May 2, 2011

USA: The New Old Age - Figuring the Odds

NEW YORK / International Herald Tribune / Health / May 2, 2011

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Figuring The Odds
By Paula Span

What if your doctor, making use of a Web site that collected a number of tested geriatric scales, could enter information about your history and your health, and then predict with reasonable accuracy your odds of living another year, or four, or nine?

What if you, with a slight fib, could log onto that same site and find that information yourself?

In a few months, this will no longer be a hypothetical question. Three San Francisco physicians and researchers, palliative care specialists teaching at the University of California, San Francisco, are developing a Web site that offers individual prognoses based on 18 to 20 different geriatric prognostic indexes. These serve different purposes: Some are meant for nursing home residents, for example, while others are aimed at patients being discharged from hospitals.

“These scores and indices are meant to help guide decision-making,” said Dr. Sei Lee, one of the site’s creators. “They let us say, ‘This person is at higher risk, so maybe we should be more aggressive with statins.’ Or, ‘Maybe we shouldn’t focus energy on cancer screenings that may not be useful here.’ Or, ‘Maybe we should start discussing end-of-life issues.’”

Dr. Lee and his colleagues Dr. Eric Widera and Dr. Alex Smith want their peers around the country to consider these common-sense questions routinely for all their older patients. They’d like to see medical students and residents carry an app on their smartphones that guides this sort of discussion.

But they are uneasy about how laypeople might use such an online tool — which is why they asked me to write about it and why they’re soliciting your comments. These scales are already available in the medical literature, but they’ve never been assembled in one spot, for anyone to access with a few keystrokes.

“It’s a very nuanced way to look at health care and treatment decisions, and it does require some expertise,” Dr. Widera acknowledged.

Lots of medical decisions depend on life expectancy — or they should. The research keeps mounting that a number of routine tests and procedures don’t make sense for those whose age and frailty mean they’re unlikely to live long enough to benefit.

Elderly women with advanced dementia, for instance, no longer benefit from undergoing mammograms; they’re much more likely to die from dementia than a newly discovered breast cancer. Or consider diabetes: It takes eight years or more for people with diabetes who maintain strict blood sugar control to see health benefits, so elderly people with diabetes who are unlikely to live that long can afford a slightly less aggressive approach and possibly fewer drugs. But controlling blood pressure pays off in a much shorter time, so prescribing hypertension drugs even to frail patients might make sense.

“These indexes are underused by health care practitioners, to a great extent,” Dr. Lee said. “If they were used more widely, we’d have better care.”

What about their use by non-professionals? I’m not naming the site yet — it’s still embryonic and probably won’t make its debut until fall — but I logged onto the test version. When I came to the question “Are you a health care professional?” I clicked the “yes” button, even though I’m not. Then I used the Lee Four Year Index, first published in The Journal of the American Medical Association five years ago and intended for use in community-dwelling adults over 50 (I qualify).

Answering 12 questions about age, gender, body mass index and several health conditions, I learned that I have a less than 5 percent chance of dying in the next four years (which dooms me to continued colonoscopies). But using the Schonberg Five Year Index, I found that my father, though reasonably healthy and independent at almost 89, probably doesn’t need any more.

Should anyone willing to masquerade briefly as a professional be able to see this? One reason the doctors set the barrier so low, they said, is that there’s no practical way to restrict use to those with medical initials after their names. And knowing that physicians often don’t consider life expectancy, they think informed patients who ask questions could help prevent unnecessary — and often intrusive, expensive, even detrimental — tests and treatments.

But will ordinary folks like us understand the limitations of these indexes? “Every index will be wrong some of the time,” Dr. Lee said. “These are population estimates, not what is definitely going to happen. It’s a ballpark estimate of the most likely course for the future.”

Then there’s the much-cited question of hope. What happens when the man who thought he’d see his granddaughter graduate from college in two years logs in and learns he has a high one-year mortality risk?

“I’d say, ‘This is not written in stone. If this is really important for you, let’s see what we can do to improve your chances,’” Dr. Lee said. “It forces the doctor and patient to confront some unpleasant but real factors.”
On the other hand, Dr. Widera said, “The flip side might be, ‘I’m doing great! I can drink more!’ People could feel falsely reassured.”

In the end, the three doctors will probably opt for greater access — and hope that people take what they’ve learned into their doctors’ offices. “I want patients to look at this information and not act on it without talking to their doctors,” Dr. Lee said.

Meanwhile, they’d like to know what you think. Would you find such a site useful in guiding your own or your elderly parents’ care? Would you be angry if it were restricted only to professionals? What would you do with the information? Do you want for us to post the site’s name and U.R.L. when it’s up and running?

This is an experiment we get to be part of.

Paula Span is the author of
“When the Time Comes:
Families With Aging Parents
Share Their Struggles and Solutions.”

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