Value-Based Medicine

The Power—and Value—of Hope

By Melissa M. Brown, MD, MN, MBA

Physicians are familiar with thinking about the science of medicine—we regularly converse about the results of clinical trials comparing the many medical interventions available to treat a myriad of medical conditions. Evidence-based evaluations can often identify which therapies may allow for a mean overall lengthening of life. The use of concepts of Value-Based Medicine discussed in this column further adds in the components of quality-of-life measurement and economic evaluations.

We increasingly extend the use of scientific process to include the methodologies of quality-of-life (QOL) measurement. Utility analysis, often combined with decision analysis, helps us evaluate the total value conferred to our patients by a particular medical intervention.

But what can we do when our repertoire of medical and surgical interventions fall short in maintaining health? If we find we have minimal choices to offer patients, do we have options to improve their quality of life? Most would believe this is the art of medicine. You will see that the art can be scientifically approached.

Glass Half Empty or Half Full?

Studies have shown that patient optimism has a direct impact on QOL as well as pain and recovery time following surgery.^1-3 But what happens if we apply some of these preference-based methodologies to our patient interactions?

A relevant study on the power of hope was performed by Godshalk and colleagues⁴ vis-a-vis the QOL of ophthalmic patients in the office. It was the belief of the authors that a physician's attitude has a direct and significant impact upon a patient's QOL.

In this study, ocular utilities were measured in approximately 250 consecutive patients to assess the quality of life associated with their current ocular health state (baseline scenario). Each was then given a scenario for the exact same health state with the same long-term prognosis and outcome in which their doctor emphasized the possible negative consequences (bad-news scenario) and one for the same health state in which their doctor emphasized the positive consequences (good-news scenario).

The mean utility for the good-news scenario was 0.87, while that for the bad-news scenario was 0.80, more than a 50% decrease in quality-of-life. Thus, for the exact same clinical scenario, the physician's emphasis on positive or negative aspects of disease impact made a significant difference on the patient's utility measurement.

When the data from the 81 patients with diabetic retinopathy were analyzed, the mean baseline utility was 0.83, significantly greater than the mean bad-news utility of 0.78 and not significantly different from the good-news utility of 0.86. Similarly, when the data from the 61 patients with macular degeneration were analyzed, the mean baseline utility of 0.81 was significantly greater than the bad-news utility of 0.71 and not significantly different from the good-news utility of 0.83.

Thirty-five patients had <20/200 vision in the better-seeing eye (legal blindness). In this cohort, the bad-news utility of 0.74 differed significantly from the mean baseline utility of 0.77. The good-news mean utility of 0.84 also differed significantly from the mean baseline utility.

Both Physician and Coach

While this study is small, the pattern becomes clear. These data support that a physician or other healthcare professional helping to maintain or improve a patient's sense of hope improves quality of life and reduces the negative consequences associated with visual loss, particularly when it is severe.

I am not suggesting that clinicians should be unrealistically positive. While honesty regarding the implications of the patient's condition is of utmost importance, some variant of optimism and encouragement is clearly important in affecting the patient's quality of life. I am, respectfully, suggesting that this study, while having limitations, should jog us to give careful thought to content and emphasis at the end of a patient encounter. The management of ophthalmic practitioners' discussions relative to their visual prognosis is key—it can make a real difference in the quality of life of our patients. OM

References

1. Hollis V. Massey K, and Jeyne R. An introduction to the intentional use of hope. J Allied Health 2007; 36;52-56.
2. Peters ML, Sommer M, de Rijke JM, et al. Somatic and psychologic predictors of longterm unfavorable outcomes after surgical intervention. Ann Surg 2007; 245: 487-494.
3. Vardaki MA, Philalithis AE, Vlachonikolis I. Factors associated with the attitudes and expectations of patients suffering from beta-thalassaemia; a cross-sectional study. Scand J Caring Sci 2004; 18;177-187.
4. Godshalk, AN et al. The power of hope: being a doctor is more than relying solely on the numbers. BJO 2008;92:783-787.

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Melissa M. Brown, MD, MN, MBA, is president and CEO of the Center for Value-Based Medicine in Philadelphia. She can be reached via e-mail at mbrown@valuebasedmedicine.com.