The Payoff Time

A Flexible Framework to Help Clinicians Decide When Patients with Comorbid Disease are Not Likely to Benefit from Practice Guidelines

This article examines a framework to indicate when patients with comorbid illness are more or less likely to benefit from colorectal cancer screening practice guidelines. The study hypothesizes that patients with chronic diseases might not survive long enough to gain from medical practice guidelines that have immediate risks and delayed benefits.

The authors first established the “payoff time” for three typical patients: the minimum length of time at which the benefits of screening for colorectal cancer exceeded the risk to the patient. They then assessed whether each patient would benefit from colorectal cancer screening based on their estimated life expectancy.

Key Findings:

  • Patient 1: A 60-year-old man with multiple serious health issues, has a life expectancy of 3.7 years and a payoff time of 7.3 years. Since his life expectancy is significantly shorter than the minimum length of time at which he would receive benefit from colorectal cancer screening, he is unlikely to benefit from the screening.
  • Patient 2: A 60-year-old woman with obesity and diabetes, has a life expectancy that exceeds 10 years and a payoff time of 5.4 years. Patient 2 may benefit from colorectal cancer screening.
  • Patient 3: A 50-year-old woman with inflammatory bowel disease, does not have a predicted payoff time due to insufficient evidence. Therefore, no conclusions can be drawn regarding the expected benefit of colorectal screening.

Determining the minimum time at which a practice guideline's benefit outweighs its costs may help physicians determine when patients are unlikely to be helped by a specific guideline.