Stumpf S, Hecker S, Raspe H
Seniorprofessur für Bevölkerungsmedizin, Universität zu Lübeck.
Gesundheitswesen. 2014 Apr;76(4):221-31. doi: 10.1055/s-0033-1347267. Epub 2013 Aug 2.
In Germany, in contrast to many foreign countries, scientists and medical professionals have been discussing prioritisation in medicine almost without consulting German citizens. We address the question of what questionnaire surveys can contribute to the understanding of citizens' attitudes towards prioritisation - with a focus on some difficulties and challenges of the method.
We conducted a postal survey with a random sample of 3 000 residents of the City of Lübeck (age ≥18). Respondents were asked to appraise different substantial and procedural criteria for prioritisation in medicine. In addition to descriptive statistical analyses, logistical regression models were performed to identify potential explanatory variables for the appraisal of prioritisation criteria.
The response rate was 45.6% (N=1 363). Some prioritisation criteria are accepted by the majority: severity of disease, effectiveness of an intervention and a firm evidence base. Other criteria were appraised controversially: personal life-style, responsibility for family members and general prioritisation of children. A patient's responsibility in society and age as well as an intervention's cost-benefit ratio were generally rejected. The results of logistic regression analyses showed some significant but minor effects of demographic and health-related variables. The citizens in our study want decision-making procedures in health care to be transparent and equally applied to all patients. According to the survey respondents decisions about the catalogue of services of Germany's statutory health insurance should mainly be made by doctors. The statutory health insurance as well as patients and scientists also should take part in the decision-making procedure.
Comparing our results to those of a national interview survey reveals some relevant differences: The respondents' assessment of some substantial criteria seems to vary according to the contextualisation and wording of the items. We found less difference - but still some inconsistent results - in the participants' appraisal of potential decision-makers in health care. To our surprise, the logistic regression models including standard demographic and health-related variables account for only a small proportion of the variance of all dependent variables.
Our discussion emphasises some difficulties and challenges of questionnaire surveys on prioritisation criteria - reflecting on the state of the German debate on prioritisation. There has been hardly any public discussion on this issue prior to our survey in autumn 2009. It is thus unlikely that people have been able to state well-informed preferences. Instead they seem to have followed some kind of "social reflexes" depending on the context and wording of each item. Subsequent studies on preferences and priorities should (i) more closely assess the understanding of each item in advance and (ii) adapt the aims of their study and its methodology to the actual stage of the public discourse on the topic in question.
在德国，与许多其他国家不同，科学家和医学专业人员在讨论医学中的优先排序时几乎没有咨询德国公民的意见。我们探讨问卷调查对于理解公民对优先排序的态度能有什么贡献——重点关注该方法的一些困难和挑战。
我们对吕贝克市3000名居民（年龄≥18岁）进行了随机抽样的邮寄调查。受访者被要求评估医学中优先排序的不同实质和程序标准。除了描述性统计分析外，还进行了逻辑回归模型分析，以确定评估优先排序标准的潜在解释变量。
回复率为45.6%（N = 1363）。一些优先排序标准被大多数人接受：疾病严重程度、干预措施的有效性和坚实的证据基础。其他标准则存在争议：个人生活方式、对家庭成员的责任以及儿童的总体优先排序。患者在社会中的责任、年龄以及干预措施的成本效益比通常被拒绝。逻辑回归分析结果显示，人口统计学和健康相关变量有一些显著但较小的影响。我们研究中的公民希望医疗保健决策程序透明且平等适用于所有患者。根据调查受访者的意见，德国法定医疗保险服务目录的决策应主要由医生做出。法定医疗保险以及患者和科学家也应参与决策程序。
将我们的结果与全国性访谈调查的结果进行比较，发现了一些相关差异：受访者对一些实质标准的评估似乎因项目的背景和措辞而异。我们发现参与者对医疗保健潜在决策者的评估差异较小——但仍有一些不一致的结果。令我们惊讶的是，包含标准人口统计学和健康相关变量的逻辑回归模型仅解释了所有因变量方差的一小部分。
我们的讨论强调了关于优先排序标准的问卷调查的一些困难和挑战——反映了德国关于优先排序的辩论状况。在我们2009年秋季调查之前，几乎没有关于这个问题的公开讨论。因此，人们不太可能能够陈述出明智的偏好。相反，他们似乎根据每个项目的背景和措辞遵循了某种“社会反应”。后续关于偏好和优先事项的研究应该（i）提前更密切地评估对每个项目的理解，以及（ii）使其研究目的及其方法适应关于该问题的公共话语的实际阶段。
