How can bedside rationing be justified despite coexisting inefficiency? The need for 'benchmarks of efficiency'

Psychometric testing of perceived implicit rationing of nursing care (PIRNCA)

AIMS

To evaluate the psychometric properties of the Perceived Implicit Rationing of Nursing Care (PIRNCA) instrument and to report the prevalence of rationed care at university and faculty hospitals.

DESIGN

A cross-sectional study.

METHODS

The study was carried out at two university and five faculty hospitals in the Slovak Republic. Participants were 895 Registered Nurses recruited by the purposive sampling method between December 2017-July 2018. Data were collected using the PIRNCA instrument. Construct validity and reliability of the instrument were tested.

RESULTS

The prevalence of rationed care at university and faculty hospitals was identified as being 42.1%. Furthermore, 87.6% of nurses reported rationing one or more nursing care activities. Using both statistical methods when evaluating the PIRNCA resulted in the confirmation that the tool is valid and reliable.

CONCLUSION

Rationed care is a common phenomenon at university and faculty hospitals. The PIRNCA is a suitable instrument to measure the phenomenon in adult acute care units because of its high reliability and validity. We recommend using the instrument in different contexts, not only for specific conditions that were presented for this study.

IMPACT

Rationed care at university and faculty hospitals has never been reported. Psychometric properties of the instrument that measures nurses´ perception of rationed care have never been evaluated by using different approaches. The most frequently rationed nursing care activities are those that nurses are competent to initiate on the basis of their knowledge and skills - the independent ones. The PIRNCA is a valid and reliable instrument. Hospital management can use the instrument to explore the prevalence of rationed care, followed by the application of prevention strategies. Our findings represent the base for further exploration of rationed care using the PIRNCA.

Context and scale: Distinctions for improving debates about physician "rationing"

Important discussions about limiting care based on professional judgment often devolve into heated debates over the place of physicians in bedside rationing. Politics, loaded rhetoric, and ideological caricature from both sides of the rationing debate obscure precise points of disagreement and consensus, and hinder critical dialogue around the obligations and boundaries of professional practice. We propose a way forward by reframing the rationing conversation, distinguishing between the scale of the decision (macro vs. micro) and its context (ordinary allocation vs. extraordinary re-allocation) avoiding the word "rationing." We propose to shift the terminology, using specific, descriptive words to defuse conflict and re-focus the debate towards substantive issues. These distinctions can clarify the real ethical differences at stake and facilitate a more constructive conversation about the clinical and social responsibilities of physicians to use resources ethically at the bedside and their role in allocating medical resources at a societal level.

Assessment for improving the performance of NICUs: The Italian experience

This paper describes neonatal intensive care units (NICU) in Italy using a set of organizational variables identifying management profile. The correlations between variables, and how these are impacted by structural aspects of the department or hospital, are investigated. The research was conducted within the 5-year far-reaching and complex SONAR study run by the Italian Neonatal Network, which maps NICU, monitors outcomes of member centres, defines organizational models, and identifies best practices to improve care quality. Seven variables relating to activities, organization processes, and behaviour models used in the SONAR study were used here to assess NICU. Data from 54 Italian NICUs, 1601 nursing staff, and 643 doctors were used. We identified high levels of variation in NICUs for all aspects of organization. We also identified important opportunities for improvement, especially in the areas of performance measurement, quality improvement, and learning for healthcare staff. In terms of structural characteristics, we identified big differences between NICUs in the north and south of Italy. The findings provide a description of NICUs in Italy and identify a set of variables useful for management in assessing NICU, which are among the most complex and costly operational units in a hospital.

Medicine price awareness in chronic patients in Belgium

INTRODUCTION

Under increasing pressure to contain health expenditures governments across Europe have implemented policies to increase responsible medicine use, e.g. by increasing co-insurance paid for by patients. In times of austerity, how do chronic disease patients perceive the medicine price they have to pay?

METHOD

We used a mixed methods research design. First, we distributed a close-ended questionnaire among 983 chronic disease patients in 30 Flemish pharmacies. Second, we performed semi-structured interviews with 15 of these patients. We surveyed for knowledge on the prescription medicine they bought, as well as for their needs for information and their therapeutic compliance.

RESULTS

Although patients express a lack (and a need) of information on prices during the consultation with the general practitioner (GP), (s)he hardly addresses medicine prices. Patients often only know the medicine price when they are at the pharmacy and patients need to decide to buy the medicine or not. This often results in patients taking the medicine when considered affordable within their social and financial context.

CONCLUSION

It seems essential that patients are better informed about medicine prices as well as the constraints on physicians to prescribe cost-effectively. Therefore, medicine prices should be discussed more often during physician consults.

[Avoidance of overuse as an integral part of medical professionalism. Conceptual analysis and new perspective]

BACKGROUND

The topics of rationing and priority setting have been increasingly discussed over the past 5 years in Germany by physicians together with other health care stakeholders. The topic of overuse, however, has not been discussed with similar intensity and publicity.

OBJECTIVES

This analysis paper outlines the relationships and differences between efficiency, priority setting, and rationing. Furthermore, it argues why and how German physicians should address the topic of overuse with more transparency and intensity.

DISCUSSION

Efforts of physicians to rationalize health care mainly comprise efforts to decrease overuse. The identification of important areas of overuse includes the prioritization of indications and medical interventions. Rationing health care can be unavoidable, for example, because other strategies such as rationalization, price regulation or disinvestments are not sufficient to avoid scarcity of financial resources. In such a case, rationing health care is unavoidable and, therefore, cannot be unethical per se. However, the debate on rationing becomes more legitimate if physicians demonstrate sufficient efforts to reduce overuse sufficiently. The Choosing Wisely initiative in the USA is outlined as one interesting option of how physicians could demonstrate and prove such efforts. Additional and more effective strategies to decrease overuse might be possible.

CONCLUSION

German physicians demand a more explicit communication within their communities and together with other stakeholders on the appropriateness of existing and potential future activities to decrease overuse. Such initiatives to avoid and decrease overuse should primarily be motivated through the ethical principle of beneficence, while the effect of cost containment should be considered as a welcomed side effect.

[Rationalization and rationing at the bedside. A normative and empirical status quo analysis]

BACKGROUND

The topic of bedside rationing is increasingly discussed in Germany. Further need for clarification exists for the question how bedside rationing (e.g., in the area of overcare) can be justified despite coexistent inefficiencies.

DISCUSSION

This paper outlines and analyses the relationship of waste avoidance and rationing from an ethical perspective. Empirical findings regarding the status quo of bedside rationing and rationalization are presented. These normative and empirical explorations will then be further specified regarding opportunities for future physician-driven activities to tackle overuse.

CONCLUSION

The self-government partners in Germany should communicate more explicitly within their communities and to the public how and with which benchmarks they aim to reduce inefficient health care (overuse) in an appropriate manner. Physician-driven activities such as the "Choosing Wisely®" initiative in the USA could provide a first step to raise the awareness for overuse among physicians as well as in the public.

[Would you mind a little bit less? Methodological and ethical challenges posed by the reduction of overtreatment]

The present paper outlines two central challenges that should be taken into account when making a concerted effort to reduce excessive medical care (overdiagnosis and overtreatment): first, the inevitability of value judgements in the risk-benefit assessment of medical treatment measures in conjunction with the need to go beyond the individual doctor-patient relationship and make these value judgements while, at least in part, assuming the role of acting deputy; and second, the need for a sufficient level of competence and trust in evidence-based medicine on the part of both physicians and patients. The paper will explain how one can say in a methodologically reasonable and ethically acceptable manner that a certain medical measure - in the context of the regular care setting - will objectively cause a "net harm" to the patient. Relevant institutions in the German healthcare system will be described that are currently conducting risk-benefit assessments (by different means and with different purposes). Taking the known entity of clinical guidelines as an example, the paper will demonstrate that the subjects of overdiagnosis and overtreatment as well as shortage of medical care can be more explicitly communicated by employing certain additional methodological tools. Finally, some central implementation barriers to a successful application of "Less is more!" will be presented and critically discussed. (As supplied by publisher).