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People at risk for major stroke vary widely in their values and treatment preferences

A major stroke that paralyzes an arm, leg, and one side of the body, leaving victims unable to take care of themselves, is considered worse than death by 45 percent of patients at risk for stroke. On the other hand, 15 percent of these patients are willing to give up only 2.5 years or life or less out of a possible 10 to avoid a major stroke, according to a study by the Stroke Prevention Patient Outcomes Research Team (PORT). The PORT is supported by the Agency for Health Care Policy and Research (PORT contract 290-92-0028).

The variation in patient response may reflect different attitudes toward physical disability, different religious and ethical values (for example, those opposed to giving up years of life regardless of the circumstances), and other factors, suggests David Matchar, M.D., of Duke University, the PORT's principal investigator.

The researchers surveyed three patient groups, speaking with a total of 1,261 patients who were at risk of stroke. The patients were presented with trade-offs between time in a certain health state and time in excellent health. For example, "Would you prefer living 10 more years following a major stroke or 8 more years in excellent health?" Patients who indicated that 10-year survival after major stroke was equivalent to 0 years in excellent health were asked if they would prefer to live 10 years after a major stroke or die from the stroke the instant it occurred.

Results showed that on a scale of 0 (death) to 1 (perfect health), most people described the state of health after a major stroke as a mere 0.30. However, willingness to trade off years of life to avoid a stroke varied. Although 45 percent considered a major stroke to be worse than death, 15 percent were willing to trade off little or no survival to avoid it.

Providers should speak directly with patients who are at risk of stroke about their preferences, recommend the researchers. Stroke-related interventions, even those that are costly or have undramatic clinical benefits, are likely to have different cost-effectiveness implications if they can prevent a major stroke considered abhorrent by the patient. Obviously, the more abhorrent the patient views the consequences of a stroke, the more willing he or she may be to accept the intervention.

More details are in "Utilities for major stroke: Results from a survey of preferences among persons at increased risk for stroke," by Gregory P. Samsa, Ph.D., Dr. Matchar, Larry Goldstein, M.D., and others, in the October 1998 American Heart Journal 136(4), pp. 703-713.

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