Life expectancy and the value of early detection

Mass spectrometry for metabolomics analysis: Applications in neonatal and cancer screening

Chemical analysis by analytical instrumentation has played a major role in disease diagnosis, which is a necessary step for disease treatment. While the treatment process often targets specific organs or compounds, the diagnostic step can occur through various means, including physical or chemical examination. Chemically, the genome may be evaluated to give information about potential genetic outcomes, the transcriptome to provide information about expression actively occurring, the proteome to offer insight on functions causing metabolite expression, or the metabolome to provide a picture of both past and ongoing physiological function in the body. Mass spectrometry (MS) has been elevated among other analytical instrumentation because it can be used to evaluate all four biological machineries of the body. In addition, MS provides enhanced sensitivity, selectivity, versatility, and speed for rapid turnaround time, qualities that are important for instance in clinical procedures involving the diagnosis of a pediatric patient in intensive care or a cancer patient undergoing surgery. In this review, we provide a summary of the use of MS to evaluate biomarkers for newborn screening and cancer diagnosis. As many reviews have recently appeared focusing on MS methods and instrumentation for metabolite analysis, we sought to describe the biological basis for many metabolomic and additional omics biomarkers used in newborn screening and how tandem MS methods have recently been applied, in comparison to traditional methods. Similar comparison is done for cancer screening, with emphasis on emerging MS approaches that allow biological fluids, tissues, and breath to be analyzed for the presence of diagnostic metabolites yielding insight for treatment options based on the understanding of prior and current physiological functions of the body.

Factors associated with the use of annual health checkups in Thailand: evidence from a national cross-sectional health and welfare survey

Introduction

Thailand has provided free annual health checkups (AHC) since universal health coverage began in 2002. However, evidence regarding the equitable use of AHC is scarce. Thus, this study explored factors associated with the use of AHC in Thailand.

Methods

A cross-sectional study was conducted using data from the national 2015 Health and Welfare Survey. Respondents aged 15 years or above (n = 57,343) were selected as the study sample. Descriptive statistical analysis and multivariable binary logistic regression were conducted to examine the association between the use of AHC and factors selected on the basis on Andersen's Behavioral Model of Access to Medical Care.

Results

Among the study sample, approximately 4.9% (n = 2,815) had used AHC during the past year. Regarding predisposing factors, the use of AHC was positively related to age (e.g., over 61 vs. 15-30: AOR = 2.90 [95% CI = 2.40-3.52], p < 0.001) and female sex (AOR = 1.23 [95% CI = 1.12-1.35] p < 0.001). For enabling factors, the AHC use was positively associated with income (e.g., Q4 vs. Q1: AOR = 1.98 [95% CI = 1.75-2.25], p < 0.001), education (e.g., high vs. low: AOR = 3.11 [95% CI = 2.75-3.51], p < 0.001), being married (e.g., vs. single: AOR = 1.27 [95% CI = 1.11-1.46], p < 0.001), and urban residency (AOR = 1.12 [95% CI = 1.04-1.22], p = 0.006). For need-for-care factors, the AHC use was positively related to chronic disease (AOR = 1.26 [95% CI = 1.15-1.38], p < 0.001), non-smoking (e.g., vs. daily: AOR = 1.18 [95% CI = 1.03-1.36], p = 0.015), non-drinking (e.g., vs. 3-4 times per week: AOR = 1.26 [95% CI = 1.04-1.53], p = 0.016), and vegetable consumption (e.g., over 5 ladles vs. below 1 ladle: AOR = 1.86 [95% CI = 1.50-2.31], p < 0.001).

Conclusion

The results indicate that health awareness could play a significant role in the use of AHC. Individuals with high socioeconomic status (e.g., high-income people) and those with low-risk health behaviors (e.g., non-smokers) generally have a high interest in health and well-being. This may have been the primary reason for the high use of AHC among these groups. Thus, the government should continue to promote the public's health awareness through various public campaigns and education programs to increase the use of AHC.

Variation in State-Level Mammography Use, 2012 and 2020

OBJECTIVES

Mammography is a screening tool for early detection of breast cancer. Uptake in screening use in states can be influenced by Medicaid coverage and eligibility policies, public health outreach efforts, and the Centers for Disease Control and Prevention-funded National Breast and Cervical Cancer Early Detection Program. We described state-specific mammography use in 2020 and changes as compared with 2012.

METHODS

We estimated the proportion of women aged ≥40 years who reported receiving a mammogram in the past 2 years, by age group, state, and demographic and socioeconomic characteristics, using 2020 Behavioral Risk Factor Surveillance System data. We also compared 2020 state estimates with 2012 estimates.

RESULTS

The proportion of women aged 50-74 years who received a mammogram in the past 2 years was 78.1% (95% CI, 77.4%-78.8%) in 2020. Across measures of socioeconomic status, mammography use was generally lower among women who did not have health insurance (52.0%; 95% CI, 48.3%-55.6%) than among those who did (79.9%; 95% CI, 79.3%-80.6%) and among those who had a usual source of care (49.4%; 95% CI, 46.1%-52.7%) than among those who did not (81.0%; 95% CI, 80.4%-81.7%). Among women aged 50-74 years, mammography use varied across states, from a low of 65.2% (95% CI, 61.4%-69.0%) in Wyoming to a high of 86.1% (95% CI, 83.8%-88.3%) in Massachusetts. Four states had significant increases in mammography use from 2012 to 2020, and 8 states had significant declines.

CONCLUSION

Mammography use varied widely among states. Use of evidence-based interventions tailored to the needs of local populations and communities may help close gaps in the use of mammography.

Association of baseline self-reported fatigue with overall survival after stereotactic body radiation therapy for localized prostate cancer

Introduction

Stereotactic Body Radiation Therapy (SBRT) has emerged as a definitive therapy for localized prostate cancer (PCa). However, more data is needed to predict patient prognosis to help guide which patients will benefit most from treatment. The FACIT-Fatigue (FACIT-F) is a well validated, widely used survey for assessing fatigue. However, the role of fatigue in predicting PCa survival has yet to be studied. Herein, we investigate the role of FACIT-F as a baseline predictor for overall survival (OS) in patients undergoing SBRT for localized PCa.

Methods

A retrospective review was conducted of 1358 patients who received SBRT monotherapy between January 2008 to April 2021 at an academic, tertiary referral center. FACIT-F scores (range 0 to 52) were summed for patients who answered all 13-items on the survey. FACIT-F total scores of ≥35 represented severe fatigue. Patients receiving androgen deprivation therapy were excluded. Differences in fatigue groups were evaluated using chi-squared tests. OS rates were determined using the Kaplan-Meier method and predictors of OS were evaluated using Cox proportional hazard method.

Results

Baseline full FACIT-F scores and survival data was available for 891 patients. 5-year OS was 87.6% and 95.2%, respectively, for the severely fatigued and non-fatigued groups. Chi-squared analysis of fatigue groups showed no significant difference in the following categories: D'Amico risk group, age, ethnicity, grade group, T-stage, or PSA density. Severe fatigue was associated with a significant decrease in OS (hazard ratio 2.76; 95%CI 1.55 - 4.89). The Cox proportional hazard model revealed that age and FACIT-F were both statistically significant (p <0.05).

Conclusion

Baseline FACIT-F scores are significantly associated with OS. Higher FACIT-F scores, representing less fatigued patients, are associated with an overall survival benefit. These results indicate that the FACIT-F survey could serve as an additional metric for clinicians in determining prognostic factors for patients undergoing SBRT.

Structured Population-based Prostate-specific Antigen Screening for Prostate Cancer: The European Association of Urology Position in 2019

Prostate cancer (PCa) is one of the first three causes of cancer mortality in Europe. Screening in asymptomatic men (aged 55-69yr) using prostate-specific antigen (PSA) is associated with a migration toward lower staged disease and a reduction in cancer-specific mortality. By 20yr after testing, around 100 men need to be screened to prevent one PCa death. While this ratio is smaller than for breast and colon cancer, the long natural history of PCa means many men die from other causes. As such, the nonselective use of PSA testing and radical treatments can lead to overdiagnosis and overtreatment. The European Association of Urology (EAU) supports measures to encourage appropriate PCa detection through PSA testing, while reducing overdiagnosis and overtreatment. These goals may be achieved using personalized risk-stratified approaches. For diagnosis, the greatest benefit from early detection is likely to come in men assessed using baseline PSA levels at the age of 45yr to individualize screening intervals. Multiparametric magnetic resonance imaging as well as risk calculators based on family history, ethnicity, digital rectal examination, and prostate volume should be considered to triage the need for biopsy, thus reducing the risk of overdiagnosis. For treatment, the EAU advocates balancing patient's life expectancy and cancer's mortality risk when deciding an approach. Active surveillance is encouraged in well-informed patients with low-risk and some intermediate-risk cancers, as it decreases the risks of overtreatment without compromising oncological outcomes. Conversely, the EAU advocates radical treatment in suitable men with more aggressive PCa. Multimodal treatment should be considered in locally advanced or high-grade cancers. PATIENT SUMMARY: Implementation of prostate-specific antigen (PSA)-based screening should be considered at a population level. Men at risk of prostate cancer should have a baseline PSA blood test (eg, at 45yr). The level of this test, combined with family history, ethnicity, and other factors, can be used to determine subsequent follow-up. Magnetic resonance imaging scans and novel biomarkers should be used to determine which men need biopsy and how any cancers should be treated.

Cardiovascular Disease Screening Among Immigrants from Eight World Regions

Inequalities between native-born and foreign-born individuals in screening rates for a variety of conditions have been well-documented in literature on immigrant health. A preponderance of this research focuses on the Latin American case and on cancer-specific screening. This study seeks to expand knowledge of such preventative-health screening differences by analyzing screening rates for blood sugar, blood pressure, and serum cholesterol among nine groups overall and (for immigrants) at various stages of US residency. Using nationally representative data from the National Health Interview Survey, we find that immigrants from eight geographic regions receive preventative care at lower rates than US-born Whites and that preventative screening is generally higher after 15 years than during the first 4 years of residency in the United States. Importantly, our data also show that screening patterns and trends vary based on region of origin and outcome. These findings improve our understanding of immigrant health and health care use in the United States.

Disability-Adjusted Life Years for Cancer in 2010⁻2014: A Regional Approach in Mexico

The disability-adjusted life years (DALYs) were used to estimate the regional (state of Colima, Mexico) cancer burden in 2010⁻2014. The years of life lost (YLL) were estimated with mortality data and years lived with disability (YLD) using incidence data. The DALYs were calculated as the arithmetic addition of YLL and YLD. Sex and cancer site-specific estimations were made and DALY rates were used to identify the leading causes of disease burden. Data from 2532 deaths were analyzed and, for all malignant tumors combined, 18,712.9 DALYs and 20,243.3 DALYs were estimated in males and females respectively. The overall contribution of YLL in DALY estimates was higher among females (93.7% vs. 87.4%). Age-standardized DALY rates (and 95% confidence intervals, CI) per 100,000 inhabitants were used to rank the leading causes of disease burden and, among males, malignant tumors from the prostate, lower respiratory tract, and colon and rectum accounted the highest rates (45.7, 95% CI 32.7⁻59.3; 37.6, 95% CI 25.7⁻49.9; and 25.9, 95% CI 16.0⁻36.1 DALYs). Breast, cervix uteri, and lower respiratory tract cancer showed the highest burden in females (66.0, 95% CI 50.3⁻82.4; 44.4, 95% CI 31.5⁻57.7; and 20.9, 95% CI 12.0⁻30.0 DALYs). The present study provides an indication of the burden of cancer at the regional level, underscoring the need to expand cancer prevention, screening, and awareness programs, as well as to improve early diagnosis and medical treatment.

Benefits and harms of prostate cancer screening - predictions of the ONCOTYROL prostate cancer outcome and policy model

Background

A recent recalibration of the ONCOTYROL Prostate Cancer Outcome and Policy (PCOP) Model, assuming that latent prostate cancer (PCa) detectable at autopsy might be detectable by screening as well, resulted in considerable worsening of the benefit-harm balance of screening. In this study, we used the recalibrated model to assess the effects of familial risk, quality of life (QoL) preferences, age, and active surveillance.

Methods

Men with average and elevated familial PCa risk were simulated in separate models, differing in familial risk parameters. Familial risk was assumed to affect PCa onset and progression simultaneously in the base-case, and separately in scenario analyses. Evaluated screening strategies included one-time screening at different ages, and screening at different intervals and age ranges. Optimal screening strategies were identified depending on age and individual QoL preferences. Strategies were additionally evaluated with active surveillance by biennial re-biopsy delaying treatment of localized cancer until grade progression to Gleason score ≥ 7.

Results

Screening men with average PCa risk reduced quality-adjusted life expectancy (QALE) even under favorable assumptions. Men with elevated familial risk, depending on age and disutilities, gained QALE. While for men with familial risk aged 55 and 60 years annual screening to age 69 was the optimal strategy over most disutility ranges, no screening was the preferred option for 65 year-old men with average and above disutilities.

Active surveillance greatly reduced overtreatment, but QALE gains by averted adverse events were opposed by losses due to delayed treatment and additional biopsies. The effect of active surveillance on the benefit-harm balance of screening differed between populations, as net losses and gains in QALE predicted for screening without active surveillance in men with average and familial PCa risk, respectively, were both reduced.

Conclusions

Assumptions about PCa risk and screen-detectable prevalence significantly affect the benefit-harm balance of screening. Based on the assumptions of our model, PCa screening should focus on candidates with familial predisposition with consideration of individual QoL preferences and age. Active surveillance may require treatment initiation before Gleason score progression to 7. Alternative active surveillance strategies should be evaluated in further modeling studies.

Differing types of medical prevention appeal to different individuals

We analyze participation in medical prevention with an expected utility model that is sufficiently rich to capture diverging features of different prevention procedures. The predictions of the model are not rejected with data from SHARE. A decrease in individual health decreases participation in breast cancer screening and dental prevention and increases participation in influenza vaccination, cholesterol screening, blood pressure screening, and blood sugar screening. Positive income effects are most pronounced for dental prevention. Increased mortality risk is an important predictor in the model for breast cancer screening, but not for the other procedures. Targeted screening and vaccination programs increase participation.

The ONCOTYROL Prostate Cancer Outcome and Policy Model: Effect of Prevalence Assumptions on the Benefit-Harm Balance of Screening

BACKGROUND

The ONCOTYROL Prostate Cancer Outcome and Policy (PCOP) model is a state-transition microsimulation model evaluating the benefits and harms of prostate cancer (PCa) screening. The natural history and detection component of the original model was based on the 2003 version of the Erasmus MIcrosimulation SCreening ANalysis (MISCAN) model, which was not calibrated to prevalence data. Compared with data from autopsy studies, prevalence of latent PCa assumed by the original model is low, which may bias the model toward screening. Our objective was to recalibrate the original model to match prevalence data from autopsy studies as well and compare benefit-harm predictions of the 2 model versions differing in prevalence.

METHODS

For recalibration, we reprogrammed the natural history and detection component of the PCOP model as a deterministic Markov state-transition cohort model in the statistical software package R. All parameters were implemented as variables or time-dependent functions and calibrated simultaneously in a single run. Observed data used as calibration targets included data from autopsy studies, cancer registries, and the European Randomized Study of Screening for Prostate Cancer. Compared models were identical except for calibrated parameters.

RESULTS

We calibrated 46 parameters. Prevalence from autopsy studies could not be fitted using the original parameter set. Additional parameters, allowing for interruption of disease progression and age-dependent screening sensitivities, were needed. Recalibration to higher prevalence demonstrated a considerable increase of overdiagnosis and decline of screening sensitivity, which significantly worsened the benefit-harm balance of screening.

CONCLUSIONS

Our calibration suggests that not all cancers are at risk of progression, and screening sensitivity may be lower at older ages. PCa screening models that use calibration to simulate disease progression in the unobservable latent phase are highly sensitive to prevalence assumptions.

Cost-effectiveness of prostate cancer screening: a simulation study based on ERSPC data

BACKGROUND

The results of the European Randomized Study of Screening for Prostate Cancer (ERSPC) trial showed a statistically significant 29% prostate cancer mortality reduction for the men screened in the intervention arm and a 23% negative impact on the life-years gained because of quality of life. However, alternative prostate-specific antigen (PSA) screening strategies for the population may exist, optimizing the effects on mortality reduction, quality of life, overdiagnosis, and costs.

METHODS

Based on data of the ERSPC trial, we predicted the numbers of prostate cancers diagnosed, prostate cancer deaths averted, life-years and quality-adjusted life-years (QALY) gained, and cost-effectiveness of 68 screening strategies starting at age 55 years, with a PSA threshold of 3, using microsimulation modeling. The screening strategies varied by age to stop screening and screening interval (one to 14 years or once in a lifetime screens), and therefore number of tests.

RESULTS

Screening at short intervals of three years or less was more cost-effective than using longer intervals. Screening at ages 55 to 59 years with two-year intervals had an incremental cost-effectiveness ratio of $73000 per QALY gained and was considered optimal. With this strategy, lifetime prostate cancer mortality reduction was predicted as 13%, and 33% of the screen-detected cancers were overdiagnosed. When better quality of life for the post-treatment period could be achieved, an older age of 65 to 72 years for ending screening was obtained.

CONCLUSION

Prostate cancer screening can be cost-effective when it is limited to two or three screens between ages 55 to 59 years. Screening above age 63 years is less cost-effective because of loss of QALYs because of overdiagnosis.

Explaining variations in breast cancer screening across European countries

OBJECTIVE

In this study I aim to explore the statistical causes of country differences in mammography screening among women aged 50-69 years in 13 European countries. I focus on the relative importance of individual (e.g. age, education, etc.) and institutional (e.g. public screening programmes) factors in explaining these differences.

DATA AND METHODS

I use individual level data from the first three waves (2004-2006-2009) of the SHARE as well as regional and country level data on institutional factors. The analytical approach is based on multilevel statistical models, which allow me to analyse the contribution of individual and institutional factors in explaining the variation in breast cancer screening across European countries.

RESULTS

I find that the standard deviation in screening rates across countries increases slightly from 19.5 to 20.8 per cent after controlling for individual factors. Observed individual factors such as age, education, health status, etc., do not significantly contribute to the explanation of cross-country differences. In contrast, after controlling for observed institutional factors such as the availability of an organised screening programme, the standard deviation drops from 20.86 to 12.92 per cent. These factors can statistically explain about 40 per cent of the between-country differences in screening rates. Moreover, I found that these institutional factors seem to prevent a woman from considering a mammogram "not necessary".

CONCLUSION

This analysis provides important insights about patient's attitudes and understanding of benefits of breast cancer prevention and highlights the importance of the availability of an organised screening programme for screening differences across European countries.

Early detection of prostate cancer: European Association of Urology recommendation

BACKGROUND

The recommendations and the updated EAU guidelines consider early detection of PCa with the purpose of reducing PCa-related mortality and the development of advanced or metastatic disease.

OBJECTIVE

This paper presents the recommendations of the European Association of Urology (EAU) for early detection of prostate cancer (PCa) in men without evidence of PCa-related symptoms.

EVIDENCE ACQUISITION

The working panel conducted a systematic literature review and meta-analysis of prospective and retrospective clinical studies on baseline prostate-specific antigen (PSA) and early detection of PCa and on PCa screening published between 1990 and 2013 using Cochrane Reviews, Embase, and Medline search strategies.

EVIDENCE SYNTHESIS

The level of evidence and grade of recommendation were analysed according to the principles of evidence-based medicine. The current strategy of the EAU recommends that (1) early detection of PCa reduces PCa-related mortality; (2) early detection of PCa reduces the risk of being diagnosed and developing advanced and metastatic PCa; (3) a baseline serum PSA level should be obtained at 40-45 yr of age; (4) intervals for early detection of PCa should be adapted to the baseline PSA serum concentration; (5) early detection should be offered to men with a life expectancy ≥ 10 yr; and (6) in the future, multivariable clinical risk-prediction tools need to be integrated into the decision-making process.

CONCLUSIONS

A baseline serum PSA should be offered to all men 40-45 yr of age to initiate a risk-adapted follow-up approach with the purpose of reducing PCa mortality and the incidence of advanced and metastatic PCa. In the future, the development and application of multivariable risk-prediction tools will be necessary to prevent over diagnosis and over treatment.

Who gets a mammogram amongst European women aged 50-69 years?

On the basis of the Survey of Health, Ageing, and Retirement (SHARE), we analyse the determinants of who engages in mammography screening focusing on European women aged 50-69 years. A special emphasis is put on the measurement error of subjective life expectancy and on the measurement and impact of physician quality. Our main findings are that physician quality, better education, having a partner, younger age and better health are associated with higher rates of receipt. The impact of subjective life expectancy on screening decision substantially increases after taking measurement error into account.

JEL CLASSIFICATION

C 36, I 11, I 18.

Serious health events and discontinuation of routine cancer screening

Recently revised US Preventive Services Task Force screening guidelines for colorectal, breast, and prostate cancer contain separate recommendations for persons younger than 75 years and those 75 years or older. Developing an understanding of whether and how patients discontinue screening is important for evaluating the potential benefits and drawbacks of age-delimited screening recommendations as a tool for reducing overdiagnosis rates. Using Surveillance, Epidemiology, and End

RESULTS

-Medicare data from 1998 to 2007, the authors identified a sample of 32,189 female and 27,669 male fee-for-service Medicare beneficiaries who received 2 consecutive breast or prostate screens, 1 year apart. They then estimated the impact of serious health events, such as heart attacks and strokes, on continuation of screening. Rescreening rates among beneficiaries who did not experience a serious health event were 78% for women and 82% for men. Rescreening rates among beneficiaries who experienced a serious health event were 55% for women and 57% for men. The rate ratios associated with a time-varying indicator for the 2-year period following a serious health event were 0.79 (95% confidence interval: 0.76 to 0.81); P < 0.001) for women and 0.87 (95% confidence interval: 0.85 to 0.89; P < 0.001) for men. Approximately one-third of patients and physicians discontinue or temporarily suspend screening for breast and prostate cancer following serious health events. Findings suggest that not all patients persist with screening until they die.

Management of low (favourable)-risk prostate cancer

What's known on the subject? and What does the study add? Most men who are diagnosed with favourable-risk prostate cancer undergo some form of active intervention, despite evidence that treatment will not improve health outcomes for many. The decision to undergo treatment after diagnosis is, in part, related to the inability to precisely determine the long-term risk of harm without treatment. Nevertheless, physicians should consider patient age, overall health, and preferences for living with cancer and the potential side effects of curative treatments, before recommending a management option. This is especially important for older men, given the high level of evidence that those with low-risk disease are unlikely to accrue any benefit from curative intervention. What is known on the subject: Over treatment of favourable-risk prostate cancer is common, especially among older men. What does the study add: A review of the natural history of favourable-risk prostate cancer in the context of choices for management of the disease. • The management of favourable-risk prostate cancer is controversial, and in the absence of controlled trials to inform best practice, choices are driven by personal beliefs with resultant wide variation in practice patterns. • Men with favourable-risk prostate cancer diagnosed today often undergo treatments that will not improve overall health outcomes. • A shared-decision approach for selecting optimal management of favourable-risk disease should account for patient age, overall health, and preferences for living with cancer and the potential side effects of curative treatments.

Immigrants and the use of preventive care in the United States

Using data from the Medical Expenditure Panel Survey, we compare immigrants' use of preventive care with that of natives. We employ a multinomial switching regression framework that accounts for non-random selection into continuous private insurance, temporary private insurance, public insurance, and no insurance. Our results indicate that among the populations with continuous private coverage and without coverage (uninsured), immigrants, especially non-citizens, are less likely to use preventive care than natives. We find that the longer immigrants stay in the US the more their use of care approximates to that of natives. However, for most types of care, immigrants' use of care never fully converges to that of natives. Among the publicly insured population, immigrants' use of care is similar to natives, but non-citizen immigrants are significantly less likely to use preventive measures. We find that the ability to speak English does not have a significant effect on the use of preventive care among publicly insured persons.

The relationship between ex ante mortality risk and end-of-life medical costs

BACKGROUND

Spending on medical care for patients in their last year of life accounts for over one-quarter of US Medicare programme outlays. While the magnitude of spending on end-of-life care is striking, it is difficult to determine if expenditures are wasteful or simply reflect the inherent uncertainty facing physicians.

METHODS

Using a sample of fee-for-service Medicare beneficiaries, we document the association between mortality risk and end-of-life medical spending. Mortality risk at 1 year before death was estimated using a logistic model with age, sex and co-morbidities as covariates.

RESULTS

We found that, among decedents, end-of-life spending is inversely related to predicted mortality risk, ranging from Dollars US 23,000 for decedents with mortality risk in the interval 0.00-0.05 to Dollars US 16,000 for decedents with mortality risk > 0.25 (1999 dollar values). In aggregate, > 50% of Medicare spending on medical care in the last year of life is for beneficiaries with below-median mortality risk.

CONCLUSIONS

We conclude that physicians treat patients who are likely to die differently than those who are not. Substituting palliative for curative care for patients with unfavourable prognoses may lower total expenditures, but probably not as much as commonly expected.