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15 March 1996 | Volume 124 Issue 6 | Pages 577-584
To fully involve patients in treatment decisions, physicians need to communicate future health prospects that patients will have both with and without newly diagnosed disease.These prospects depend not only on the risks patients face from the new disease but also on the risks they face from other causes. Nowhere is an understanding of these competing risks more relevant than in the care of the elderly.
In this study, we use the declining exponential approximation for life expectancy (DEALE) to provide a framework to help clinicians gauge the effect of competing risks as a function of age.Because older patients have many competing risks for death, the absolute effect of a new diagnosis on life expectancy is often relatively small. Consequently, the potential gain in survival even from perfect therapy may also be small. Moreover, no therapy is perfect, and the risks of therapy often increase with age. In the elderly, the combination of a high burden of competing risks and high rates of treatment-related complications conspires to reduce the net benefit of numerous interventions. We conclude that, compared with younger patients, the elderly should request only the more clearly effective treatments and should be willing to tolerate fewer associated complications before they agree to initiate therapy.
Author and Article Information
From Department of Veterans Affairs Medical Center, White River Junction, Vermont; Dartmouth Medical School, Hanover, New Hampshire; the University of Connecticut, Farmington, Connecticut; and Washington University School of Medicine, St. Louis, Missouri.
ACADEMIA AND CLINIC
Estimating Treatment Benefits for the Elderly: The Effect of Competing Risks
Acknowledgments: The authors thank J. Robert Beck for his methodologic review; R. Peter Mogielnicki, Robert S. Pritchard, and Gregory W. Froehlich for their thoughtful critique of the manuscript; and James O. Taylor for data from the East Boston Senior Health Project, one of the National Institute on Aging's Established Populations for the Epidemiologic Study of the Elderly (contract AG02107).
Grant Support: Dr. Welch is supported by a Veterans Affairs Career Development Award in health services research and development. Dr. Nease is a Picker/Commonwealth Scholar.
Requests for Reprints: John Wasson, MD, Department of Community and Family Medicine, Dartmouth Medical School, 7265 Butler Building, Hanover, NH 03755-3862.
Current Author Addresses: Dr. Welch: Veterans Affairs Outcomes Group (111B), Department of Veterans Affairs Hospital, White River Junction, VT 05009.
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