Clinical Priority Setting and Decision-Making in Sweden: A Cross-sectional Survey Among Physicians

Document Type : Original Article

Authors

1 Division of Biomedical Ethics, Institute of Experimental Medicine, Christian-Albrechts-University of Kiel, Kiel, Germany

2 Department of Health, Medicine and Caring Sciences, Unit of Health Care Analysis, Linköping University, Linköping, Sweden

3 National Centre for Priorities in Health, Linköping University, Linköping, Sweden

4 NU Hospital Group, The Research and Development Unit, Trollhättan, Sweden

5 Institute of Medical Informatics and Statistics, University Hospital Schleswig-Holstein, Kiel, Germany

6 Institute of History and Ethics in Medicine, Technical University of Munich, Munich, Germany

7 Institute for Biomedical Ethics, University of Basel, Basel, Switzerland

Abstract

Background 
Priority setting in healthcare that aims to achieve a fair and efficient allocation of limited resources is a worldwide challenge. Sweden has developed a sophisticated approach. Still, there is a need for a more detailed insight on how measures permeate clinical life. This study aimed to assess physicians’ views regarding (1) impact of scarce resources on patient care, (2) clinical decision-making, and (3) the ethical platform and national guidelines for healthcare by the National Board of Health and Welfare (NBHW).
 
Methods 
An online cross-sectional questionnaire was sent to two groups in Sweden, 2016 and 2017. Group 1 represented 331 physicians from different departments at one University hospital and group 2 consisted of 923 members of the Society of Cardiology.
 
Results 
Overall, a 26% (328/1254) response rate was achieved, 49% in group 1 (162/331), 18% in group 2 (166/923). Scarcity of resources was perceived by 59% more often than ‘at least once per month,’ whilst 60% felt less than ‘wellprepared’ to address this issue. Guidelines in general had a lot of influence and 19% perceived them as limiting decisionmaking. 86% professed to be mostly independent in decision-making. 36% knew the ethical platform ‘well’ and ‘very well’ and 64% NBHW’s national guidelines. 57% expressed a wish for further knowledge and training regarding the ethical platform and 51% for support in applying NBHW’s national guidelines.
 
Conclusion 
There was a need for more support to deal with scarcity of resources and for increased knowledge about the ethical platform and NBHW’s national guidelines. Independence in clinical decision-making was perceived as high and guidelines in general as important. Priority setting as one potential pathway to fair and transparent decision-making should be highlighted more in Swedish clinical settings, with special emphasis on the ethical platform.

Keywords

References

  1. UN. 74/2. Political Declaration of the High-level Meeting on Universal Health Coverage. United Nations General Assembly; 2019.
  2. World Health Organization (WHO). Together on the Road to Universal Health Coverage: A Call to Action. Geneva: WHO; 2017.
  3. World Health Organization (WHO. Global Spending on Health: A World in Transition. Geneva: WHO; 2019.
  4. Ethikrat D. Nutzen und Kosten im Gesundheitswesen: Zur normativen Funktion ihrer Bewertung, Stellungnahme. 2011.
  5. World Health Organization (WHO). Introduction: Innovative Governance Strategies in European Public Hospitals. Copenhagen: WHO, on behalf of the European Observatory on Health Systems and Policies; 2011.
  6. Blomqvist A. The doctor as double agent: information asymmetry, health insurance, and medical care. J Health Econ. 1991;10(4):411-432. doi:10.1016/0167-6296(91)90023-g
  7. Shortell SM, Waters TM, Clarke KW, Budetti PP. Physicians as double agents: maintaining trust in an era of multiple accountabilities. JAMA. 1998;280(12):1102-1108. doi:10.1001/jama.280.12.1102
  8. Buyx AM. Gesundheit für alle? Einführung in Gerechtigkeitsfragen der modernen Medizin. In: Jüttemann V, ed. Mehr schlecht als recht? Eine interdisziplinäre Auseinandersetzung mit der Gerechtigkeit. Münster: Waxmann; 2007:73-101.
  9. Raspe H, Schulze J. Ärztlich unterstützte Priorisierung ist notwendig und hilfreich. Dtsch Arztebl. 2013;110(22):1091-1096.
  10. Schmitz-Luhn B. Priorisierung in der Medizin: Erfahrungen und Perspektiven. Heidelberg: Springer-Verlag; 2015.
  11. Glenngård AH. The Swedish health care system. In: International Health Care System Profiles. The Commonwealth Fund; 2018. https://international.commonwealthfund.org/countries/sweden.
  12. OECD. Sweden: Country Health Profile 2019. Paris: OECD Publishing; 2019. doi:10.1787/2dcb7ca6-en
  13. Riksdagen TSP. Regeringsbeslut om prioriteringar i sjukvården. Stockholm: 1997.
  14. Socialdepartementet. Vårdens svåra val (Swedish Government Official Reports. SOU 1995:5). Stockholm: Ministry of Health and Social Affairs; 1995:115-134.
  15. Ridderstolpe L, Collste G, Rutberg H, Ahlfeldt H. Priority setting in cardiac surgery: a survey of decision making and ethical issues. J Med Ethics. 2003;29(6):353-358. doi:10.1136/jme.29.6.353
  16. Ekerstad N, Löfmark R, Carlsson P. Elderly people with multi-morbidity and acute coronary syndrome: doctors' views on decision-making. Scand J Public Health. 2010;38(3):325-331. doi:10.1177/1403494809354359
  17. Arvidsson E. Priority Setting and Rationing in Primary Health Care [thesis]. Linköping, Sweden: Linköping University, Faculty of Health Sciences; 2013.
  18. Vårdanalys. Lång väg till patientnytta - en uppföljning av nationella riktlinjers inverkan på vården i ett decentraliserat system. Stockholm: Myndigheten för vård- och omsorgsanalys; 2015.
  19. Werntoft E, Edberg AK. Lack of support structures in prioritization decision making concerning patients and resources. Interviews with Swedish physicians. Scand J Public Health. 2011;39(6):627-633. doi:10.1177/1403494811414250
  20. Ekerstad N. Micro Level Priority Setting for Elderly Patients with Acute Cardiovascular Disease and Complex Needs: Practice What We Preach or Preach What We Practice? [thesis]. Linköping, Sweden: Department of Medical and Health Sciences, Linköping University; 2011.
  21. SFS. SFS 2003:460, Lagen om etikprövning av forskning som avser människor. Stockholm: Justitiedepartementet: 2003.
  22. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191-2194. doi:10.1001/jama.2013.281053
  23. Evasys Survey Automation Suite (Version 7) [computer program]. London, UK: 2016.
  24. McColl E, Jacoby A, Thomas L, et al. Design and use of questionnaires: a review of best practice applicable to surveys of health service staff and patients. Health Technol Assess. 2001;5(31):1-256. doi:10.3310/hta5310
  25. Edwards P. Questionnaires in clinical trials: guidelines for optimal design and administration. Trials. 2010;11:2. doi:10.1186/1745-6215-11-2
  26. Marckmann G, Strech D. Ärztliche Entscheidungen unter Kostendruck. In: Schwartz FW, Angerer P, eds. Arbeitsbedingungen und Befinden von Ärztinnen und Ärzten: Befunde und Interventionen. Köln: Deutscher Ärzte-Verlag; 2009:271-282.
  27. Strech D, Danis M, Löb M, Marckmann G. [Extent and impact of bedside rationing in German hospitals: results of a representative survey among physicians]. Dtsch Med Wochenschr. 2009;134(24):1261-1266. doi:10.1055/s-0029-1225273
  28. SPSS -Statistical Package for the Social Science (version 24 for Mac) [computer program]. Armonk, NY: 2016.
  29. Field A. Discovering Statistics Using SPSS. London: SAGE Publications; 2009.
  30. Bortz JS, Schuster C. Statistik: für Human-und Sozialwissenschaftler. In: Lehrbuch mit Online-Materialien. Springer; 2010.
  31. Braunschweig F. Kardiologföreningens enkät, hur fungerar fortbildningen? Svensk Kardiologi. 2015;3:26.
  32. Zentrale Ethikkommission. Priorisierung medizinischer Leistungen im System der Gesetzlichen Krankenversicherung (GKV). Dtsch Ärztebl. 2007;104(40):2750-2754.
  33. Strech D. Klinische Ethikberatung bei Rationierungsfragen im Krankenhaus. In: Vollmann J, Schildmann J, Simon A, eds. Klinische Ethik. Frankfurt: Campus; 2009:87-106.
  34. Hurst SA, Slowther AM, Forde R, et al. Prevalence and determinants of physician bedside rationing: data from Europe. J Gen Intern Med. 2006;21(11):1138-1143. doi:10.1111/j.1525-1497.2006.00551.x
  35. Alexander GC, Werner RM, Ubel PA. The costs of denying scarcity. Arch Intern Med. 2004;164(6):593-596. doi:10.1001/archinte.164.6.593
  36. Strech D, Synofzik M, Marckmann G. How physicians allocate scarce resources at the bedside: a systematic review of qualitative studies. J Med Philos. 2008;33(1):80-99. doi:10.1093/jmp/jhm007
  37. Hood C. The Blame Game: Spin, Bureaucracy, and Self-Preservation in Government. Princeton: Princeton University Press; 2011.
  38. Timmermans S, Berg M. The Gold Standard: The Challenge of Evidence-Based Medicine and Standardization in Health Care. Philadelphia: Temple University Press; 2003.
  39. Makdessi L, Halmin M. Läkarupprop för en bättre sjukvård, Det är dags att vi som profession formulerar vår oro och skapar en gemensam röst för en bättre sjukvård. Läkartidningen; 2013.
  40. Jansson B, Nitz L, Wedin M. Våra yrken har kidnappats av ekonomernas modeller. Dagens Nyheter; 2013.
  41. Hansson SO. Medical ethics and new public management in Sweden. Camb Q Healthc Ethics. 2014;23(3):261-267. doi:10.1017/s0963180113000868
  42. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996;312(7023):71-72. doi:10.1136/bmj.312.7023.71
  43. Statens offentliga utredningar (SOU). Kunskapsbaserad och jämlik vård, Förutsättningar för en lärande hälso- och sjukvård. Stockholm: SOU; 2017.
  44. Simon HA. Designing organizations for an information-rich world. In: Greenberger M, ed. Computers, Communications and the Public Interest. Baltimore: Johns Hopkins Press; 1971:37-72.
  45. Prioriteringscentrum. Vårdens alltför svåra val? Kartläggning av prioriteringsarbete och analys av riksdagens principer och riktlinjer för prioriteringar i hälso- och sjukvården. (Health care’s too difficult choices?). Linköping: 2007.
  46. Eckard N, Nedlund AC, Janzon M, Levin LÅ. Reaching agreement in uncertain circumstances: the practice of evidence-based policy in the case of the Swedish National Guidelines for heart diseases. Evid Policy. 2017;13(4):687-707.
  47. Eckard N. The Matter of Economic Evaluations in Health Policy Decision-Making: The Case of the Swedish National Guidelines for Heart Diseases. Linköping University Electronic Press, Linköping University; 2015.
  48. Kalkan A, Sandberg J, Garpenby P. Management by Knowledge in Practice – Implementation of National Healthcare Guidelines in Sweden. Soc Policy Adm. 2015;49(7):911-927. doi:10.1111/spol.12102
  49. Waldau S. Local prioritisation work in health care--assessment of an implementation process. Health Policy. 2007;81(2-3):133-145. doi:10.1016/j.healthpol.2006.05.007
  50. NAO. Primärvårdens styrning—efter behov eller efterfrågan? (Primary health care governance - based on need or demand? Stockholm: Swedish National Audit Office; 2014.
  51. Kongsved SM, Basnov M, Holm-Christensen K, Hjollund NH. Response rate and completeness of questionnaires: a randomized study of Internet versus paper-and-pencil versions. J Med Internet Res. 2007;9(3):e25. doi:10.2196/jmir.9.3.e25
  52. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol. 1997;50(10):1129-1136. doi:10.1016/s0895-4356(97)00126-1
  53. Bolton K, Kuteeva M. English as an academic language at a Swedish university: parallel language use and the ‘threat’ of English. J Multiling Multicult Dev. 2012;33(5):429-447. doi:10.1080/01434632.2012.670241
International Journal of Health Policy and Management
Volume 11, Issue 7
July 2022
Pages 1148-1157

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History

  • Receive Date: 25 June 2020
  • Revise Date: 16 February 2021
  • Accept Date: 20 February 2021
  • First Publish Date: 15 March 2021

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