Self-Reported Rationing Behavior Among US Physicians: A National Survey

Journal of General Internal Medicine, Jul 2016

Background Rationing is a controversial topic among US physicians. Understanding their attitudes and behaviors around rationing may be essential to a more open and sensible professional discourse on this important but controversial topic. Objective To describe rationing behavior and associated factors among US physicians. Design Survey mailed to US physicians in 2012 to evaluate self-reported rationing behavior and variables related to this behavior. Setting US physicians across a full spectrum of practice settings. Participants A total of 2541 respondents, representing 65.6 % of the original mailing list of 3872 US addresses. Interventions The study was a cross-sectional analysis of physician attitudes and self-reported behaviors, with neutral language representations of the behaviors as well as an embedded experiment to test the influence of the word “ration” on perceived responsibility. Main Outcome Measures Overall percentage of respondents reporting rationing behavior in various contexts and assessment of attitudes toward rationing. Key Results In total, 1348 respondents (53.1 %) reported having personally refrained within the past 6 months from using specific clinical services that would have provided the best patient care, because of health system cost. Prescription drugs (n = 1073 [48.3 %]) and magnetic resonance imaging (n = 922 [44.5 %]) were most frequently rationed. Surgical and procedural specialists were less likely to report rationing behavior (adjusted odds ratio [OR] [95 % CI], 0.8 [0.9–0.9] and 0.5 [0.4–0.6], respectively) compared to primary care. Compared with small or solo practices, those in medical school settings reported less rationing (adjusted OR [95 % CI], 0.4 [0.2–0.7]). Physicians who self-identified as very or somewhat liberal were significantly less likely to report rationing (adjusted OR [95 % CI], 0.7 [0.6–0.9]) than those self-reporting being very or somewhat conservative. A more positive opinion about rationing tended to align with greater odds of rationing. Conclusions More than one-half of respondents engaged in behavior consistent with rationing. Practicing physicians in specific subgroups were more likely to report rationing behavior.

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Self-Reported Rationing Behavior Among US Physicians: A National Survey

J Gen Intern Med Self-Reported Rationing Behavior Among US Physicians: A National Survey Robert D. Sheeler Tim Mundell Samia A. Hurst Ph.D. 2 Susan Dorr Goold M.H.S.A. Bjorg Thorsteinsdottir Jon C. Tilburt M.P.H. 4 6 7 8 Marion Danis 0 Department of Family Medicine, Mayo Clinic , Rochester, MN , USA 1 University of Iowa , Iowa , USA 2 Institute for Ethics , History, and Humanities , University of Geneva , Geneva , Switzerland 3 Division of General Internal Medicine, Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical Center , Ann Arbor, MI , USA 4 Biomedical Ethics Program, Mayo Clinic , Rochester, MN , USA 5 Division of Primary Care Internal Medicine, Mayo Clinic , Rochester, MN , USA 6 Division of General Internal Medicine, Mayo Clinic , Rochester, MN , USA 7 Knowledge and Evaluation Research Unit, Mayo Clinic , Rochester, MN , USA 8 Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, MN , USA 9 Department of Bioethics, National Institutes of Health , Bethesda, MD , USA BACKGROUND: Rationing is a controversial topic among US physicians. Understanding their attitudes and behaviors around rationing may be essential to a more open and sensible professional discourse on this important but controversial topic. OBJECTIVE: To describe rationing behavior and associated factors among US physicians. DESIGN: Survey mailed to US physicians in 2012 to evaluate self-reported rationing behavior and variables related to this behavior. SETTING: US physicians across a full spectrum of practice settings. PA R T I C I PA N T S : A t o t a l o f 2 5 4 1 r e s p o n d e n t s , representing 65.6 % of the original mailing list of 3872 US addresses. INTERVENTIONS: The study was a cross-sectional analysis of physician attitudes and self-reported behaviors, with neutral language representations of the behaviors as well as an embedded experiment to test the influence of the word ?ration? on perceived responsibility. MAIN OUTCOME MEASURES: Overall percentage of respondents reporting rationing behavior in various contexts and assessment of attitudes toward rationing. KEY RESULTS: In total, 1348 respondents (53.1 %) reported having personally refrained within the past 6 months from using specific clinical services that would have provided the best patient care, because of health system cost. Prescription drugs (n = 1073 [48.3 %]) and magnetic resonance imaging (n = 922 [44.5 %]) were most frequently rationed. Surgical and procedural specialists were less likely to report rationing behavior (adjusted odds ratio [OR] [95 % CI], 0.8 [0.9-0.9] and 0.5 [0.4-0.6], respectively) compared to primary care. Compared with small or solo practices, those in medical school settings reported less rationing (adjusted OR [95 % CI], 0.4 AMA MRI OR cost; physician attitudes; physician behavior; rationing - [0.2?0.7]). Physicians who self-identified as very or somewhat liberal were significantly less likely to report rationing (adjusted OR [95 % CI], 0.7 [0.6?0.9]) than those selfreporting being very or somewhat conservative. A more positive opinion about rationing tended to align with greater odds of rationing. CONCLUSIONS: More than one-half of respondents engaged in behavior consistent with rationing. Practicing physicians in specific subgroups were more likely to report rationing behavior. Abbreviations INTRODUCTION Research has shown that physicians believe that they bear some responsibility for controlling health care costs, but tend to think that greater responsibility should be shouldered by others.1 Physicians have also more typically expressed the belief that they have a greater obligation to do whatever is needed for their patients than to be the primary agents for withholding health care resources for the sake of society.1,2 Studies have tended to focus more on physician attitudes regarding allocation of costly resources than on physician behavior. While attitudes might be a primary driver of behavior in clinical practice, this behavior may not be exclusively a function of a physician?s stated beliefs, particularly because these beliefs pertain to the sensitive topic of rationing. Little is known about self-reported rationing behavior among US physicians. The present paper describes self-reported behavior of a random sample of US physicians consistent with a behavioral definition of rationing, and analyzes its association with demographic and practice factors. We also report an experiment designed to test for empirical evidence of social desirability bias surrounding the term ?ration.? Finally, we compare selfreported rationing behavior to self-reported attitudes toward the appropriateness of rationing. METHODS This study was approved by the Mayo Clinic Institutional Review Board and the Office of Human Subjects Research Protections at the National Institutes of Health Clinical Center. Its methods have been described in detail elsewhere.1 Briefly, (...truncated)


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Robert D. Sheeler, Tim Mundell, Samia A. Hurst, Susan Dorr Goold, Bjorg Thorsteinsdottir, Jon C. Tilburt, Marion Danis. Self-Reported Rationing Behavior Among US Physicians: A National Survey, Journal of General Internal Medicine, 2016, pp. 1444-1451, Volume 31, Issue 12, DOI: 10.1007/s11606-016-3756-5