Criteria for the Allocation of Medical Resources: Citizens' Perspectives

The aim of this research was to assess which criteria laypeople use to evaluate the importance of treatments the Italian National Health Service (NHS) should or should not guarantee and the relationship with their degree of importance. A convenience
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  Criteria for the Allocation of Medical Resources:Citizens’ Perspectives E   C  1 Department of Sciences of Education“G.M. Bertin”University of Bologna, Italy T   M  Department of PsychologyUniversity of Parma, Italy M   A   N  Health AgencyRegion Emilia-Romagna, Italy The aim of this research was to assess which criteria laypeople use to evaluate the impor-tance of treatments the Italian National Health Service (NHS) should or should notguarantee and the relationship with their degree of importance. A convenience sample of 100 individuals (22–65 years old) were asked to evaluate 52 treatments partly included andpartly not included in the Essential Assistance Levels. Results showed that laypeopleemploy a wide range of criteria, only part of which corresponds to those traditionallyinvestigated in the psychosocial literature. Two main dimensions emerge as organizingprinciples underlying their judgments, referring to NHS function (prevention vs. treatment)and to the opportunity to focus on the specific health needs of particular categories of citizens (selectivity). Advances in medical research have increased the number and types of effec-tive forms of treatment for conditions that were once considered untreatable,significantly improving patients’ quality of life. The greater knowledge of theprogresses of medicine, the awareness of the possible treatments, and the wide-spread optimistic belief that actual diagnostic-therapeutical possibilities of medi-cine are almost unlimited resulted in a growing health demand from the generalpopulation. However, several treatments are still inaccessible for a large numberof people, owing to their cost, lack of accessibility, or complexity. All healthsystems in Western industrialized countries are facing the need to guarantee 1 Correspondence concerning this article should be addressed to Elvira Cicognani, Department of Sciences of Education “G.M. Bertin,” University of Bologna, Via Filippo Re, 6, 40127 Bologna (Italy).E-mail: 13  Journal of Applied Biobehavioral Research , 2007,  12,  1, pp. 13–34.Copyright ©  2007 by Bellwether Publishing, Ltd. All rights reserved.  services and treatments that are more and more costly and complex in a situationof scarce economic resources.Since the beginning of the 1990s, several attempts have been made to modifythe institutional and administrative systems in order to increase the quality andeffectiveness of treatments and to prevent the waste of scarce resources. In severalnations, specific committees have been appointed to make decisions about theallocation of economic resources and define a common set of agreed criteria tomake such decisions. In Italy, the government followed such international move-ment by introducing the Essential Assistance Levels (LEA) as an instrument tomake explicit the treatments and services that are guaranteed to the populationand to develop economic policies that favor the introduction of the privatemarket into the health arena.In this context, the issue of how to achieve an efficient and fair allocation of scarce medical resources becomes crucial. In fact, there are no agreed-uponstandards on how decisions should be made, which may result in inconsistenciesand possible biases. The adoption of economic criteria, such as cost-effectivenesscalculations, has proved to be unsatisfactory, increasing the risk of inequalities inhealth provision between the different categories of citizens. Therefore, theissues of equity, ethics, and “fair” allocation of resources have been the subjectof considerable discussion by economists, physicians, philosophers, and socialpolicy scholars (Bowling, 1993; Domenighetti & Maggi, 2001; Shmueli, 1999;Taroni, 2000). Debates focused on who should do the rationing and how, and thecriteria that should be used when setting priorities (e.g., severity of the disease,clinical effectiveness, cost-effectiveness, Quality Adjusted Life Year (QALY),egalitarianism, social utility; Cookson & Dolan, 2000; Olsen, Richardson, Dolan,& Menzel, 2003).More recently, ethicists, public policy researchers, and psychologists havetaken an interest in consulting the lay public (Domenighetti & Maggi, 2001;Reeves, 2000). In fact, it is widely recognized that, although experts can advise onthe technical “facts” in priority setting, only members of the local community canexpress community health values (Bowling, 1993).Several studies have been conducted to investigate laypeople opinions, usingboth quantitative (e.g., ranking techniques, rating scales, choice-based tech-niques) and qualitative (e.g., citizens’ juries, focus groups) methods. Moreover,both microallocation (i.e., which individuals should be provided with theresources available) and macroallocation decisions (i.e., decisions about whichservices should be provided to the population or to specific groups) have beeninvestigated (Boyd & Potter, 1986).Research attention has been devoted to  factors influencing laypeople judg-ment processes  about the allocation of medical resources. In a series of con-trolled experimental studies with samples of citizens, Furnham and colleaguesexamined the role of patient characteristics and participant personality in 14  CICOGNANI ET AL.  influencing hypothetical allocation decisions concerning both life-saving (e.g.,dialysis and renal transplant, heart transplant) and life-enhancing treatments(e.g., in vitro fertilization treatment, cosmetic surgery; Furnham, 1996;Furnham, Meader, & McClelland, 1998; Furnham, Simmons, & McClelland,2000; Furnham, Thomas, & Petrides, 2002; Wiseman, 2006). Characteristics of hypothetical patients (including sociodemographic variables, personality, andlifestyle) were systematically varied. Results showed that participants tend tofavor younger individuals (vs. older), females (vs. males), those who aremarried (vs. unmarried) and who have children, patients who are more intelli-gent, extroverts, those with lower income, those who are religious and withleft-wing political opinions, those who have an occupation, and those whoactively contribute to their community. Moreover, patients who are seen asresponsible for their condition (e.g., owing to the adoption of risky behaviorssuch as smoking and alcohol consumption) are discriminated against in allo-cation decisions. Participants’ choices differ according to the type of treatment(life saving vs. life enhancing) and participants’ characteristics (e.g., religiousand political affiliation), providing evidence of an in-group, self-serving bias.Such results appear fairly consistent across countries, even though some differ-ences suggest the existence of possible biases associated with different healthpolicy systems (Furnham, Hassomal, & McClelland, 2002).Other authors focused more explicitly on the  types of criteria  used to makeallocation decisions (e.g., Bowling, 1993; Domenighetti & Maggi, 2001; Lian,2001; Neuberger, Adams, & MacMaster, 1998; Oddsson, 2003; Shmueli, 1999).Shmueli tested, using a social dilemma situation, the relative importance of the“rule of rescue” (claiming that individuals whose lives are threatened should havepriority over all other needs, even when the costs consist of detracting from thequality of life of other individuals in need) and quality of life according toQALYs calculation (according to which, treatment that increases quality of lifemay be superior to treatments that prolong low quality of life). The findingsindicate that the rule of rescue is dominant for more than a quarter of thepopulation, even when death is postponed by only 1 month. More than a tenth of the population are ready to adopt prioritization by lottery. Economic condition,gender, and health status have no effect on priority choices.Most research studies investigating the types of criteria used in making allo-cation decisions have considered, and experimentally manipulated, a prioridefined criteria selected by researchers. This leaves open the question about therelative importance of the different criteria that are potentially relevant in theconcrete situation in which the choices are made, for example, by ad hoc healthcommittees. Moreover, the importance of considering the citizens’ perspective(besides the experts’ perspective) has been emphasized. There is evidence of thetendency of experts to overemphasize economic criteria and of laypeople toemphasize the severity of the condition. ALLOCATION OF MEDICAL RESOURCES  15  The Study LEA have been officially introduced in Italy by the Decree of the President of the Council of Ministers 29 November 2001, “Definition of Essential AssistanceLevels,” published in the Official Gazette 8 February 2002, n. 33. They comprisethe list of treatments that the Italian National Health Service (NHS) shouldguarantee to all citizens.Moving from the mentioned considerations, the Health Agency of the RegionEmilia Romagna (Italy) started a research program aimed at assessing Italiancitizens’ opinions about priority setting concerning LEA. 2 This involved engage-ment in a process of constructing and validating an instrument that could allowthe collection of laypeople opinions, taking into account the criteria that they usewhen reasoning about the allocation of treatments included in the LEA list. Thisexploratory study describes the first step of the research program. Its aims wereto assess which criteria laypeople use to evaluate the relative importance of different kinds of treatments the Italian NHS should or should not guarantee andhow they differ according to sociodemographic variables. Moreover, we wantedto assess the relationship between the degree of importance given to specifictreatments and the type of criteria used to justify such judgments.Methods Participants Participants included a convenience sample of 100 individuals living in theEmilia-Romagna region (North Italy), balanced by gender. Ages ranged from 22to 65 years ( M   =  42 years, standard deviation [ SD ]  =  12.4). Participants wererecruited through a snowball sampling technique. Twenty-six participantscompleted compulsory education, 37 have a high school degree, and 37 have auniversity degree. Of the participants, 79% have a job, whereas 15 participantsare students, 5 are retired, and 1 is unemployed. Instruments and Procedure Stimulus materials consisted of a list of treatments covering all the principalcategories of treatments included in the LEA. Included were some treatmentsthat are partially excluded from the LEA, but that can be guaranteed by regionswith their own funding, such as dental care, and a few treatments totally excludedfrom LEA, such as nonconventional medicine and aesthetic surgery. Each of the 2 “Instruments for the assessment of health priorities: Citizens’ perspectives” project (HealthAgency of Region Emilia-Romagna, in collaboration with the Department of Psychology, Universityof Parma and Department of Sciences of Education “G.M. Bertin,” University of Bologna). 16  CICOGNANI ET AL.  52 treatments selected was written down on a small card. Participants took partin a semistructured interview lasting about 1 hour. Interviews were conducted bytwo trained researchers and took place within a setting ad hoc prepared toguarantee an optimal level of attention and to minimize bias. The procedure wasstandardized and included two steps:1. The 52 cards displaying the different treatments were shown in a casual order.Participants were then asked to sort the cards into 10 groups ( baskets ) and toorder them according to the degree of importance of the treatments includedin each basket (from the  least important  =  1, to the  most important  =  10). Thefollowing constraints were set: (1) the number of treatments placed in each of the 10 baskets could differ, even though at least one card should be present,and (2) in order to classify the treatments, the only criterion that should befollowed was the importance given to the treatments.2. After the sorting task, participants were asked to specify, for each of the 52treatments, the criteria used to assess its importance.Interviews were audiotaped and transcribed. Data Analysis In this article, we will focus on the criteria that guided the subjects’ choice of basket (corresponding to the degree of importance) in which to place the treat-ments (Point 2 above). A more detailed analysis of the procedures and resultsconcerning the importance participants attributed to that list is presented in aprevious article (Mancini, Nicoli, & Cicognani, 2005). To analyze the criteriaused to assess the treatments’ importance, the responses were content analyzed bytwo independent judges according to a two-step procedure.In the first step, the answers provided by he participants (5,200 statements: 52treatments  ¥  100 participants) were analyzed in an attempt to identify theirunderlying criteria of prioritization. Attempts were made to capture laypeopleopinions without forcing responses to fit preexisting criteria identified in theliterature. Every new answer was assessed on the basis of the previously definedcriteria and, if it did not fit any of them, a new criterion was identified. Theprocedure continued until all the material had been examined. At the end of thisphase, 24 different criteria had been identified; some of them included subcriteriarelated to specific types of treatments (e.g., drug users, terminal patients; total of 31). The judges reached a 100% agreement.In the second step, the two independent judges evaluated the participants’answers by classifying them into one of the categories previously identified. Afurther category was added, including answers that were difficult to classify. Of the 5,200 answers, 4,801 could be classified into one of the 24 criteria categories,257 were missing (4.9%), and 142 were of difficult classification (2.7%). A decision ALLOCATION OF MEDICAL RESOURCES  17
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