Bedside rationing is reported by physicians in all European countries studied. Physicians who personally agree with rationing, perceive more pressure to ration, and perceive more scarcity are more likely to report rationing. The interventions reported as being rationed the most frequently are personal time spent with patients, MRI, screening tests, lab tests, and prescription drugs. Although the most frequently mentioned criteria were a small expected benefit, and low chances of success, a majority of respondents also reported being more likely to refrain from using an intervention if the patient was over age 85.
Our study has several limitations. Using self-reports may have led to an underestimation of actual bedside rationing given its controversial nature. Additionally, self-reports will only capture instances of rationing of which practitioners are aware. Moreover, information gathered in the survey about withheld services did not include details regarding the particular circumstances. Cases where physicians may have reassessed medical indications so they are better aligned to match available resources are thus excluded. As we only surveyed general physicians, generalizations to other medical specialties, or to other health care systems should be cautious. Finally, the response rate was modest, as is often the case for physicians35
and questionnaires addressing sensitive topics.34
Nonrespondent bias is most likely to be associated either with lack of time, which we would expect yields an underestimation of the rationing of time, or with lack of interest in the topic, which we would expect to yield an overestimation of reported rationing of interventions. Reluctance to report a controversial practice could also have led to underreporting of bedside rationing. However, extrapolating our results to a response rate of 100%, and considering all nonrespondents to report no rationing results in a percentage of physicians reporting rationing of interventions of 23%. One concern could be that the associations between variables could be affected by nonresponse bias. Variables independently associated with reported rationing were perceived scarcity, pressure to ration, agreement with rationing, and country of practice. If nonresponse were due primarily to lack of interest in the topic, then we could expect overestimation of pressure to ration. As this would also likely be associated with overestimation of reported rationing, however, the association between these 2 variables may not be affected.
Our results complement studies that have examined clinical rationing such as nonreferral to dialysis.25,26
While it has been suggested that physicians often deny scarcity,36
our findings indicate that physicians are aware of personally denying some modicum of benefit to their patients. These findings will need to be supplemented with additional data gathered from sources such as medical records and administrative data sets. However, despite the exploratory nature of this study, our results raise a number of intriguing points.
We found significant differences between countries regarding the frequency of reported rationing. While one might expect that physicians in countries that spend more money per capita would report rationing less, this does not appear to be the case. Physicians in Switzerland, where the most is spent, report the most rationing. One plausible explanation is that, when more leeway is left to physicians by the structure of their health care system, a larger share of the responsibility for rationing falls to them. Thus, they may indeed more often “personally refrain from using interventions,” which a more rule-bound system would simply not have given them the discretion to use. Whether more leeway for clinical decisions regarding rationing is a favorable arrangement depends upon judgments about where rationing decisions ought to take place and upon clinical outcomes that we did not measure here. Moreover, we cannot know precisely all the factors that dictate the reported frequency of rationing. In addition to scarcity, or to agreement with rationing, it could also be a function of how often the clinical need arises.
This study has several implications. First, our results suggest an interaction between resource allocation at the levels of health care systems and individual provivders. This interaction may occur at various levels of health care organization including national and more local levels. The literature on practice variation shows that the availability of resources such as hospital and ICU beds varies geographically within a country and that utilization rates parallel this availability.37
Our finding that physicians's self-reports of rationing correlate with their perception of scarcity helps to provide an insight into this relationship. At a national level, we found that Italy, the country with the highest number of physicians per 1,000 population,38
is also where our respondents reported the least rationing of time. This suggests that manpower allocation decisions at the system level, whether intentionally or otherwise, impact reported bedside rationing.
Second, it seems that both health care systems that are more centralized, as exemplified by the United Kingdom, and those that are more market based, as exemplified by Switzerland,39
include clinical rationing behavior, as judged by physician self-reports. Of what interest might the findings in this study be to practitioners and patients in the United States where rationing is often thought to be driven by inability to pay due to uninsurance40
or by insurance coverage rules?41
While expansion of insurance may reduce inequities in access to care, it will not eliminate rationing. One can only hope that the pattern of rationing might be fairer. In this regard, this study is aimed at providing initial insights that may yield fair rationing strategies.
Overall, our study indicates that bedside rationing is ubiquitous but its extent and patterns vary with system-wide factors. Those who consider bedside rationing by physicians to be ethically unacceptable can glean from our findings that it would be prudent to promote aspects of any health care delivery systems that reduce pressure for physicians to take responsibility personally for the cost of care. But they might also be reassured by the finding that those interventions that are reportedly rationed involve nonvital benefits and interventions for which there are clinical alternatives.
While it is reassuring to see so few physicians report rationing based on poverty, criteria such as a patient's work status may suggest worrisome practices. While rationing criteria such as cognitive impairement may be viewed as discriminatory, they may, alternatively, reflect concerns for quality of life that are shared by patients and their families. In sum, physicians report a range of criteria for forgoing medical interventions that appear to be more and less equitable. These findings highlight the need for a more detailed attention both to the factors that do and to those that should influence rationing decisions. Given the prevalence of rationing, the public may be well served by more explicit discussion of how best to ration care at the bedside in an ethically justifiable manner. The concepts and skills required for fair rationing would also need to be included in medical curricula, which typically do not currently include such training.