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Bedside Treatment Decisions: an Evaluation of the Factors Physicians Take Into Consideration When Making Complex Rationing Decisions

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Bedside Treatment Decisions: an Evaluation of the Factors Physicians Take Into Consideration When Making Complex Rationing Decisions Journal of Medical Psychology 22 (2020) 11–19 11 DOI 10.3233/JMP-170005 IOS Press Research Report Bedside Treatment Decisions: An Evaluation of the Factors Physicians Take into Consideration When Making Complex Rationing Decisions Judith Trarbach∗, Stephan Schosser and Bodo Vogt Department of Empirical and Health Economics, Otto-von-Guericke-Universit¨at Magdeburg, Magdeburg, Germany Abstract. Background: The budget limitations that are imposed on health care providers often force caregivers to become rationers, and physicians are required to select which patients receive treatments and which go without on a daily basis. This involves making highly complex decisions, and physicians are required to evaluate both relevant and irrelevant parameters to ensure the final decision is sound. Objective: This research examined which of seven parameters physicians used to make rational decisions as to which of a group of five patients in need received treatment. Method: An experiment was conducted in which the decision relevance of objective parameters and additional information about the needy, such as gender or smoking habits, were investigated. Results and conclusion: The findings indicated that physicians focus on central disease-related criteria very well and, thus, arrive at a comprehensive rationing decision, even in complex situations. Keywords: Complexity, decision-making, rationing, resource allocation INTRODUCTION and rationing. On a macro level, prioritization and rationing are often determined by politics; for exam- Health care systems all over the world have the ple, specific services are openly excluded from fund- same target: To provide people with access to the ing or more patients are allocated to a given hospital. essential health care services they need. For various As such, in most cases, a transparent and distinct pro- reasons, including the availability of new expensive cess is in place. However, prioritization and rationing treatment options and the aging population of soci- decisions are more complicated on a micro level in eties, health care resources are becoming increasingly that the caregiving physician is required to make bed- scarce. This problem results in questions emerging as side decisions relating to aspects such as how much to who should be treated, which patients have prior- time to spend with each patient and when to prescribe ity, and which therapy is adequate; i.e., prioritization or withhold an expensive therapy [1]. Accordingly, ∗ this decision-making process is much less transpar- Correspondence to: Judith Trarbach, Department of Empir- ical and Health Economics, Otto-von-Guericke-Universitat¨ Mag- ent, and different interests can have an influence on deburg, Magdeburg, Germany. E-mail: [email protected]. the choices that are made; for example, the physician ISSN 2468-3884/20/$35.00 © 2020 – IOS Press and the authors. All rights reserved This article is published online with Open Access and distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC 4.0). 12 J. Trarbach et al. / Bedside Treatment Decisions may make decisions that aim to save money for the perceive to be decision relevant. Thus, these studies hospital he is working for, i.e., to release a patient do not provide insights into real decision-making from hospital earlier, maximize his own earnings in behavior as applied to real situations in which situations in which he is compensated for every single individuals are in need. surgery he performs, and/or eradicate or reduce the This study aimed to complement the existing stud- suffering of his patients and enhance their quality of ies using an experimental approach; a method that life by implementing the most appropriate, yet most remains lacking in the related literature [7]. There- complex and expensive, treatment [2]. fore, in our laboratory, we arranged real decision However, it is not just these varying interests situations in which one physician decided which of that make physicians’ day-to-day decision-making five patients in need would receive treatment. The processes complex. To arrive at a valid diagno- research question was as follows: When available sis and treatment plan, they must consider various treatment resources are limited, which individual information, parameters, and aspects concerning the attributes do physicians take into consideration to condition of the individual being treated. The more arrive at a rationing decision? holistically physicians observe all facets, the more probable it is that they will ultimately take actions METHOD that result in the patient achieving the best level of care. However, in addition to ensuring all relevant Experimental design aspects are taken into consideration, it is also essential that physicians make sure that any information that The task is not relevant to the treatment process is ignored to Sixteen physicians with a minimum of 6 months avoid any specific groups being discriminated against work experience in a hospital participated in this or unfairly treated [1]. Consequently, rationing care research, and each one was allocated to a group of at the bedside involves a complex decision-making five subjects (henceforth patients). A pain dose was process that requires maximal attention and contin- randomly allocated to each patient; i.e., the param- uous reflection on self-leading motives and decision eters of the cold pressor test (cp. Paragraph on pain patterns. induction): water temperature and hand immersion In the literature presented so far, various poten- duration. These doses varied for every patient. In tial prioritization and rationing criteria have been addition, we randomly allocated treatment costs to discussed. Objective criteria especially presented every patient. The physician was allocated a fixed to medical staff for example concern medical or budget of five Euros, which he was free to invest in sociodemographic aspects. Also included are valu- treatments for the patients awaiting pain as he saw ing criteria. Participants here evaluate the relevance fit. The allocation was realized with an algorithm that of compliance, social contribution and self-infliction ensured that, with his restricted budget, the physician [1, 6]. Further studies work with participants with- could treat i. e. select up to three or four patients, but out medical expertise [3–5]. Presented criteria also never all of them (cp. Tab. 2b). Treatment costs were include objective aspects such as severity of dis- not linearly related to pain doses because, in reality, ease and anticipated health state after treatment. there is not necessarily a positive correlation between However, subjects refused valuing criteria such as the severity of the pain and the cost of the treatment. socio-economic status, age, social responsibility or In addition, the budgets that were available to treat a positive cost-utility-ration. Summing up, opin- the patients were not related to the final payment the ions of the relevance of socio-economic differences physicians received for participating in the experi- strongly varied across the people who were ques- ment. This was purposely designed to replicate the tioned. However, this could be attributed to the fact standard payment system that is in use in the majority that the authors of these studies implemented differ- of public hospitals, where the monthly salary is fixed, ent methods, including discrete choice experiments irrelevant of the number of patients treated or perfor- and interviews, as part of the research process. mance against budget. Accordingly, any remaining Despite the differences in methodologies emplo- credit expired. yed, the existing studies have typically involved methods that ask participants to either imagine them- Real consequences for decisions selves in the shoes of a physician who is required The experiment was designed to ensure that the to ration or to generally report which criteria they decisions the physicians made had real consequences. J. Trarbach et al. / Bedside Treatment Decisions 13 Table 1 Overview of previous studies that have investigated the application of prioritization criteria when making medical decisions Participants Relevant/ rejected criteria Method Reference for prioritization Care-givers Physicians Medical criteria Qualitative [1] interviews Cost-effectiveness Age Compliance Social contribution Physicians and Medical criteria Semistructured [6] nurses interviews Self-infliction of disease Sociodemographic criteria Samples without medical Students Healthy lifestyle Conjoint analysis [4] background Social class Life expectancy after treatment Quality of life after treatment General public Life threatening disease Rejected: Questionnaire, [3] Acute disease Socio-economic status Discrete choice experiment General public Severity of disease Rejected: Postal survey of [5] Treatment effectiveness random sample Age Social responsibility Positive cost-utility-ratio Table 2 a: Criteria that was available for rationing decisions (left), b: Examples of allocated costs to pain doses (right) Criteria Description Levels Allocation of costs (examples) Water temperature Randomly allocated to every participant at 4◦Celsius for 1 minute 0,80EUR 0,80EUR Immersion duration in the beginning of the experiment, coupled 4◦Celsius for 3 minutes 0,50EUR 1,00EUR cold water with immersion duration 7◦Celsius for 2 minutes 1,00EUR 2,00EUR 9◦Celsius for 2,5 minutes 1,30EUR 1,30EUR 12◦Celsius for 3 minute 4,50EUR 3,00EUR Costs to be treated Randomly allocated to
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