Abstract
BackgroundHealthcare rationing can be defined as withholding beneficial care for cost reasons. One form in particular, hidden bedside rationing, is problematic because it may result in conflicting loyalties for physicians, unfair inequality among patients and illegitimate distribution of resources. Our aim is to establish whether bedside rationing occurs in the Netherlands, whether it qualifies as hidden and what physician characteristics are associated with its practice.MethodsCross-sectional online questionnaire on knowledge of -, experience with -, and opinion on rationing among physicians in internal medicine within the Dutch healthcare system. Multivariable ordinal logistic regression was used to explore relations between hidden bedside rationing and physician characteristics.ResultsThe survey was distributed among 1139 physicians across 11 hospitals with a response rate of 18% (n = 203). Most participants (n = 129; 64%) had experience prescribing a cheaper course of treatment while a more effective but more expensive alternative was available, suggesting bedside rationing. Subsequently, 32 (24%) participants never disclosed this decision to their patient, qualifying it as hidden. The majority of participants (n = 153; 75%) rarely discussed treatment cost. Employment at an academic hospital was independently associated with more bedside rationing (OR = 17 95%CI 6.1–48). Furthermore, residents were more likely to disclose rationing to their patients than internists (OR = 3.2, 95%CI 2.1–4.7), while salaried physicians were less likely to do so than physicians in private practice (OR = 0.5, 95%CI 0.4–0.8).ConclusionHidden bedside rationing occurs in the Netherlands: patient choice is on occasion limited with costs as rationale and this is not always disclosed. To what extent distribution of healthcare should include bedside rationing in the Netherlands, or any other country, remains up for debate.
Highlights
Healthcare rationing can be defined as withholding beneficial care for cost reasons
Residents are more likely to disclose bedside rationing decisions to their patients than internists while salaried physicians are less likely to do so than physicians who are in private practice
Our study indicates that hidden bedside rationing occurs in the Netherlands
Summary
Healthcare rationing can be defined as withholding beneficial care for cost reasons. Bedside rationing has been defined as ‘the withholding by a physician of a medically beneficial service because of that service’s cost to someone other than the patient’ [5, 7]. Ubel and Goold have proposed three conditions by which to define bedside rationing: “a physician must (1) withhold, withdraw, or fail to recommend a service that, in the physician’s best clinical judgment, is in the patient’s best medical interests; (2) act primarily to promote the financial interests of someone other than the patient (including an organisation, society at large, and the physician himself or herself); and (3) have control over the use of the medically beneficial service” [5, 7]. When bedside rationing is done without revealing the decision to ration or its rationale to the patient, it qualifies as hidden bedside rationing [2, 8]
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