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Physicians' views on resource availability and equity in four European health care systems

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Background In response to limited resources, health care systems have adopted diverse cost-containment strategies and give priority to differing types of interventions. The perception of physicians, who witness the effects of these strategies, may
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  BioMed   Central Page 1 of 11 (page number not for citation purposes) BMC Health Services Research Open Access Research article Physicians' views on resource availability and equity in four European health care systems SamiaAHurst  1 , ReidunForde 2 , StellaReiter-Theil 3 , Anne-MarieSlowther  4 , ArnaudPerrier  5 , RenzoPegoraro 6 and MarionDanis* 7  Address: 1 Institute for Biomedical Ethics, Geneva University Medical School, Switzerland, 2  The Research Institute, Norwegian Medical Associationand University of Oslo, Norway, 3 Institute for Applied Ethics and Medical Ethics, University of Basel, Switzerland, 4  The Ethox Centre, OxfordUniversity, Headington, UK, 5 General Internal Medicine Service, Geneva University Hospital, Geneva, Switzerland, 6 Fondazione Lanza, Padova,Italy and 7 National Institutes of Health, Bethesda, MD, USA Email: SamiaAHurst-samia.hurst@medecine.unige.ch; ReidunForde-reidun.forde@legeforeningen.no; StellaReiter-Theil-s.reiter-theil@unibas.ch; Anne-MarieSlowther-anne-marie.slowther@ethox.ox.ac.uk; ArnaudPerrier-Arnaud.Perrier@medecine.unige.ch;RenzoPegoraro-info@fondazionelanza.it; MarionDanis*-mdanis@cc.nih.gov * Corresponding author  Abstract Background: In response to limited resources, health care systems have adopted diverse cost-containment strategies and give priority to differing types of interventions. The perception of physicians, who witness the effects of these strategies, may provide useful insights regarding theimpact of system-wide priority setting on access to care. Methods: We conducted a cross-sectional survey to ascertain generalist physicians' perspectiveson resources allocation and its consequences in Norway, Switzerland, Italy and the UK. Results: Survey respondents (N = 656, response rate 43%) ranged in age from 28–82, andaveraged 25 years in practice. Most respondents (87.7%) perceived some resources as scarce, withthe most restrictive being: access to nursing home, mental health services, referral to a specialist,and rehabilitation for stroke. Respondents attributed adverse outcomes to scarcity, and somerespondents had encountered severe adverse events such as death or permanent disability. Despiteuniversal coverage, 45.6% of respondents reported instances of underinsurance. Most respondents(78.7%) also reported some patient groups as more likely than others to be denied beneficial careon the basis of cost. Almost all respondents (97.3%) found at least one cost-containment policyacceptable. The types of policies preferred suggest that respondents are willing to participate incost-containment, and do not want to be guided by administrative rules (11.2%) or restrictions onhospital beds (10.7%). Conclusion: Physician reports can provide an indication of how organizational factors may affectavailability and equity of health care services. Physicians are willing to participate in cost-containment decisions, rather than be guided by administrative rules. Tools should be developedto enable physicians, who are in a unique position to observe unequal access or discrimination intheir health care environment, to address these issues in a more targeted way. Published: 31 August 2007 BMC Health Services Research 2007, 7 :137doi:10.1186/1472-6963-7-137Received: 4 December 2006Accepted: 31 August 2007This article is available from: http://www.biomedcentral.com/1472-6963/7/137© 2007 Hurst et al; licensee BioMed Central Ltd.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),which permits unrestricted use, distribution, and reproduction in any medium, provided the srcinal work is properly cited.  BMC Health Services Research 2007, 7 :137http://www.biomedcentral.com/1472-6963/7/137Page 2 of 11 (page number not for citation purposes) Background Limited resources are a reality to which health care sys-tems respond in very different ways. As physicians areconfronted with scarcity and with the effects of cost-con-tainment policies on clinical practice, they occupy aunique position from which to observe the impact of pri-orities set by health care systems.Contradictory data exist as to whether physicians areaware of facing scarcity. In The Painful Prescription: Ration-ing Hospital Care , Aaron and Schwartz noted that Britishphysicians rationalized, or redefined health care stand-ards to face scarcity more comfortably. [1] Twenty yearslater, researchers conducting interviews with physiciansregarding scarcity reported being struck with the strength with which scarcity was denied. [2] US general internists,intensive care specialists, and oncologists, however, doreport difficulties explicitly associated with resource scar-city. [3] Data suggest that physicians accept prioritizationdecisions, both when faced with hypotheotical scenarios,[4-13] and when reporting on their practice. [3,14-16] Physicians at the point of care are uniquely situated toobserve the impact of priority setting decisions onpatients in the form of scarcity, or less than equitable care. Their experience may thus yield useful insights and feed-back about the impact of priorities on clinical care, whichcould contribute to evidence-based health policy. [17]Despite this, insufficient attention is paid to their experi-ence. To examine the perceptions and attitudes of physiciansregarding resource allocation in the European context, weconducted a three-part international survey of generalphysicians in Italy, Norway, Switzerland, and the UK.Results from the two other parts of this survey have beenreported elsewhere. [16,18] In this paper, we report phy-sicians' perception regarding lack of resource availability in their health care system and its adverse effects, their  views regarding the equity of their health care system, andtheir attitudes towards various cost-containment policies. Methods Participants General physicians were identified through the 2002 offi-cial list of the Norwegian Medical Association, the SwissMedical Association, published listings of UK generalpractitioners and general physicians, and regional listingsof Italian general practitioners and members of the ItalianSociety of Internal Medicine. A random sample of 400individuals was drawn in each country in proportions of general practitioners and general internists reflecting that of each national physician population. This sample waschosen to capture similar physician populations, who dothe same kind of work in general internal medicine, inboth in- and outpatient care. We chose four Europeancountries offering universal access to health care through very different systems, with per capita expenditure onhealth care ranging from $3,322 in Switzerland to $1,989in the UK (2002 US $). Despite differences in structureand health care expenditure, the health care systems of allfour countries received similar evaluations regarding fair-ness of financial contribution to the health system anddistribution of responsiveness in the WHO world healthreport of 2000 (Table1). Survey methods  We developed a survey instrument to explore general phy-sicians' perception of scarcity and rationing both at thesystem-wide level, through resource unavailability, and inclinical practice, through bedside rationing. Whenever possible, we used validated items from other studies pub-lished in the literature [14,15,19,20]. This included items relating to agreement with various cost-containment pol-icies [14]. New items were independently rated by twoethicists with relevant expertise. The questionnaire was Table 1: Four Health Care Systems: WHO and OECD data Per capita expenditure onhealth care a ItalyNorwaySwitzerlandUK  Total (2002 US $)2,1663,4093,4462,160Public (2002 US $)1,6392,8451,9951,801Out of pocket (2002 US$)4405461,085200 Proportion of expenditureon health care a Social security0.1%0%40%0%Other public75.5%83.5%17.9%83.4%Pre-paid plan1%0%9.6%3%Out of pocket20.3%16%31.4%9.2%Other private3%0.5%1.4%4.3% Beds, physicians, nurses b Acute care beds/1000 p.3.73.13.93.7Nursing home beds/1000 p.2.79.111.63.1Nurses/1000 pop.5.410.410.79.7Physicians/1000 pop.4.13.43.72.2 Elements of health policy  Universal coverageYesYesYesYesFreedom to choose generalphysicianYesYesYesNoGatekeeping for specialistconsultationYesYesNoYes WHO assessment of equity  c  Fairness of financialcontribution to health system0.9610.9770.9640.977Distribution of responsiveness0.9950.9950.9950.995a WHO 2002 country information [40]b OECD 2003 country information [33]c WHO 2000 World health report [41]  BMC Health Services Research 2007, 7 :137http://www.biomedcentral.com/1472-6963/7/137Page 3 of 11 (page number not for citation purposes) refined following their comments and piloted on 96 phy-sicians in the US, the UK, and Switzerland. Each scale wastested for internal consistency on the pilot sample, andagain on the complete sample. Survey development wasfurther described elsewhere [16]. A Perceived scarcity scale assessed resource unavailability  was worded as follows: "During the last 6 months, how often were you unable to obtain the following services for  your patients when you thought they were necessary (thisincludes unacceptable waiting times)?". It was based onitems worded as shown in Figure1. Response options were: never or not applicable (0), less than once a month(1), monthly (2), weekly (3), and daily (4). Scale range was 0–44. Internal consistency was good with a Crohn-bach's alpha of 0.84, range was 0–44 We also askedrespondents about pressure to ration and underinsuranceusing the following items: "In the last six months, how often have you felt under pressure to deny an expensiveintervention that you thought was indicated? ", and "Inthe last six months, how often have you found in your  work that patients have problems that cannot be treatedbecause they cannot afford their share of the costs?". These items used the same response options as the per-ceived scarcity scale.Physicians' experience regarding adverse effects of scarcity  was explored using items worded as follows: "In the last six months, how often have you seen a situation where apatient suffered adverse consequences as a result of lim-ited resources in the health care system?". This item usedthe same response options as the perceived scarcity scale. A follow-up item asked: "What is the most severe adverseconsequence you have seen as a result of limited resourcesin the health care system?". Response options were:inconvenience, temporary disability, permanent disabil-ity, an acute life-threatening event, death, or none. A Perceived equity scale (Cronbach's alpha 0.78, range 3–15) was based on items worded as shown in table2.Responses were on a 5 point Likert scale ranging from"strongly agree" (5) to "strongly disagree" (1). A Perceiveddiscrimination index was worded as shown in Figure2.Response options were "yes" or" no".Physicians' attitudes towards cost-containment policies were explored using the items shown in Figure3.Responses were on a 5 point Likert scale ranging from"not at all acceptable" (1) to "very acceptable" (5), withan additional option of "I have no experience with this". We also gathered demographic information about respondents and their practice environment.Participants were contacted by mail, and told about theaims of the study in a cover letter. Questionnaires wereself-administered by the respondents. To maximizeresponse rate, cover letters were addressed by localresearchers affiliated with universities in the respondents'country. A repeat mailing was sent, including an addi-tional copy of the questionnaire, and an incentive of  € 10,or the closest equivalent in local currency that could beenclosed as a single bill [21]. Questionnaires were mailedto 1600 physicians. Data collection was open from Febru-ary 2003 to June 2004. Human subjects protection Participation was voluntary and responses were madeanonymous before analysis. Approval was given by theIRB of the National Institute of Child Health and Devel-opment at the US National Institutes of Health, and by the Trent Multi-Centre Research Ethics Committee in the UK. This study was examined and designated exempt fromethics committee review by IRBs in Norway, Italy, andSwitzerland. Statistical analysis Data were analyzed using descriptive statistics, and bivar-iate correlations were analyzed using Pearson Chi-square,Mann-Whitney, or Kruskall-Wallis tests as appropriate. We selected a significance level of 0.01 (two-tailed).Logistic regression was used to identify variables inde-pendently associated with perceived scarcity, perceivedequity, and perceived discrimination. The models werebuilt using the variables that were found to be associated with these in bivariate analysis. We chose individualrespondents, rather than countries, as our unit of analysis. This was based on the literature on practice variation, which shows availability of resources and utilization ratesto vary geographically within a country [22], including inmost of the countries we surveyed [23-25]. Consequently,  we made the assumption of multiple micro-environments within countries, and chose individual respondents asmore likely to reflect these multiple environments in our analysis. Results Respondents Respondents, (N = 656, 43% of eligible sample) ranged inage from 28–82, and were predominantly male (85%), with the percentage of women ranging from 42.1% under the age of thirty to 7.8% from 61 to 70 years of age. Theaverage length of time in practice was 25 years, and 38.4% were at least partly hospital-based. (Table3)Respondents from different countries reported signifi-cantly different population density in their practice envi-ronments with the greatest percentage of physicians  BMC Health Services Research 2007, 7 :137http://www.biomedcentral.com/1472-6963/7/137Page 4 of 11 (page number not for citation purposes) reporting rural environments in Norway (29%), and morereporting urban settings in Italy (49%) and the UK (38%)(p < 0.001). Maximum working hours in outpatient careranged from 44 in Italy to 80 in Norway and Switzerland.(Table2) Median number of patients seen in clinic, and waiting time for appointments, also differed significantly between the four surveyed countries. Maximum working hours in inpatient care ranged from 50 in Norway, to 100in the UK. Scarcity   The vast majority of respondents (87.7%) perceived someresources as sometimes unavailable, with the most prom-inent being: access to nursing home, mental health serv-ices, referral to a specialist, referral to surgery, and Table 3: Respondent characteristics Physicians (N = 656)Characteristics Age, years28–82 (mean 51)Years in practice1–62 (mean 25)Male546 (85%)SpecialtyFamily medicine195 (30%)General medicine188 (29%)Internal medicine179 (28%)Country of practiceItaly139 (21%)Norway222 (34%)Switzerland183 (28%)UK112 (17%)Primary practice siteHospital258 (38%)Solo practice182 (28%)Primary care group practice164 (25%)Multi-specialty group23 (4%)Other28 (4%)Admitting hospitalPublic572 (94%)Private21 (3%)For-profit81 (17%)Not-for-profit406 (82%)Teaching hospital264 (46%)Numbers in parentheses are percentages of the sample shown exclusive of missing data, and rounded to the nearest whole number Table 2: Four Health Care Systems: survey responses Outpatient care ItalyNorwaySwitzerlandUK  Hours a week* (median, range)12 (2–44)33 (1–80)40 (2–80)12 (1–56)Number of patients in half a day in clinic* (median,range)11 (1–30)10 (1–50)12 (1–30)15 (4–50)Waiting time for an appointment* (median)Within a weekWithin two weeksNext dayWithin a month Inpatient care Hours a week* (median, range)35 (8–60)20 (1–50)14 (1–60)24 (1–100)Number of inpatients cared for at one time (median,range)18 (3–150)15 (2–82)15 (1–270)20 (1–85) Health system equityAgree or Strongly agree I am given enough means to treat my patients fairly *65%73%81%29%Health resources in my country are distributed fairly*35%39%69%21%Everyone in my country has equal access to neededmedical services*50%36%59%11%*Kruskall-Wallis: p < 0.01; null hypothesis is "no difference"  BMC Health Services Research 2007, 7 :137http://www.biomedcentral.com/1472-6963/7/137Page 5 of 11 (page number not for citation purposes) Limited resources Figure 1Limited resources . During the last six months, how often were you unable to obtain the following services for your patientswhen you thought they were necessary (this includes unacceptable waiting times)?. Panel A: Percentage of respondents who reported unavailability of resources . ‡Chi-square: p < 0.01; null hypothesis is "no difference". Panel B: mean fre-quency of reported unavailability of resources . 0 = "never", 1 = "less than once a month", 2 = "once a month", 3 ="weekly", 4 = "daily". *Kruskall-Wallis: p < 0.01; null hypothesis is "no difference".
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