Being There Is Important, but Getting There Matters Too: The Role of Path in the Valuation Process

Purpose . Traditional decision-analytic models presume that utilities are invariant to context. The influence of 2 types of context on patients' utility assessments was examined here the path by which one reaches a health state and personal experience with a health state. Methods . Three groups of patients were interviewed: men older than age 49 years with prostate cancer but no diabetes (CaP), diabetes but no prostate cancer (DM), and neither disease (ND). The utility of erectile dysfunction (ED) was assessed using a standard gamble (SG). Each subject completed 2 SGs: 1) a no-context version that gave no explanation for the cause of ED and 2) a contextualized version in which prostate cancer treatment, the failure to manage diabetes, or the natural course of aging was said to be the cause. Results . Patients with disease assigned higher utilities to ED in a matching context than in discrepant contexts. Regression models found that the valuation process was also sensitive to the match between disease path in the utility assessment and patients' personal experiences. Conclusions . These findings lend insight into why acontextual utility assessments typically used in decision analyses have not been able to predict patient behavior as well as expected. The valuation process appears to change systematically when context is specified, suggesting that unspecified contexts rather than random error may lead to fluctuations in the values assigned to identical health states.