Quality of Life, Utilities, Quality-Adjusted Life-years, and Health Care Decision Making: Comment on “Estimating Quality of Life in Acute Venous Thrombosis”

Of what importance is knowing how patients assess the quality of life (QOL) of health states when trying to make decisions about health care? Consider the case of routine prophylaxis of hospitalized medical patients to prevent venous thromboembolism. In a recent review sponsored by the Agency for Healthcare Research and Quality, Lederle et al¹ pooled data from more than a dozen randomized trials comparing the use of heparin with no heparin. They found that the best estimate was that use of heparin prophylaxis was associated with 2 fewer cases of symptomatic deep vein thrombosis and 4 fewer cases of pulmonary embolism per 1000 patients, but an increase in 9 cases per 1000 of bleeding events, of which 1 case per 1000 patients was a “major” bleeding event. How is a clinician to balance these benefits and harms? The Clinical Guidelines Committee of the American College of Physicians (on which we have both served) made the assumption that most patients would decide that the benefits from reduction in deep vein thrombosis and pulmonary embolus would outweigh the harms associated with bleeding complications, and therefore recommended that hospitalized medical patients (without stroke) receive heparin prophylaxis.² But was this assumption correct? The answer rests in part on how patients view the QOL of health states associated with venous thromboembolism and complications of therapy.