Patients' and oncologists' perceptions towards the discussion on high-cost innovative cancer therapies: findings from a qualitative study

OBJECTIVES

In the last decades, innovative technologies for cancer treatment were developed rapidly. In most cases, their price is high, with no funding offered by public health systems. The present study examined the perceptions of oncologists, patients and family members regarding the challenges in discussing innovative cancer treatments.

DESIGN

Qualitative study, using in-depth semistructured interviews. Interviews examined public versus private financing, therapist-patient-family discourse, modes of decision making and implications on health policy and inequalities.

PARTICIPANTS

Sixteen cancer patients, six family members of cancer patients and 16 oncologists participated in the study.

RESULTS

Four themes emerged from data analysis: the economic consideration in the decision on cancer treatment, the options of funding high-cost private treatments, psychosocial aspects of the discussion on treatment costs and health policy in oncology and its social aspects.

CONCLUSIONS

Findings emphasise the importance of considering costs when recommending expensive care and addressing the emotional element of innovative treatment, as most patients expect. The findings present various psychosocial aspects taking part in the complicated decision to use unfunded cancer treatment and its broad implications, which may use as a basis for developing a guided framework for oncologist-patient discourse.

Bedside rationing and moral distress in nephrologists in sub- Saharan Africa

Background

Kidney diseases constitute an important proportion of the non-communicable disease (NCD) burden in Sub-Saharan Africa (SSA), though prevention, diagnosis and treatment of kidney diseases are less prioritized in public health budgets than other high-burden NCDs. Dialysis is not considered cost-effective, and for those patients accessing the limited service available, high out-of-pocket expenses are common and few continue care over time. This study assessed challenges faced by nephrologists in SSA who manage patients needing dialysis. The specific focus was to investigate if and how physicians respond to bedside rationing situations.

Methods

A survey was conducted among a randomly selected group of nephrologists from SSA. The questionnaire was based on a previously validated survey instrument. A descriptive and narrative approach was used for analysis.

Results

Among 40 respondents, the majority saw patients weekly with acute kidney injury (AKI) or end-stage kidney failure (ESKF) in need of dialysis whom they could not dialyze. When dialysis was provided, clinical compromises were common, and 66% of nephrologists reported lack of basic diagnostics and medication and > 80% reported high out-of-pocket expenses for patients. Several patient-, disease- and institutional factors influenced who got access to dialysis. Patients’ financial constraints and poor chances of survival limited the likelihood of receiving dialysis (reported by 79 and 78% of nephrologists respectively), while a patient’s being the family bread-winner increased the likelihood (reported by 56%). Patient and institutional constraints resulted in most nephrologists (88%) frequently having to make difficult choices, sometimes having to choose between patients. Few reported existence of priority setting guidelines. Most nephrologists (74%) always, often or sometimes felt burdened by ethical dilemmas and worried about patients out of hospital hours. As a consequence, almost 46% of nephrologists reported frequently regretting their choice of profession and 26% had considered leaving the country.

Conclusion

Nephrologists in SSA face harsh priority setting at the bedside without available guidance. The moral distress is high. While publicly funded dialysis treatment might not be prioritized in essential health care packages on the path to universal health coverage, the suffering of the patients, families and the providers must be acknowledged and addressed to increase fairness in these decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02827-2.

Measuring medically unjustified hospitalizations in Switzerland

Background

Inappropriate use of acute hospital beds is a major topic in health politics. We present here a new approach to measure unnecessary hospitalizations in Medicine and Pediatrics.

Methods

The necessity of a hospital admission was determined using explicit criteria related to the recorded diagnoses. Two indicators (i.e. “unjustified” and “sometimes justified” stays) were applied to more than 800,000 hospital stays and a random sample of 200 of them was analyzed by two clinicians, using routine data available in medical statistics. The validation of the indicators focused on their precision, validity and adjustment, as well as their usefulness (i.e. interest and risk of abuse).

Results

Rates, adjusted for case mix (i.e. age of patient, admission planned or not), showed statistically significant differences among hospitals. Only 6.5% of false positives were observed for “unjustified stays” and 17% for “sometimes justified stays”. Respectively 7 and 12% of stays had an unknown status, due to a lack of sufficiently precise data. Considering true positives only, almost one third of medical and pediatric stays were classified as not strictly justified from a medical point of view in Switzerland. Among these stays, about one fifth could have probably been avoided without risk. To enable a larger ambulatory shift, recommendations were made to strengthen the ambulatory care, notably regarding post-emergency follow-up, cardiac and pulmonary functions’ monitoring, pain management, falls prevention, and specialized at-home services that should be offered.

Conclusion

We recommend using “unjustified stays” and “sometimes justified stays” indicators to monitor inappropriate hospitalizations. The latter could help the planning of reinforced ambulatory care measures to pursue the ambulatory shift. Nonetheless, we clearly advise against the use of these two indicators for hospitals financing purposes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07569-3.

Rationing cancer treatment: a qualitative study of perceptions of legitimate limit-setting

Background

Governments are facing tough choices about whether to fund new, promising but highly expensive drugs within the public healthcare system. Decisions that some drugs are not sufficiently beneficial relative to their cost to merit public funding are often contentious. The importance of making decisions that stakeholders can understand and accept as legitimate is increasingly recognized and is commonly understood to be a crucial component for stakeholder support and successful implementation. Yet, little is known about clinicians’ perceptions of legitimate limit-setting. This study aimed to examine oncologists’ perceptions of the legitimacy of governmental decisions to deny patients access to new cancer drugs because effectiveness and cost-effectiveness of the drugs has not been demonstrated.

Methods

Semi-structured in-depth interviews with 12 Norwegian oncologists were carried out. Data were interpreted with the use of theory driven thematic analysis. The analytical framework of Accountability for reasonableness aided data gathering and interpretation.

Results

The participants endorsed the ideal of explicit criteria-based priority setting. Yet, when confronted with actual rationing decisions, they were far more equivocal. They advocated for increased access to drugs and were not always prepared to accept rationing of drugs they felt would benefit their patient. Distrust in the Norwegian centralised drug review process was found and different rationales were identified: i) Lack of engagement with the process, ii) Disagreement with the use of rationing criteria, iii) Lack of transparency and lack of dispute resolution procedures. Concerns about the wider implications of rationing decisions were reported. Most importantly, these related to negative impact on patient-doctor relationship of micro-level rationing and to inequities in drug availability resulting from privatisation of high-cost cancer treatment.

Conclusions

Drawing on the analytical framework, we conclude that perceptions of legitimacy regarding rationing of high-cost drugs include procedural fairness. However, notions of substantive justice also seem to be important for accepting reasons given for decisions. Regulatory legitimacy may further warrant a more sophisticated theoretical account of second-order beliefs about the justifiability of rationing new technologies. These findings indicate a need for a broader concept of legitimacy than is commonly used in the literature on healthcare prioritisation.

Self-responsibility, rationing and treatment decision making - managing moral narratives alongside fiscal reality in the obesity surgery clinic

Background

Addressing the prevalence of severe obesity and its concomitant morbidities is widely acknowledged as one of the most pressing global health priorities. Nevertheless, a paucity of effective interventions and universal pressure on health‐care budgets means that access to obesity treatments is often limited. Although health‐care rationing can be conceived as a socially constructed process, little is known about how decisions emerge within the context of face‐to‐face doctor–patient interactions.

Methods

In this study, we used in‐depth interviews and clinic observations to investigate clinicians’ (n = 11) and patients’ (n = 22) experiences of the rationing of obesity surgery and to examine how broader cultural assumptions around personal responsibility for health emerged in the context of clinical interactions.

Results

Patients and clinicians worked within similar frameworks when it came to self‐responsibility for health and the appropriateness of providing publicly‐funded weight loss surgery. Issues around personal accountability dominated consultations, and patients were expected to provide narratives of the development of their obesity and to account for the failure of previous interventions. Clinicians faced the added pressure of having to prioritise a limited number of patients for surgery, which was predominantly managed through mandating pre‐referral weight loss targets.

Discussion

Although clinicians sought to maintain an empathic attitude towards individual patients, in practice they were conflicted by their responsibility to ration health‐care resources and tended to rely on entrenched models of behaviour change to allocate treatment. As a result, the content of consultations was mostly focused on issues of personal responsibility, reflecting wider stigmatized attitudes towards extreme obesity.

How clinical rationing works in practice: A case study of morbid obesity surgery

Difficulties in setting healthcare priorities are encountered throughout the world. There is no agreement on the most appropriate principles or methods for healthcare rationing although there is some consensus that it should be undertaken as systematically and accountably as possible. Although some steps towards achieving accountability have been made at the macro and meso level, at the consultation level rationing remains implicit and poorly understood. Using morbid obesity surgery as a case study, we observed a series of UK National Health Service consultations where rationing was ongoing and conducted in-depth interviews with doctors and patients (2011-2014). A longitudinal approach was taken to research and in total 22 consultations were observed and 78 interviews were undertaken. Sampling was undertaken purposively and theoretically and analyses were undertaken thematically. Clinicians needed to prioritise 55 patients from 450 eligible referrals, but disagreed over the extent to which clinical and financial factors were the driving force behind decision-making. The most prominent rationing technique observed in consultations was rationing by selection, but examples of rationing by delay, by deterrence, and by deflection were also commonplace. Although all clinicians sought to avoid rationing by denial, only six of the 22 patients recruited to the research were known to have been treated at the end of the three-year period. Most clinicians sought to manage rationing implicitly, and only one explained the link between decision-making criteria and financial constraints on care availability. Although existing frameworks for categorising NHS rationing techniques were useful in identifying implicit strategies, in practice these techniques over-lapped substantially and we have proposed a simpler framework for analysing NHS rationing decisions at the consultation level, which includes just three categories - rationing by exclusion, rationing by deterrence, and rationing by delay.

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Background

NHS expenditure has stagnated since the economic crisis of 2007, resulting in financial pressures. One response is for policy-makers to regulate use of existing health-care technologies and disinvest from inefficiently used health technologies. A key challenge to disinvestment is to identify existing health technologies with uncertain cost-effectiveness.

Objectives

We aimed to explore if geographical variation in procedure rates is a marker of clinical uncertainty and might be used by local commissioners to identify procedures that are potential candidates for disinvestment. We also explore obstacles and solutions to local commissioners achieving disinvestment, and patient and clinician perspectives on regulating access to procedures.

Methods

We used Hospital Episode Statistics to measure geographical variation in procedure rates from 2007/8 to 2011/12. Expected procedure numbers for each primary care trust (PCT) were calculated adjusting for proxies of need. Random effects Poisson regression quantified the residual inter-PCT procedure rate variability. We benchmarked local procedure rates in two PCTs against national rates. We conducted rapid systematic reviews of two high-use procedures selected by the PCTs [carpal tunnel release (CTR) and laser capsulotomy], searching bibliographical databases to identify systematic reviews and randomised controlled trials (RCTs). We conducted non-participant overt observations of commissioning meetings and semistructured interviews with stakeholders about disinvestment in general and with clinicians and patients about one disinvestment case study. Transcripts were analysed thematically using constant comparison methods derived from grounded theory.

Results

There was large inter-PCT variability in procedure rates for many common NHS procedures. Variation in procedure rates was highest where the diffusion or discontinuance was rapidly evolving and where substitute procedures were available, suggesting that variation is a proxy for clinical uncertainty about appropriate use. In both PCTs we identified procedures where high local use might represent an opportunity for disinvestment. However, there were barriers to achieving disinvestment in both procedure case studies. RCTs comparing CTR with conservative care indicated that surgery was clinically effective and cost-effective on average but provided limited evidence on patient subgroups to inform commissioning criteria and achieve savings. We found no RCTs of laser capsulotomy. The apparently high rate of capsulotomy was probably due to the coding inaccuracy; some savings might be achieved by greater use of outpatient procedures. Commissioning meetings were dominated by new funding requests. Benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. Most patients were unaware of rationing.

Conclusions

Policy-makers could use geographical variation as a starting point to identify procedures where health technology reassessment or RCTs might be needed to inform policy. Commissioners can use benchmarking to identify procedures with high local use, possibly indicating overtreatment. However, coding inconsistency and limited evidence are major barriers to achieving disinvestment through benchmarking. Increased central support for commissioners to tackle disinvestment is needed, including tools, accurate data and relevant evidence. Early engagement with patients and clinicians is essential for successful local disinvestment.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

"Vicious circles": the development of morbid obesity

Although there has been extensive research around the etiology of moderate obesity, there are still important questions relating to the development and lived experience of extreme obesity. We present a synthesis of data from two in-depth qualitative studies in which morbidly obese participants (N = 31) were able to explain the development of the condition in their own terms. We identified consistent themes in the two datasets, and undertook a detailed data synthesis. Particularly salient themes in the development of morbid obesity related to family structures and early socialization experiences, and the role of emotional distress was dominant in both initial weight gain and ongoing cycles of loss and regain. All informants accepted some responsibility for their health state, but identified a number of mitigating factors that limited personal culpability that were often related to the fulfillment of gendered social expectations.

Exploring public attitudes towards approaches to discussing costs in the clinical encounter

BACKGROUND

Patients' willingness to discuss costs of treatment alternatives with their physicians is uncertain.

OBJECTIVE

To explore public attitudes toward doctor-patient discussions of insurer and out-of-pocket costs and to examine whether several possible communication strategies might enhance patient receptivity to discussing costs with their physicians.

DESIGN

Focus group discussions and pre-discussion and post-discussion questionnaires.

PARTICIPANTS

Two hundred and eleven insured individuals with mean age of 48 years, 51 % female, 34 % African American, 27 % Latino, and 50 % with incomes below 300 % of the federal poverty threshold, participated in 22 focus groups in Santa Monica, CA and in the Washington, DC metro area.

MAIN MEASUREMENTS

Attitudes toward discussing out-of-pocket and insurer costs with physicians, and towards physicians' role in controlling costs; receptivity toward recommended communication strategies regarding costs.

KEY RESULTS

Participants expressed more willingness to talk to doctors about personal costs than insurer costs. Older participants and sicker participants were more willing to talk to the doctor about all costs than younger and healthier participants (OR = 1.8, p = 0.004; OR = 1.6, p = 0.027 respectively). Participants who face cost-related barriers to accessing health care were in greater agreement than others that doctors should play a role in reducing out-of-pocket costs (OR = 2.4, p = 0.011). Participants did not endorse recommended communication strategies for discussing costs in the clinical encounter. In contrast, participants stated that trust in one's physician would enhance their willingness to discuss costs. Perceived impediments to discussing costs included rushed, impersonal visits, and clinicians who are insufficiently informed about costs.

CONCLUSIONS

This study suggests that trusting relationships may be more conducive than any particular discussion strategy to facilitating doctor-patient discussions of health care costs. Better public understanding of how medical decisions affect insurer costs and how such costs ultimately affect patients personally will be necessary if discussions about insurer costs are to occur in the clinical encounter.

Affordability as a discursive accomplishment in a changing National Health Service

Health systems worldwide face the challenges of rationing. The English National Health Service (NHS) was founded on three core principles: universality, comprehensiveness, and free at the point of delivery. Yet patients are increasingly hearing that some treatments are unaffordable on the NHS. We considered affordability as a social accomplishment and sought to explore how those charged with allocating NHS resources achieved this in practice. We undertook a linguistic ethnography to examine the work practices of resource allocation committees in three Primary Care Trusts (PCTs) in England between 2005 and 2012, specifically deliberations over 'individual funding requests' (IFRs)--requests by patients and their doctors for the PCT to support a treatment not routinely funded. We collected and analysed a diverse dataset comprising policy documents, legal judgements, audio recordings, ethnographic field notes and emails from PCT committee meetings, interviews and a focus group with committee members. We found that the fundamental values of universality and comprehensiveness strongly influenced the culture of these NHS organisations, and that in this context, accomplishing affordability was not easy. Four discursive practices served to confer legitimacy on affordability as a guiding value of NHS health care: (1) categorising certain treatments as only eligible for NHS funding if patients could prove 'exceptional' circumstances; (2) representing resource allocation decisions as being not (primarily) about money; (3) indexical labelling of affordability as an ethical principle, and (4) recontextualising legal judgements supporting refusal of NHS treatment on affordability grounds as 'rational'. The overall effect of these discursive practices was that denying treatment to patients became reasonable and rational for an organisation even while it continued to espouse traditional NHS values. We conclude that deliberations about the funding of treatments at the margins of NHS care have powerful consequences both for patients and for redrawing the ideological landscape of NHS care.

Negotiating refusal in primary care consultations: a qualitative study

BACKGROUND

How GPs negotiate patient requests is vital to their gatekeeper role but also a source of potential conflict, practitioner stress and patient dissatisfaction. Difficulties may arise when demands of shared decision-making conflict with resource allocation, which may be exacerbated by new commissioning arrangements, with GPs responsible for available services.

OBJECTIVES

To explore GPs' accounts of negotiating refusal of patient requests and their negotiation strategies.

METHODS

A qualitative design was employed with two focus groups of GPs and GP registrars followed by 20 semi-structured interviews. Participants were sampled by gender, experience, training/non-training, principal versus salaried or locum. Thematic content analysis proceeded in parallel with interviews and further sampling. The setting was GP practices within an English urban primary care trust.

RESULTS

Sickness certification, antibiotics and benzodiazepines were cited most frequently as problematic patient requests. GP trainees reported more conflict within interactions than experienced GPs. Negotiation strategies, such as blaming distant third parties such as the primary care organization, were designed to prevent conflict and preserve the doctor-patient relationship. GPs reported patients' expectations being strongly influenced by previous encounters with other health care professionals.

CONCLUSIONS

The findings reiterate the prominence of the doctor-patient relationship in GPs' accounts. GPs' relationships with colleagues and the wider National Health Service (NHS) are particular of relevance in light of provisions in the Health and Social Care Bill for clinical commissioning consortia. The ability of GPs to offset blame for rationing decisions to third parties will be undermined if the same GPs commission services.

Rationing in the intensive care unit: to disclose or disguise?

INTRODUCTION

Growing pressures to ration intensive care unit beds and services pose novel challenges to clinicians. Whereas the question of how to allocate scarce intensive care unit resources has received much attention, the question of whether to disclose these decisions to patients and surrogates has not been explored.

KEY CONSIDERATIONS

We explore how considerations of professionalism, dual agency, patients' and surrogates' preferences, beneficence, and healthcare efficiency and efficacy influence the propriety of disclosing rationing decisions in the intensive care unit.

CONCLUSIONS

There are compelling conceptual reasons to support a policy of routine disclosure. Systematic disclosure of prevailing intensive care unit norms for making allocation decisions, and of at least the most consequential specific decisions, can promote transparent, professional, and effective healthcare delivery. However, many empiric questions about how best to structure and implement disclosure processes remain to be answered. Specifically, research is needed to determine how best to operationalize disclosure processes so as to maximize prospective benefits to patients and surrogates and minimize burdens on clinicians and intensive care units.

To accept, or not to accept, that is the question: citizen reactions to rationing

BACKGROUND

The publicly financed health service in Sweden has come under increasing pressure, forcing policy makers to consider restrictions.

OBJECTIVE

To describe different perceptions of rationing, in particular, what citizens themselves believe influences their acceptance of having to stand aside for others in a public health service.

DESIGN

Qualitative interviews, analysed by phenomenography, describing perceptions by different categories.

SETTING AND PARTICIPANTS

Purposeful sample of 14 Swedish citizens, based on demographic criteria and attitudes towards allocation in health care.

RESULTS

Participants expressed high awareness of limitations in public resources and the necessity of rationing. Acceptance of rationing could increase or decrease, depending on one's (i) awareness that healthcare resources are limited, (ii) endorsement of universal health care, (iii) knowledge and acceptance of the principles guiding rationing and (iv) knowledge about alternatives to public health services.

CONCLUSIONS

This study suggests that decision makers should be more explicit in describing the dilemma of resource limitations in a publicly funded healthcare system. Openness enables citizens to gain the insight to make informed decisions, i.e. to use public services or to 'opt out' of the public sector solution if they consider rationing decisions unacceptable.

Health systems and sustainability: doctors and consumers differ on threats and solutions

BACKGROUND

Healthcare systems face the problem of insufficient resources to meet the needs of ageing populations and increasing demands for access to new treatments. It is unclear whether doctors and consumers agree on the main challenges to health system sustainability.

METHODOLOGY

We conducted a mail survey of Australian doctors (specialists and general practitioners) and a computer assisted telephone interview (CATI) of consumers to determine their views on contributors to increasing health care costs, rationing of services and involvement in health resource allocation decisions. Differences in responses are reported as odds ratios (OR) and 99% confidence intervals (CI).

RESULTS

Of 2948 doctors, 1139 (38.6%) responded; 533 of 826 consumers responded (64.5% response). Doctors were more concerned than consumers with the effects of an ageing population (OR 3.0; 99% CI 1.7, 5.4), and costs of new drugs and technologies (OR 5.1; CI 3.3, 8.0), but less likely to consider pharmaceutical promotional activities as a cost driver (OR 0.29, CI 0.22, 0.39). Doctors were more likely than consumers to view 'community demand' for new technologies as a major cost driver, (OR 1.6; 1.2, 2.2), but less likely to attribute increased costs to patients failing to take responsibility for their own health (OR 0.35; 0.24, 0.49). Like doctors, the majority of consumers saw a need for public consultation in decisions about funding for new treatments.

CONCLUSIONS

Australian doctors and consumers hold different views on the sustainability of the healthcare system, and a number of key issues relating to costs, cost drivers, roles and responsibilities. Doctors recognise their dual responsibility to patients and society, see an important role for physicians in influencing resource allocation, and acknowledge their lack of skills in assessing treatments of marginal value. Consumers recognise cost pressures on the health system, but express willingness to be involved in health care decision making.

The usefulness of NICE guidance in practice: Different perspectives of managers, clinicians, and patients

Objectives: The UK National Institute for Health and Clinical Excellence (NICE) has been widely hailed as an international leader in health technology assessment. The objectives of its guidance are to ensure uniformity in healthcare provision, and promote a systematic and accountable way to allocate resources. However, research relating to the implementation of guidance is limited, and little is known about how it influences decision making at the consultation level or how useful it is to individual patients.

Methods: In-depth interviews were undertaken with professionals involved in healthcare provision at the community level, and with clinical professionals and patients providing or receiving care for morbid obesity and breast cancer (n = 52).

Results: Although NICE guidance was generally well-regarded, in practice it was of more importance and usefulness to managerial than clinical professionals. Clinicians used a patchy approach to implementation depending on whether recommendations accorded with their personal interpretation of the evidence available, and whether funding was available locally. Many patients had not heard of NICE, and clinical professionals did not alert them to its existence. Even where patients knew about relevant guidance, they were rarely able to use it to assert their right to treatment.

Conclusions: These findings challenge the perception that NICE guidance results in consistent and accountable decision making, and the limited accessibility and usefulness of guidance to patients suggests more information and support is needed at the point of provision if these objectives are to be achieved.