Dataset Information

Prevalence and determinants of physician bedside rationing: data from Europe.

ABSTRACT:

Background

Bedside rationing by physicians is controversial. The debate, however, is clouded by lack of information regarding the extent and character of bedside rationing.

Design, setting, and participants

We developed a survey instrument to examine the frequency, criteria, and strategies used for bedside rationing. Content validity was assessed through expert assessment and scales were tested for internal consistency. The questionnaire was translated and administered to General Internists in Norway, Switzerland, Italy, and the United Kingdom. Logistic regression was used to identify the variables associated with reported rationing.

Results

Survey respondents (N=656, response rate 43%) ranged in age from 28 to 82, and averaged 25 years in practice. Most respondents (82.3%) showed some degree of agreement with rationing, and 56.3% reported that they did ration interventions. The most frequently mentioned criteria for rationing were a small expected benefit (82.3%), low chances of success (79.8%), an intervention intended to prolong life when quality of life is low (70.6%), and a patient over 85 years of age (70%). The frequency of rationing by clinicians was positively correlated with perceived scarcity of resources (odds ratio [OR]=1.11, 95% confidence interval [CI] 1.06 to 1.16), perceived pressure to ration (OR=2.14, 95% CI 1.52 to 3.01), and agreement with rationing (OR=1.13, 95% CI 1.05 to 1.23).

Conclusion

Bedside rationing is prevalent in all surveyed European countries and varies with physician attitudes and resource availability. The prevalence of physician bedside rationing, which presents physicians with difficult moral dilemmas, highlights the importance of discussions regarding how to ration care in the most ethically justifiable manner.

SUBMITTER: Hurst SA

PROVIDER: S-EPMC1831659 | biostudies-literature | 2006 Nov

REPOSITORIES: biostudies-literature

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Publications

Prevalence and determinants of physician bedside rationing: data from Europe.

Hurst Samia A SA Slowther Anne-Marie AM Forde Reidun R Pegoraro Renzo R Reiter-Theil Stella S Perrier Arnaud A Garrett-Mayer Elizabeth E Danis Marion M

Journal of general internal medicine 20060707 11

<h4>Background</h4>Bedside rationing by physicians is controversial. The debate, however, is clouded by lack of information regarding the extent and character of bedside rationing.<h4>Design, setting, and participants</h4>We developed a survey instrument to examine the frequency, criteria, and strategies used for bedside rationing. Content validity was assessed through expert assessment and scales were tested for internal consistency. The questionnaire was translated and administered to General ...[more]

PMID: 16836629

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Project description:Objectives Many UK primary care trusts have recently introduced eligibility criteria restricting total knee replacement (TKR) to patients with low pre-operative Oxford Knee Scores (OKS) to cut expenditure. We evaluate these criteria by assessing the cost-effectiveness of TKR compared with no knee replacement for patients with different baseline characteristics from an NHS perspective. Design The cost-effectiveness of TKR in different patient subgroups was assessed using regression analyses of patient-level data from the Knee Arthroplasty Trial, a large, pragmatic randomised trial comparing knee prostheses. Setting 34 UK hospitals. Participants 2131 osteoarthritis patients undergoing TKR. Interventions and outcome measures Costs and quality-adjusted life years (QALYs) observed in the Knee Arthroplasty Trial within 5 years of TKR were compared with conservative assumptions about the costs and outcomes that would have been accrued had TKR not been performed. Results On average, primary TKR and 5 years of subsequent care cost £7458 per patient (SD: £4058), and patients gained an average of 1.33 (SD: 1.43) QALYs. As a result, TKR cost £5623/QALY gained. Although costs and health outcomes varied with age and sex, TKR cost <£20?000/QALY gained for patients with American Society of Anaesthesiologists grades 1-2 who had baseline OKS <40 and for American Society of Anaesthesiologists grade 3 patients with OKS <35, even with highly conservative assumptions about costs and outcomes without TKR. Body mass index had no significant effect on costs or outcomes. Restricting TKR to patients with pre-operative OKS <27 would inappropriately deny a highly cost-effective treatment to >10?000 patients annually. Conclusions TKR is highly cost-effective for most current patients if the NHS is willing to pay £20?000-£30?000/QALY gained. At least 97% of TKR patients in England have more severe symptoms than the thresholds we have identified, suggesting that further rationing by OKS is probably unjustified. Trial registration number ISRCTN 45837371.

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Dataset Information

Prevalence and determinants of physician bedside rationing: data from Europe.

Background

Design, setting, and participants

Results

Conclusion

Publications

Prevalence and determinants of physician bedside rationing: data from Europe.

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