Tsevat J, Dawson N V, Wu A W, Lynn J, Soukup J R, Cook E F, Vidaillet H, Phillips R S
Department of Internal Medicine, Institute for Health Policy and Health Services Research, University of Cincinnati Medical Center, Ohio 45267-0535, USA.
JAMA. 1998 Feb 4;279(5):371-5. doi: 10.1001/jama.279.5.371.
Health values (utilities or preferences for health states) are often incorporated into clinical decisions and health care policy when issues of quality vs length of life arise, but little is known about health values of the very old.
To assess health values of older hospitalized patients, compare their values with those of their surrogate decision makers, investigate possible determinants of health values, and determine whether health values change over time.
A prospective, longitudinal, multicenter cohort study.
Four academic medical centers.
Four hundred fourteen hospitalized patients aged 80 years or older and their surrogate decision makers who were interviewed and understood the task.
Time-trade-off utilities, reflecting preferences for current health relative to a shorter but healthy life.
On average, patients equated living 1 year in their current state of health with living 9.7 months in excellent health (mean [SD] utility, 0.81 [0.28]). Although only 126 patients (30.7%) rated their current quality of life as excellent or very good, 284 (68.6%) were willing to give up at most 1 month of 12 in exchange for excellent health (utility > or =0.92). At the other extreme, 25 (6.0%) were willing to live 2 weeks or less in excellent health rather than 1 year in their current state of health (utility < or =0.04). Patients were willing to trade significantly less time for a healthy life than their surrogates assumed they would (mean difference, 0.05; P=.007); 61 surrogates (20.3%) underestimated the patient's time-trade-off score by 0.25 (3 months of 12) or more. Patients willing to trade less time for better health were more likely to want resuscitation and other measures to extend life. Time-trade-off score correlated only modestly with quality-of-life rating (r=0.28) and inversely with depression score (r=-0.27), but there were few other clinical or demographic predictors of health values. When patients who survived were asked the time-trade-off question again at 1 year, they were willing to trade less time for better health than at baseline (mean difference, 0.04; P=.04).
Very old hospitalized patients who could be interviewed were able, in most cases, to have their health values assessed using the time-trade-off technique. Most patients were unwilling to trade much time for excellent health, but preferences varied greatly. Because proxies and multivariable analyses cannot gauge health values of elderly hospitalized patients accurately, health values of the very old should be elicited directly from the patient.
当出现生活质量与寿命长短的问题时，健康价值观（对健康状态的效用或偏好）常常被纳入临床决策和医疗保健政策中，但对于高龄老人的健康价值观却知之甚少。
评估老年住院患者的健康价值观，将其价值观与他们的替代决策者的价值观进行比较，调查健康价值观的可能决定因素，并确定健康价值观是否随时间变化。
一项前瞻性、纵向、多中心队列研究。
四个学术医疗中心。
414名80岁及以上的住院患者及其替代决策者，他们接受了访谈并理解任务。
时间权衡效用，反映相对于较短但健康的生活对当前健康的偏好。
平均而言，患者将在当前健康状态下生活1年等同于在极佳健康状态下生活9.7个月（平均[标准差]效用，0.81[0.28]）。尽管只有126名患者（30.7%）将他们当前的生活质量评为极佳或非常好，但284名（68.6%）患者愿意放弃最多12个月中的1个月以换取极佳健康（效用≥0.92）。在另一个极端，25名（6.0%）患者愿意在极佳健康状态下生活2周或更短时间，而不是在当前健康状态下生活1年（效用≤0.04）。患者愿意为健康生活所放弃的时间明显少于他们的替代决策者所认为的（平均差异，0.05；P = 0.007）；61名替代决策者（20.3%）将患者的时间权衡得分低估了0.25（12个月中的3个月）或更多。愿意为更好的健康放弃更少时间的患者更有可能希望进行复苏和其他延长生命的措施。时间权衡得分与生活质量评分仅适度相关（r = 0.28），与抑郁评分呈负相关（r = -0.27），但几乎没有其他临床或人口统计学因素可预测健康价值观。当存活的患者在1年后再次被问及时间权衡问题时，他们愿意为更好的健康放弃的时间比基线时少（平均差异，0.04；P = 0.04）。
大多数情况下，能够接受访谈的高龄住院患者可以使用时间权衡技术来评估其健康价值观。大多数患者不愿意为极佳健康放弃太多时间，但偏好差异很大。由于代理人和多变量分析无法准确衡量老年住院患者的健康价值观，因此高龄老人的健康价值观应直接从患者那里获取。
