bedside 和 policy 之间的医疗资源分配差异。

Discrepancy between Health Care Rationing at the Bedside and Policy Level.

机构信息

Department of Management and Engineering, Division of Economics, Linköping University, Linköping, Sweden (EP, DA, LB, EJ, GT).

National Center for Priority Setting in Health Care, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden (TD, GT).

出版信息

Med Decis Making. 2018 Oct;38(7):881-887. doi: 10.1177/0272989X18793637. Epub 2018 Sep 10.

DOI:10.1177/0272989X18793637

PMID:30198412

Abstract

BACKGROUND

Whether doctors at the bedside level should be engaged in health care rationing is a controversial topic that has spurred much debate. From an empirical point of view, a key issue is whether there exists a behavioral difference between rationing at the bedside and policy level. Psychological theory suggests that we should indeed expect such a difference, but existing empirical evidence is inconclusive.

OBJECTIVE

To explore whether rationing decisions taken at the bedside level are different from rationing decisions taken at the policy level.

METHOD

Behavioral experiment where participants ( n = 573) made rationing decisions in hypothetical scenarios. Participants (medical and nonmedical students) were randomly assigned to either a bedside or a policy condition. Each scenario involved 1 decision, concerning either a life-saving medical treatment or a quality-of-life improving treatment. All scenarios were identical across the bedside and policy condition except for the level of decision making.

RESULTS

We found a discrepancy between health care rationing at policy and bedside level for scenarios involving life-saving decisions, where subjects rationed treatments to a greater extent at the policy level compared to bedside level (35.6% v. 29.3%, P = 0.001). Medical students were more likely to ration care compared to nonmedical students. Follow-up questions showed that bedside rationing was more emotionally burdensome than rationing at the policy level, indicating that psychological factors likely play a key role in explaining the observed behavioral differences. We found no difference in rationing between bedside and policy level for quality-of-life improving treatments (54.6% v. 55.7%, P = 0.507).

CONCLUSIONS

Our results indicate a robust "bedside effect" in the life-saving domain of health care rationing decisions, thereby adding new insights to the understanding of the malleability of preferences related to resource allocation.

摘要

背景

医生是否应该参与医疗资源配置是一个有争议的话题，引发了广泛的讨论。从经验的角度来看，一个关键问题是床边和政策层面的资源配置是否存在行为差异。心理学理论表明，我们确实应该期望存在这种差异，但现有的经验证据尚无定论。

目的

探讨床边层面的资源配置决策是否与政策层面的资源配置决策存在差异。

方法

采用行为实验的方法，让参与者（n=573）在假设情境中做出资源配置决策。参与者（医学生和非医学生）被随机分配到床边组或政策组。每个情境涉及 1 个决策，涉及挽救生命的医疗治疗或提高生活质量的治疗。除决策级别外，床边组和政策组的所有情境均相同。

结果

我们发现，在涉及挽救生命的决策的卫生保健资源配置中，政策层面和床边层面之间存在差异，与床边层面相比，政策层面的治疗分配更为严格（35.6%比 29.3%，P=0.001）。医学生比非医学生更有可能进行护理配给。后续问题表明，床边配给比政策层面的配给更具情感负担，表明心理因素可能在解释观察到的行为差异方面发挥关键作用。我们没有发现床边和政策层面的生活质量改善治疗之间的配给差异（54.6%比 55.7%，P=0.507）。