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Background: Practice guidelines rarely consider comorbid illness, and resulting overuse of health services may increase costs without conferring benefit.
Objective: To individualize a framework for inferring when patients who were considered unfit for open repair are not likely to benefit from endovascular repair of abdominal aortic aneurysm (EVAR) guidelines.
Methods: We modified the “payoff time” framework (the minimum time until a guideline’s cumulative benefits exceed its cumulative harms) to increase its applicability to a wide range of primary care patients. We show how it may inform EVAR decisions for 3 typical patients for whom EVAR would be recommended by current guidelines: (1) 65-year-old man, smoker, with diabetes and 6 cm abdominal aortic aneurysm (AAA); (2) 85-year-old woman smoker, with severe lung disease requiring home oxygen therapy, has difficulty breathing, and 5.7 cm AAA; and (3) 70-year-old woman with concomitant thoracic aneurysm and 6 cm AAA
Results: For patient 1, the payoff time for EVAR (minimum time until benefits exceed harms) is 5.1 years, and for patient 2, the payoff time for EVAR is 5.8 years. Evidence is insufficient to estimate the payoff time for patient 3. Because patient 1’s estimated life expectancy is ≥ 10 years (more than his payoff time), he is likely to benefit from EVAR. Because patient 2’s estimated life expectancy exceeds 4.7 years (less than her payoff time), she may not benefit from EVAR. Because evidence is insufficient to estimate the payoff time for patient 3, the payoff time framework does not inform decision making.
Conclusion: The payoff time framework may identify patients for whom particular clinical guidelines are unlikely to confer benefit, and has the potential to decrease unnecessary health care.