with making a medically superior treatment choice. CONCLUSION Pictographs are the best format for communicating probabilistic information to patients in shared decision making environments, particularly among lower numeracy individuals. PRACTICE IMPLICATIONS Providers can consider using pictographs to communicate risk and benefit information to patients of different numeracy levels.

Barriers to influenza immunization in a low-income urban population

BACKGROUND Although influenza immunization significantly reduces mortality from influenza, over one third of elderly Americans are not immunized each year. Low rates of immunization are particularly concerning among African-American low-income populations. Preliminary interviews suggested that fear of undisclosed ingredients in the influenza vaccine may impede vaccine acceptance in this vulnerable population. OBJECTIVES To assess the role of concern about vaccine contents and other factors in the use of influenza immunization among a predominantly African-American low-income urban population. METHODS Cross-sectional, health-system-population-based, telephone survey of a random sample of West Philadelphia residents aged > or =65 years. RESULTS Of 659 eligible individuals, 486 (73.8%) were successfully interviewed. Concern about undisclosed shot contents was reported by 132 (20%) respondents and was inversely associated with vaccine receipt (OR 0. 49, 95% CI 0.26-0.91). This association was similar among African Americans and Caucasians. In addition, receipt of influenza vaccine was inversely associated with belief that immunization is inconvenient (OR 0.14, 95% CI 0.05-0.36), belief that immunization is painful (OR 0.21, 95% CI 0.08-0.54), and history of previous side effects (OR 0.33, 95% CI 0.18-0.60), and positively associated with physician recommendation (OR 3.22, 95% CI 1.76-5.93). CONCLUSIONS In a low-income urban population, concern about undisclosed vaccine contents appears to impede acceptance of influenza immunization among both African Americans and Caucasians. Directly addressing this concern offers a new approach to increasing immunization in this vulnerable population.

Misimagining the unimaginable: the disability paradox and health care decision making.

Good decision making often requires accurate predictions about how potential outcomes will make one feel. However, people often mispredict the emotional impact of unfamiliar circumstances. For example, they often overestimate the emotional impact that chronic illnesses and disability will have on their lives. In the present article, the authors look at possible sources of error in both the happiness reports of patients with chronic illness or disability and the happiness predictions of healthy people asked to imagine the same illnesses and disabilities. On balance, the available evidence suggests that, whereas patients misreport their well-being, healthy people also mispredict the emotional impact that chronic illness and disability will have on their lives.

Cost-Effectiveness Analysis in a Setting of Budget Constraints — Is It Equitable?

BACKGROUND: One of the promises of cost-effective analysis is that it can demonstrate how to maximize health benefits attainable within a specific limited budget. Many people argue, however, that when there are budget limitations, the use of cost-effectiveness analysis leads to health care policies that are inequitable. METHODS: We asked prospective jurors, medical ethicists, and experts in medical decision making to choose between two screening tests for a population at low risk for colon cancer. One test was more cost effective than the other but because of budget constraints was too expensive to be given to everyone in the population. With the use of the more effective test for only half the population, 1100 lives could be saved at the same cost as that of saving 1000 lives with the use of the less effective test for the entire population. RESULTS: Fifty-six percent of the prospective jurors, 53 percent of the medical ethicists, and 41 percent of the experts in medical decision making recommended offering the less effective screening test to everyone, even though 100 more lives would have been saved by offering the more expensive test to only a portion of the population. Most of the study participants justified this recommendation on the basis of equity. A smaller number stated either that it was not politically feasible to offer a test to only half the population or that the additional benefit of the more expensive test (100 more lives saved) was too small to justify offering it to only a portion of the public. CONCLUSIONS: People place greater importance on equity than is reflected by cost-effectiveness analysis. Even many experts in medical decision making -- those often responsible for conducting cost-effectiveness analyses -- expressed discomfort with some of its implications. Basing health care priorities on cost effectiveness may not be possible without incorporating explicit considerations of equity into cost-effectiveness analyses or the process used to develop health care policies on the basis of such analyses.

Assessing the economic challenges posed by orphan drugs.

Historically, patients with rare diseases have been underserved by commercial drug development. In several jurisdictions, specific legislation has been enacted to encourage the development of drugs for rare diseases (orphan drugs), which would otherwise not be commercially viable. However, because of the small market, these drugs are often very expensive. Under the standard methods of health technology assessment (HTA) incorporating economic evaluation, orphan drugs do not usually prove to be cost-effective and this, coupled with their high cost, means that funding and patient access may be limited. However, these restrictions may not be in line with societal preferences. Therefore, this study discusses whether the standard methods of HTA are adequate for assisting decisions on patient access to and funding of orphan drugs and outlines a research agenda to help understand the societal value of orphan drugs and issues surrounding their development, funding, and use.