Elsevier

Health Policy

Volume 90, Issues 2–3, May 2009, Pages 113-124
Health Policy

Review
Are physicians willing to ration health care? Conflicting findings in a systematic review of survey research

https://doi.org/10.1016/j.healthpol.2008.10.013Get rights and content

Abstract

Background

Several quantitative surveys have been conducted internationally to gather empirical information about physicians’ general attitudes towards health care rationing. Are physicians ready to accept and implement rationing, or are they rather reluctant? Do they prefer implicit bedside rationing that allows the physician–patient relationship broad leeway in individual decisions? Or do physicians prefer strategies that apply explicit criteria and rules?

Objectives

To analyse the range of survey findings on rationing. To discuss differences in response patterns. To provide recommendations for the enhancement of transparency and systematic conduct in reviewing survey literature.

Methods

A systematic search was performed for all English and non-English language references using CINAHL, EMBASE, and MEDLINE. Three blinded experts independently evaluated title and abstract of each reference. Survey items were extracted that match with: (i) willingness to ration health care or (ii) preferences for different rationing strategies.

Results

16 studies were eventually included in the systematic review. Percentages of respondents willing to accept rationing ranged from 94% to 9%.

Conclusions

The conflicting findings among studies illustrate important ambivalence in physicians that has several implications for health policy. Moreover, this review highlights the importance to interpret survey findings in context of the results of all previous relevant studies.

Section snippets

Background

Health care rationing, here understood as withholding beneficial interventions for cost reasons, occur at all levels in all health care systems around the world. Countries with very different health care systems and levels of health care spending all grapple with the challenge of reconciling a steadily increasing demand for health care services with limited or even declining financial resources. If health care rationing is inevitable, it must be done fairly and efficiently. Several approaches

Search strategy

We performed a systematic literature search using CINAHL (1982–December 2007), EMBASE (1988–December 2007), and MEDLINE (1966–December 2007). No time or language restrictions were applied. The keyword catalogue and indexing of articles differ considerably from database to database. This was of special importance in our case because the search algorithms had to reflect a broad review question including three core search terms: (1) quantitative survey research, (2) physicians as participants, and

Selection of studies

The systematic literature search yielded 557 references, of which 15 were eventually included in the systematic review after relevance assessment (see Table 1) [13], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29]. Cronbach's alpha was 0.91.

Characteristics and quality of selected studies

The 15 studies were conducted in 8 different countries (Canada, Italy, The Netherlands, Norway, Sweden, Switzerland, the United Kingdom, and the United States of America). Altogether, the studies included 10,921

Discussion

At first sight, an average score (mean) of 60.6% of general willingness to ration health care among physicians could indicate that there is substantial willingness to consider cost and efficiency data in addition to effectiveness data and patient preferences, when making medical decisions. The average score of 60.7% and 39.7% for acceptance of more specific strategies of rationing indicate that willingness to ration health care decreases when rationing is seen in practice. However, due to the

Acknowledgements

Funding: Supported in part by grant 01GP0608 from the German Federal Ministry of Education and Research and a grant for Daniel Strech from the German Academic Exchange Service.

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