The Impact of Socioeconomic Status (SES) on Patient Preference for Aggressive Treatment Options

In our recent seminar, jointly hosted by the Institute for the Public Understanding of Risk, National University of Singapore, and the Institute for Behavioural and Decision Science, Hong Kong University, featured Prof Jill Lei from the University of Melbourne, who presented her interdisciplinary research on how socioeconomic status (SES) shapes patient preferences for aggressive versus conservative medical treatments.  

This seminar is the first session of a two-part series, “Shaping the Future of Risk Communication Research in Healthcare.” This session focused on Prof Lei’s research into the growing relevance of patient involvement in medical decisions and the need to understand the underlying factors influencing these choices, particularly as they pertain to health outcomes. 

Prof Lei’s research emerged from both personal experiences and scholarly interest. From observing medical decision-making in her family to the hospital environment, she emphasized that patients are increasingly empowered. Surveys conducted showed that a substantial portion of patients feel confident in making health decisions. This shift in patient agency underscores the importance of investigating how patients evaluate treatment options, especially in scenarios that might lack information for either aggressive or conservative interventions. The research focused on real-world decisions, such as choosing between active surveillance and minimally invasive surgery for benign thyroid nodules, and extended to more acute conditions like myocardial infarction, where options range from less invasive procedures like PCI to major surgeries such as CABG. 

The research had a central hypothesis, which was that SES significantly influences treatment preferences. The initial studies shared by Prof Lei, suggested that individuals with lower SES tend to favour aggressive treatments. This tendency was explained through the lens of psychological mechanisms: those with lower SES often experience greater environmental and financial uncertainty, leading to a lower tolerance for ambiguity and heightened risk perception. This, in turn, drives a preference for immediate and decisive treatments, which are perceived as both faster and more effective, albeit riskier and more costly at times. Conversely, even patients of a higher SES may value their lives differently, sometimes opting for aggressive treatments out of a sense of greater personal worth and the desire to maximize health outcomes, though for very different motivational reasons. 

The research utilized both experimental and secondary data approaches. Online panel studies across various health conditions confirmed beliefs that invasive treatments are viewed as more effective and revealed that low SES individuals marginally prefer aggressive options. Secondary analysis of Australian healthcare data on heart attack patients confirmed these findings, showing that patients from lower SES backgrounds and those without private health insurance were more likely to receive more invasive CABG surgery. This runs true even when access and affordability factors were controlled by the public healthcare system. Interestingly, this effect was strongest when the health condition was less severe, suggesting that SES exerts more influence on medical decisions. 

Further investigation uncovered an unexpected yet interesting finding of two parallel psychological pathways through which SES affects treatment choice. Lower SES individuals demonstrated greater intolerance of uncertainty, leading to higher risk perceptions and a preference for aggressive treatment. Higher SES individuals, on the other hand, may pursue aggressive treatment because they ascribe higher subjective value to their lives, which also heightens perceived risk. The interplay of these mechanisms sometimes cancels out the overall main effect, explaining the inconsistency in direct SES-treatment links observed across different studies. The seminar concluded with a discussion on practical implications such as targeted interventions, and to provide a holistic view of life, addressing the problem of unnecessary aggressive medical care. 

In summary, Prof Lei’s research findings highlight the importance of psychological factors beyond mere economic constraints suggesting that SES acts as a cognitive switch activating different decision processes. This insight introduces patient-centered interventions, aiming for better health outcomes and more efficient use of medical resources.