Daunted by dollars? Many docs self-report rationing MRI

If more than 2,500 physicians responding to a national survey reflect the changing state of clinical decision-making, MRI is frequently getting rationed due to doctors’ concerns about cost. In fact, only drug prescriptions are curtailed more—and not by much.

The picture on who’s refraining from ordering what over money jitters has come into focus thanks to a new study published online July 20 in the Journal of General Internal Medicine.

The Mayo Clinic’s Robert Sheeler, MD, and colleagues snail-mailed the survey to 3,872 physicians in 2012. The reach-out drew an impressive 65.6 percent response, as 2,541 physicians filled in and returned the forms.

The researchers used neutral language to get recipients to self-report clinical decisions made over the preceding six months. Meanwhile they embedded an experimental component to test the influence of the word “ration” on perceived personal responsibility.

The team’s most striking finding:

More than half of respondents (53.1 percent, n = 1,348) reported refraining from using one or more of 10 specific clinical services despite their awareness that said service would have provided the best patient care.

Some 44.5 percent had said no to MRI, while 48.3 percent declined to prescribe drugs.

Around one-fourth had rationed MRI at least monthly.

Among the least frequently rationed services were referral to an intensive care unit (10.9 percent), hospital admission (18.8 percent) and referral for surgery (20.2 percent).

Also getting rationed less often than drugs and MRI, where applicable, were routine radiography, lab tests, screening tests, referral to a specialist and referral for dialysis.

Other findings of interest:

• Surgical and procedural specialists were less likely to report rationing behavior compared to primary care doctors.
• Compared with small or solo practices, respondents in medical school settings reported less rationing.  
• Physicians who self-identified as very or somewhat liberal were significantly less likely to report rationing than those self-reporting being very or somewhat conservative.

In their discussion, Sheeler et al. consider the disconnect between what physicians consider the best clinical course and what they quite often do—out of concern over cost—to act against their own best clinical judgment.

“One explanation of the discordance between opinion and behavior is the possibility of implicit, subconscious factors influencing clinical decision-making,” they write. “We recognize that a variety of circumstances may cause physicians to choose a less costly service, such as the desire to reduce patient out-of-pocket expense, not all of which would fall under a narrow definition of rationing.”

“Even with a conservative definition of what constitutes ‘bedside rationing,’ however, we found that a significant number of U.S. physicians reported such behavior.”

JGIM publisher Springer has posted the full study for free.