Utilities for major stroke: Results from a survey of preferences among persons at increased risk for stroke

doi:10.1016/S0002-8703(98)70019-5

American Heart Journal

Volume 136, Issue 4, October 1998, Pages 703-713

https://doi.org/10.1016/S0002-8703(98)70019-5 Get rights and content

Abstract

Background Patient beliefs, values, and preferences are crucial to decisions involving health care. In a large sample of persons at increased risk for stroke, we examined attitudes toward hypothetical major stroke. Methods and Results Respondents were obtained from the Academic Medical Center Consortium (n = 621), the Cardiovascular Health Study (n = 321), and United Health Care (n = 319). Preferences were primarily assessed by using the time trade off (TTO). Although major stroke is generally considered an undesirable event (mean TTO = 0.30), responses were varied: although 45% of respondents considered major stroke to be a worse outcome than death, 15% were willing to trade off little or no survival to avoid a major stroke. Conclusions Providers should speak directly with patients about beliefs, values, and preferences. Stroke-related interventions, even those with a high price or less than dramatic clinical benefits, are likely to be cost-effective if they prevent an outcome (major stroke) that is so undesirable. (Am Heart J 1998;136:703-13.)

Section snippets

Methods

The study design, including potential limitations, is described in greater detail elsewhere.9, 10 Briefly, we surveyed patients at increased risk for stroke. These patients included those with previous cerebrovascular symptoms (transient ischemic attack [TIA] or minor stroke) as well as those without a history of cerebrovascular symptoms but at increased risk for stroke because of conditions such as atrial fibrillation, hypertension, and valvular heart disease. Institutional Review Board

Demographic characteristics

There were 613 respondents from AMCC (43% response rate), 319 respondents from UHC (67% response rate), and 321 respondents from CHS (90% response rate).

Table I presents selected demographic characteristics.

. Demographic characteristics

Empty Cell	All (n= 1253)	AMC (n = 613)	CHS (n = 321)	UHC (n = 319)
Age
20-54	23.4	20.9	0.0	51.9
55-64	21.8	24.5	0.0	38.9
65-74	28.9	31.6	43.0	9.2
75+	25.9	22.9	57.0	0.0
Sex
Female	48.0	44.9	54.5	47.3
Male	52.0	55.1	45.5	52.7
Race
White	90.1	88.7	93.8	89.0
Other	9.9	11.3	6.2	11.0
Education
Did not complete high school	20.0

Discussion

To our knowledge, this is the largest study to elicit preferences for major stroke directly from patients at risk for stroke. We found that stroke was a widely feared event—approximately 45% of respondents judged a major stroke to be a worse outcome than death. This result is consistent with previous work with case series and smaller samples. For example, Soloman et al⁷ interviewed 117 patients who were undergoing ultrasound evaluation of the carotid arteries at a single medical center and

Acknowledgements

We thank Annette Jurgelski, Ellen Metcalf, and Paul Abrahamse for editorial assistance. Vic Hasselblad provided critical comments on the algorithm described in the Appendix.

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Ocular time trade-off utilities most highly correlate with central vision in the better-seeing eye.5–18,21–23
Because most medical schools in the United States and Canada require no formal ophthalmology training, the authors queried medical student and ophthalmic patients to compare their perceptions of the quality of life (QOL) associated with vision loss.
Cross-sectional comparative study of consecutive medical students and patients with vision loss using a validated, reliable, time trade-off utility instrument.
Consecutive Jefferson Medical College medical students (cohort 1: 145 second-year student; cohort 2: 112 third-year/fourth-year students) and 283 patients with vision loss (patient cohort).
Time trade-off vision utilities with anchors of 0.0 (death) to 1.0 (normal vision permanently) were used to quantify the QOL associated with vision loss. Students were asked to assume they had: (i) mild vision loss (20/40 to 20/50 vision in the better-seeing eye), (ii) legal blindness (20/200 in the better-seeing eye), and (iii) absolute blindness (no light perception bilaterally).
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Puisque la plupart des écoles de médecine des États-Unis et du Canada n’exigent pas de formation formelle en ophtalmologie, les auteurs ont interrogé les étudiants en médecine et les patients en ophtalmologie pour comparer leurs perceptions réciproques de la qualité de vie associée à la perte de vision.
Étude transversale comparative d’étudiants en médecine consécutifs et de patients atteints d’une perte de vision à l’aide d’un instrument validé et fiable utilisant la méthode de l’arbitrage temporel.
Étudiants en médecine du Jefferson Medical College : 145 étudiants de 2e année (cohorte 1) et 112 étudiants de 3e ou 4e année (cohorte 2); et 283 patients atteints d’une perte de vision (cohorte de patients).
Des énoncés sur la vision utilisant la méthode de l’arbitrage temporel correspondant à des valeurs allant de 0,0 (décès) à 1,0 (vision normale permanente) ont servi à quantifier la qualité de vie associée à la perte de vision. On a demandé aux étudiants de supposer qu’ils avaient : 1) une faible perte de vision (vision de 20/40-20/50 dans le meilleur œil), 2) une cécité pratique (20/200 dans le meilleur œil) et 3) une cécité totale (aucune perception de la lumière - perte bilatérale).
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^☆: From the Center for Clinical Health Policy Research, Sanford Institute of Public Policy, the Department of Medicine, the Department of Community and Family Medicine, and the Department of Neurology, Duke University; the Department of Veterans Affairs Medical Center; Research Triangle Institute; the Center for Aging, University of Kansas Medical Center; the Department of Health Services Administration, University of Kansas; Bowman Gray School of Medicine, Wake Forest University; Academic Medical Center Consortium and the Department of Community and Preventive Medicine; the Center for Health Care Policy and Evaluation, United Health Care; Roudebush Medical Center, Department of Veterans Affairs, Regenstrief Institute for Health Care, Indiana University, and the Division of General Internal Medicine, Indiana University School of Medicine.

^☆☆: This work was performed as part of the Stroke Prevention Patient Outcomes Research Team (PORT) and was funded through contract 282-91-0028 from the US Agency for Health Care Policy and Research.

^★: Reprint requests: Gregory P. Samsa, PhD, Duke University Center for Clinical Health Policy Research, First Union Tower, Suite 230, 2200 W Main St, Durham NC 27705.

^★★: 4/1/90223

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Utilities for major stroke: Results from a survey of preferences among persons at increased risk for stroke☆,☆☆,★,★★

Abstract

Section snippets

Methods

Demographic characteristics

Discussion

Acknowledgements

Ann Epidemiol

Clinical decision analysis

Cost-effectiveness of thrombolytic therapy with tissue plasminogen activator as compared with streptokinase for acute myocardial infarction

N Engl J Med

Treatment of chronic nonvalvular atrial fibrillation in the elderly: a decision analysis

Med Decis Making

Decision analytic and cost-effectiveness issues concerning anticoagulant prophylaxis in heart disease

Chest

Endarterectomy in carotid artery disease: a decision analysis

JAMA

Should all patients with atrial fibrillation be screened with echocardiography?

J Gen Intern Med

Patient preferences for stroke outcomes

Stroke

The effect of stroke and stroke prophylaxis with aspirin or warfarin on quality of life

Arch Intern Med

Knowledge of risk among patients at increased risk for stroke

Stroke

Health status of individuals with mild stroke

Stroke

Comparisons of time-tradeoff utilities and rating scale values of cancer patients and their relatives: evidence for a possible plateau relationship

Med Decis Making