Rationing of Care: Conceptual Ambiguity and Transparency in Data Collection and Synthesis

Journal of General Internal Medicine, Jul 2016

Rebekah J. Walker PhD, Leonard E. Egede MD,MS

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Rationing of Care: Conceptual Ambiguity and Transparency in Data Collection and Synthesis

Rationing of Care: Conceptual Ambiguity and Transparency in Data Collection and Synthesis Rebekah J. Walker 0 1 2 Leonard E. Egede 0 Department of Medicine, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina , Charleston, SC , USA 1 Center for Health Disparities Research, Medical University of South Carolina , Charleston, SC , USA 2 Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson Veterans Affairs Medical Center , Charleston, SC , USA - R sial issue, with great disagreement over not only whether ationing continues to be a hotly debated and controverrationing is acceptable, but what it means to ration care. In this issue of JGIM, Sheeler et al. present findings of a crosssectional study that aims to describe physician rationing behaviors and characteristics of rationing in the United States.1 Surveys mailed to physicians randomly selected from the American Medical Association master file asked about frequency with which they Bpersonally refrained, because of cost to the health care system,^ from using ten different interventions, including laboratory tests, magnetic resonance imaging (MRI), referral, or prescription drugs. They found overall that 53 % of respondents reported refraining from using services in the past 6 months.1 Prescription drugs and MRI were most frequently reported at 48 % and 45 %, respectively.1 Surgical and procedural specialists, medical school settings, and physicians who self-identified as very or somewhat politically conservative reported higher frequency of refraining from using at least one of the ten services than primary care, small or solo practice, and those identifying as very or somewhat liberal.1 In addition, the survey asked respondents one of three randomly assigned questions to gauge perceived responsibility for containing costs, phrasing questions either as responsibility to Bexercise wise financial resource stewardship,^ Bpromote cost consciousness^ or Bration in my daily care of patients.^ Compared to 88 % agreeing with the Bwise-stewardship^ and 81 % agreeing with the Bcost-conscious^ statements, only 22 % agreed with the Brationing^ statement.1 As seen in the results reported by Sheeler et al., the phrasing used to ask about rationing has an impact on responses. As a result, it is necessary to be clear regarding the definition of rationing. Ubel and Goold suggested in 1998 the use of a broad interpretation Bencompassing any explicit or implicit measures that allow people to go without beneficial health care services.^2 They argued that this would highlight the frequency with which rationing occurs, and remove the de facto negative connotation.2 However, discussions of rationing over the past 5 years consistently note there is no agreed upon definition, and point out that the term is often used synonymously with ideas such as ‘resource allocation,’ ‘priority setting’ and ‘cost containment.’3–6 The political processes surrounding the Affordable Care Act in the United States, and the National Health Service in the United Kingdom have added to the conceptual and methodological struggle to measure and understand clinician attitudes and willingness to accept rationing either in their own practice or through policy measures.3–5 Even what is considered rationing is unclear; for example, limitations on services by ability to pay, or lack of care resulting from lack of health insurance, is seen as implicit rationing by some definitions, but not others.2, 5, 6 By not directly asking about rationing, Sheeler et al. avoided possible reactions to the term itself, and stated this could prompt more professional discourse on the topic.1 However, given the widespread disagreement on what does and does not constitute rationing, the conclusions drawn could be inadvertently misleading and may be inconsistent with the intent of survey participants at the time they answered the questions. Previous studies have investigated the willingness of physicians to ration health care as well as their perceptions of rationing. Hurst et al. used a similarly phrased questionnaire in Norway, Switzerland, Italy, and the United Kingdom, and found a similar overall response, with 56 % of physicians refraining from at least one of the ten interventions in the past 6 months.7 When asked more detailed questions regarding criteria for rationing, respondents most often reported a small expected benefit (82 %) and low chance of success (80 %).7 A national survey of intensive care units (ICU) in the United States found that a majority of respondents perceived questions about specific situations or practices that may be associated with rationing occurred Brarely^ or Bnot at all.^8 Few ICUs perceived rationing as occurring Bfrequently^; however, 46 % of respondents felt Btoo much care^ was provided Bsometimes or frequently.^8 In this study, the word rationing was used, but not until the end of the survey in an effort to minimize bias resulti (...truncated)


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Rebekah J. Walker PhD, Leonard E. Egede MD,MS. Rationing of Care: Conceptual Ambiguity and Transparency in Data Collection and Synthesis, Journal of General Internal Medicine, 2016, pp. 1415-1416, Volume 31, Issue 12, DOI: 10.1007/s11606-016-3801-4