Session 6.2 – Clinician’s Views on Explicit Priority Setting
Friday October 31 9:00-10:30
High Weight Criteria for Priority-Setting in Health Care in Peru: Exploration of Physician’s Values.
(Abstract 0056)Renzo Sotomayor, Pedro Mendoza
Universidad Nacional Mayor de San Marcos, Peru
Objective: To explore physician’s acceptance of criteria for setting priorities (SP) for the health care system in Peru.
Methods: Self-administered questionnaire. It was distributed to physicians from the National (NS) and Social Security Systems. Participants were asked if they agreed with 19 criteria that could be used to SP. Predetermined cut-off points were used to rank the criteria into three different categories: high weight (≥67% of respondents agreed), average weight (34–66% agreed) and low weight (≤33%). There was a clarifying question about age priority. We tested for associations between respondents’ characteristics and whether they agreed with the criteria.
Results: A total of 164 people took part. More than 67% agreed that the following criteria should be considered: cost-effectiveness of the intervention (95%), equity of access (91%) benefit (90%), age (87%), severity of disease (85%), quality of the data on effectiveness (84%) and cost of the intervention (77%). lifestyle (77%), place of residence (71%). The 76% indicated that group 0-11 years-old should be given priority. We found that if the physician worked at the NS it was more likely to agreed with place of residence and community’s view criteria (p<0.05). Also, the younger physicians were more likely to considerer the community’s view criteria (p<0.05).
Conclusion: All the disease-related criteria were highly accepted. It also should be considered the age, lifestyle, place of residence and equity of access. The 0-11 years-old should be the one prioritised.
Explicit Priority Setting with Cost-Conscious Guidelines: An Empirical Study of Physician Attitudes
(Abstract 0086)Daniel Strech, Georg Marckmann
University of Tuebingen, Germany
Background: There is wide consensus around the world that unavoidable priority setting in health care should be explicit and transparent. Cost-conscious guidelines can assist clinicians to make explicit allocation decisions at the bedside. The success of these explicit instruments however, largely depends on the physicians’ acceptance. Knowing physicians attitudes towords cost-conscious guidelines can be important to overcome implementation barriers.
Objective: To assess physicians’ experiences with micro-level allocation decisions and their attitudes towards explicit tools of priority setting.
Methods: We conducted a postal random-sample survey of 1200 physicians in the field of cardiology and intensive care medicine in Germany in 2007 and 2008. The survey explored several aspects of physicians’ attitudes towards cost-conscious guidelines and other explicit tools of priority setting.
Results: The survey confirms that physicians frequently have to make rationing decisions at the bedside without any explicit guidance. On the one hand, a large majority of the respondents agree that physicians should follow cost-conscious guidelines that exclude interventions with a bad cost-effectiveness. On the other hand, almost half of the respondents considered cost-conscious guidelines an unjustified limitation of the physician’s decision-making authority and half of the respondents thought it unacceptable for physicians to use a slightly less beneficial intervention in order to save scarce resources.
Policy Implications: Taking into account physicians’ attitudes towards cost-conscious guidelines might help to bridge the theory-to-practice gap in explicit priority setting on the micro level.
Are Physicians Willing to Ration Health Care? A Systematic Review of Survey Findings
(Abstract 0087)Daniel Strech1, Govind Persad2, Georg Marckmann1, Marion Danis2
1University of Tuebingen, Germany, 2National Institutes of Health, United States
Background: A broad spectrum of quantitative survey research has been conducted internationally to gather empirical information about physicians’ general attitude towards health care rationing (HCR). Are physicians ready to accept and implement health care rationing? Do they prefer bedside rationing based on explicit criteria or do they prefer implicit forms of rationing that permits varying decisions among patients?
Objectives: First, to analyse the range of quantitative survey findings on HCR. Second, to discuss differences in response patterns. Third, to provide conceptual and practical recommendations that can enhance transparency and systematic conduct in the process of reviewing survey literature.
Methods: We performed a systematic search for all English and non-English language references using CINAHL, EMBASE, and MEDLINE. To frame the analysis, we extracted survey items that match with one of the following issues: (i) willingness to ration health care or (ii) preferences for different strategies of HCR.
Results: The systematic literature search yielded 557 references, of which 16 were eventually included in the systematic review after relevance and quality assessment. 28 items focused on the physicians’ willingness to accept HCR and 18 items focused on the physicians’ attitudes to different explicit and implicit strategies of HCR. Percentages of respondents willing to accept HCR ranged from 94% to 9%.
Policy Implications: The conflicting findings among studies illustrate important ambivalence in physicians that has several implications for health policy. In addition, this review highlights conceptual and practical recommendations to enhance transparency and systematic conduct in the process of reviewing survey literature.
“Now I Would Ask Things Differently”: Understanding the Management of Explicit Rationing Within the Shared Doctor-Patient Relationship
(Abstract 0089)Amanda Owen-Smith1, Joanna Coast2, Jenny Donovan1
1University of Bristol, United Kingdom, 2University of Birmingham, United Kingdom
How best to manage the obligation to ration healthcare, and in particular how explicit such processes should be, is a matter of increasing international interest. Despite this, there exists very limited empirical evidence about the views of clinicians on this issue, and none relating to the views of patients. Qualitative methods were used to conduct a multi-stage empirical investigation, including an initial study at the community level, followed by two clinical case studies (of morbid obesity and breast cancer treatments) within secondary care. In total, 21 healthcare professionals and 31 patients were interviewed. The results revealed that patients had a broad awareness of healthcare rationing, and nearly all said they wanted to know how financial factors affected the provision of their healthcare. However, the data also demonstrated that the experience of explicit rationing could be extremely distressing for patients, particularly when decision-making was viewed as arbitrary or unfair. Clinical professionals reported a strong commitment to being open about rationing, although in practice this was sometimes over-ridden by ethical or pragmatic concerns. Important factors in deciding whether to disclose included whether treatments were available in the private sector, whether decisions were likely to be revealed anyway, and whether patients had raised questions about the availability of other treatments. However, the accounts of patients revealed that many did not know they needed to ask to be told about all available treatments, and therefore relying on the questioning techniques of patients is an unreliable approach to eliciting preferences for explicitness.