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					Decision Challenges in
     Health Care
          Alan M. Garber
Center for Health Policy/Center for
   Primary Care and Outcomes
             Research

         Stanford University
     Center for Advancing Decision
           Making for Aging
 Stanford’s Roybal Center
 Medicine, Economics, Psychology
  collaboration
    – Alan Garber PI, Laura Carstensen co-PI
    – Provides seed funding for junior
      faculty/advanced trainee projects
   All the current and planned work
    discussed here supported by NIA
 Incorporating Health Preferences of Older
  Adults into the Electronic Medical Record
  Amar Das, MD, PhD
 Affective Forecasting and Decision Making
  in Older Adults, Brian Knutson, PhD
 Age Differences in the Processing of
  Health Care Information, Joseph A. Mikels,
  PhD
 Age Differences in Emotional and
  Cognitive Decision-Making Ian H. Gotlib,
  PhD & Elaine R. Robertson, PhD
 Risk-Taking and Financial Decision-Making
  in Older Adults Gregory Larkin, PhD, Brian
  Knutson,PhD, & Camelia Kuhnen, MBA:
    Difficult Health Care Decisions at
              Advanced Ages

 End-of-life care
 Treatment choices
 Selecting high-quality health care
  providers
 Health plan choice (supplemental
  insurance, Medicare Part D)
        Life-Threatening Illness
   Treatment for cancer often toxic and
    expensive
    – Erbitux - $9,600/month
    – Avastin for lung and breast cancer -
      $8,800/month
 Would you want very aggressive care?
 Should Medicare cover it?
    Stanford alumni various ages
 20-35 year olds: 31
 35-59 year-olds: 39
 60-87 year-olds: 31
               Scenario
Imagine that you have just received a
diagnosis of pancreatic cancer, a serious
life-threatening disease that can cause
considerable discomfort and is difficult to
treat. Your doctor tells you that without
treatment it is unlikely that you will
survive for more than a year. Please
answer the following questions about
possible options.
            Treatment options
Option 1: Relatively new and untested treatment that takes
  one year to administer, is relatively painless but side-
  effects are not well known.
Option 2: A combination of chemotherapy and radiation
  therapy that takes one year to administer, has very
  uncomfortable side effects.
Option 3. Treatment focuses on comfort, including
  treatment of pain and discomfort, hospice care, and
  support for you and your loved ones in managing your
  household and helping you stay in your home as long as
  possible.
Option 4. Hospital intensive care with life support at the
  end of life.
                                   Questions
   How likely are you to want this option?
    1            2             3             4            5               6             7
Not at all likely ----------------------------------------------------------------Very likely


   How strongly do you feel that Medicare should pay for
    these options?
    1            2             3             4            5               6             7
Not at all strongly ----------------------------------------------------------Very strongly
                      Option 1
   Percentage wanting new treatment, by age group:
    – Young:         48.4%
    – Middle-aged:   64.1%
    – Old:           44.8%



   Percentage wanting Medicare to pay for new treatment,
    by age group.
    – Young:         58.1%
    – Middle-aged:   71.8%
    – Old:           56.7%
           Wanting new treatment
 Chance treatment will work, F(1,93)=3.800, p=.054
  More likely to want treatment if it is thought to have a
  good chance of working.
 Age group X Chance, F(2,93)=3.507, p=.034
    – Young and middle-aged more likely to want new treatment
                                                    do
      when chances of success are good, whereas old* not
      show this change in preference.
   No predictors of wanting Medicare to pay for new
    treatment.
                                              Want new treatment
                                        7.0



                                        6.0



                                        5.0
             Estimated Marginal Means




                                        4.0


                                                                                         Age Group
                                        3.0

                                                                                            Young (20-34)
                                        2.0
                                                                                            Middle-aged (35-59)

                                        1.0                                                 Old (60+)
                                                    low chance             good chance


                                              chance of additional years
Option 2: Traditional treatment
                (chemo & radiation)
   Percentage wanting chemo & radiation, by age group:
    – Young:         29%
    – Middle-aged:   38.5%
    – Old:           16.1%


   Percentage wanting Medicare to pay for chemo &
    radiation, by age group.
    – Young:         83.9%
    – Middle-aged:   84.6%
    – Old:           60%
    Wanting traditional chemotherapy
               treatment
   Age Group, F(2,89)=4.508,
    p=.014                                                                                7.0
                                                                                                Want chemotherapy


    – Middle-aged most likely to                                                          6.0




      want treatment.                                                                     5.0




                                                             Estimated Marginal Means
    – Old vs. Middle-aged (p=.006)
                                                                                          4.0



                                                                                          3.0



   Chance treatment will work,                                                           2.0



    F(1,89)=10.634, p=.002                                                                1.0
                                                                                                        Young (20-34)    Middle-aged (35-59)     Old (60+)




    – More likely to want treatment
                                                                                                Age Group




      if it has a good chance of
      working.
                                                                                              Want chemotherapy
                                                                                        7.0



                                                                                        6.0



                                                                                        5.0
                                  Estimated Marginal Means




                                                                                        4.0



                                                                                        3.0



                                                                                        2.0


                                                                                        1.0
                                                                                                            low chance                   good chance


                                                                                              chance of additional years
         Should Medicare pay for
             chemotherapy?
   Age group, F(2,88)=2.827, p=.065
    – Older adults least likely to want Medicare to
      cover traditional treatment.
    – Old vs. Middle-aged (p=.081)
   Time perspective, F(1,88)=3.853, p=.053
    – Payment preference increases when
      treatment offers 10 (vs. 1) additional years of
      life.
   Chance treatment will work, F(1,88)=7.758,
    p=.007
    – Less likely to want treatment if it has a poor
      chance of working.
         Option 3: Comfort Care
   Percentage wanting comfort care, by age group:
    – Young:         56.7%
    – Middle-aged:   74.4%
    – Old:           54.8%


   Percentage wanting Medicare to pay for comfort care, by
    age group.
    – Young:         71%
    – Middle-aged:   94.9%
    – Old:           77.4%
            Wanting comfort care
   When treatment options (in
    prior questions regarding new
                                                      Want comfort care
    treatment or traditional                    7.0

    treatment) are presented as
    having a low chance of
                                                6.0



    success, participants are more              5.0


    likely to want comfort care.                4.0
                        likelihood of wanting




   Chance treatment will work,                 3.0

    F(1,94)=9.866, p=.002
                                                                                                         chance of additional
                                                2.0

    No age effect.
                                                                                                            low chance
                                               1.0                                                         good chance
                                                       Young (20-34)                         Old (60+)
                                                                       Middle-aged (35-59)


                                                      Age Group
        Option 4: Intensive Care
   Percentage wanting intensive care, by age group:
    – Young:         29%
    – Middle-aged:   12.8%
    – Old:           6.9%


   Percentage wanting Medicare to pay for intensive care,
    by age group.
    – Young:         61.3%
    – Middle-aged:   51.3%
    – Old:           39.3%
           Wanting intensive care
   Age group, F(2,96)=4.592,
    p=.012
    – Old vs. Young (p=.009)                      7.0



                                                  6.0



                                                  5.0
                    Mean of Want intensive care




                                                  4.0



                                                  3.0



                                                  2.0



                                                  1.0
                                                                    20-34   35-59   60+


                                                        Age Group
          Should Medicare pay for
              intensive care?
   Age group, F(2,92)=4.154,
    p=.019
                                                                                        Pay for intensive care
                                                                                  7.0




     – Old vs. Young (p=.015)                                                     6.0




     – Old vs. Middle-aged (p=.068)                                               5.0




                             Estimated Marginal Means
    Life or death frame,
                                                                                  4.0


    F(1,92)=4.741, p=.032
                                                                                  3.0



                                                                                  2.0


     – If ICU will “delay death” it is                                            1.0


       preferred to when it is                                                                  Young (20-34)       Middle-aged (35-59)    Old (60+)




       described as “prolonging life”
                                                                                        Age Group



       – a sort of inverse negative
       framing effect.                                                            7.0
                                                                                        Pay for intensive care


   If ICU described as “prolonging                                               6.0




    your life” one is less likely to                                              5.0
                                                        strength of endorsement




    want it as one gets older; if it                                              4.0




    “delays your death” you are
                                                                                  3.0
                                                                                                                                           life or death frame


    more likely to want it overall.
                                                                                  2.0
                                                                                                                                                death frame

                                                                                  1.0                                                           live frame
                                                                                         Young (20-34)                         Old (60+)
                                                                                                         Middle-aged (35-59)


                                                                                        Age Group
               Preference for type of
                   Medicare Plan
   Percentage wanting plan focusing on comfort and quality of life, by
    age group:
     – Young:            75.9%
     – Middle-aged:      79.5%
     – Old:              88.9%


   Percentage wanting plan providing hospital & treatment services
    regardless of life expectancy and quality of life concerns, by age
    group.
     – Young:            24.1%
     – Middle-aged:      20.5%
     – Old:              11.1%
     Complex Health Plan Choice
   Choosing a Medicare drug plan

      http://www.medicare.gov/
           Decision Challenges
 Choices facing older Americans likely to become
  more complex and more consequential
 Improving the ways we frame choices
 How to determine whether a choice is optimal or
  even successful

   Can we employ knowledge of changes in
    emotional processing and cognitive performance
    with age to improve design of cho