Systematic review: Factors associated with return to work in burnout.

BACKGROUND: Professional burnout predicts sick leave and even permanent withdrawal from the labour force. However, knowledge of the barriers to and facilitators of return to work (RTW) in such burnout is limited. AIMS: To identify factors associated with RTW of burned-out individuals to inform occupational health care (OHC) RTW policy. METHODS: A systematic search of peer-reviewed quantitative and mixed-method studies published from January 2005 to July 2016 in English and Finnish in ARTO, CINAHL (EBSCO), Medic, PsycINFO (ProQuest), PubMed, Scopus and Web of Science databases, followed by a manual search. We included studies that identify burnout with valid burnout measures and measure the degree of RTW or sick leave as outcomes. We excluded studies with heterogeneous samples without subgroup analyses of RTW in burnout cases. RESULTS: We included 10 studies (three experimental and seven observational) of the initial 1345 identified. The studies reported work-related factors; enhanced communication (positive association) and low control at work (negative association) and individual-related factors; male gender (positive association), covert coping (negative association), high over-commitment to work (positive association) and burnout-related factors; unimpaired sleep (positive association), duration of sick leave over 6 months (negative association) and part-time sick leave (positive association) associated with RTW in burnout. Associations between burnout rehabilitation and RTW, and the level of symptoms and cognitive impairment and RTW remained unclear. CONCLUSIONS: Few quantitative studies, of varied methodological quality, explore factors associated with RTW in burnout. Further research is needed to build an evidence base and develop guidelines for supportive OHC actions.

Economic evaluation of exercise-based cardiac rehabilitation in patients with a recent acute coronary syndrome.

Health care decision-making requires evidence of the cost-effectiveness of medical therapies. We evaluated the cost-effectiveness of exercise-based cardiac rehabilitation (ECR) implemented according to guidelines. All the patients (n = 204) had experienced a recent acute coronary syndrome and were randomized to a 1-year ECR (n = 109) or usual care (UC) group (n = 95). The patients' health-related quality of life was followed using the 15D instrument and health care costs were collected from electronic health registries. The cost-effectiveness of ECR was estimated based on intervention and health care costs and quality-adjusted life years (QALYs) gained. The total average cost per patient was lower in ECR than in UC. The incremental cost was divided by the baseline-adjusted incremental QALYs (0.045), yielding an incremental cost-effectiveness ratio of -€24511/QALYs. A combined endpoint of mortality, recurrent coronary event, or hospitalization for a heart failure occurred for five patients in ECR and 16 patients in UC (HR 3.9, 95% CI 1.4-10.6, P = 0.004, relative risk reduction 73%, number needed to treat eight). ECR is a dominant treatment option and decreases the occurrence of adverse cardiac events. These results are useful for decision-making when planning optimal utilization of resources in Finnish health care.

Primary-care-based episodes of care and their costs in a three-month follow-up in Finland.

OBJECTIVE: To explore patient characteristics, resource use, and costs related to different episodes of care (EOC) in Finnish health care. DESIGN: Data were collected during a three-month prospective, non-randomized follow-up study (Effective Health Centre) using questionnaires and an electronic health record. SETTING: Three primary health care practices in Pirkanmaa, Finland. SUBJECTS: Altogether 622 patients were recruited during a one-week period. Inclusion criteria: the patient had a doctor's or nurse's appointment on the recruiting day and agreed to participate. Exclusion criteria: patients visiting a specialized health guidance clinic for pregnant women, children, and mothers. MAIN OUTCOME MEASURES: Patient characteristics, resource use, and costs based on the ICPC-2 EOC classification. RESULTS: On average, the patients had 1.22 EOCs during the three months. Patient characteristics and resource use differed between the EOC chapters. Chapter L, "Musculoskeletal", had the most episodes (17%). The most common (8%) single EOC was "upper respiratory infection". The mean cost of an episode (COE) was €389.56 (standard error 61.11) and the median COE was €165.00 (interquartile range €118.46-288.56) during the three-month follow-up. The most expensive chapter was K, "Circulatory", with a mean COE of €909.85. The most expensive single COE was in chapter K, €32 545.56. The most expensive 1% of the COEs summed up covered 36% of the total COEs. CONCLUSION: Patient characteristics, resource use, and costs differed between the ICPC-2 chapters, which could be taken into account in service planning and pricing. Future studies should incorporate more specific diagnoses, larger data sets, and longer follow-up times. Key points The most common episodes were under the ICPC-2 "Musculoskeletal" chapter, but the highest mean and single-episode costs were related to the "Circulatory" chapter. The mean (median) cost of episodes that started in primary care was €390 (€165) during the three-month follow-up. Patient characteristics, resource use, and costs differed significantly between the ICPC-2 chapters. The most expensive 1% of the episodes covered 36% of the total costs of all the episodes.

Efficacy of a multicomponent support programme for the caregivers of disabled persons: a randomised controlled study.

AIM: The goal of the present work was to measure the efficacy of a multicomponent programme designed to provide tailored support for the caregivers of disabled persons. SUBJECTS: A total of 135 caregivers-care receiver dyads were randomly divided into an intervention group (n = 66) and a control group (n = 69). One-third of the care receivers were demented, and two-thirds had other diseases. SETTING: Health centres (publicly funded primary health care systems) in 8 rural and urban communities in southeast Finland. INTERVENTION: The multicomponent support programme for the caregivers consisted of a 2-week rehabilitation period. The control group received standard care. OUTCOME MEASUREMENTS: Continuation of the caregiver and care receiver relationship, care receiver mortality at the 2-year follow-up as well as the health-related quality of life (15D scale) and Zung's depression scale of the caregiver at the 1-year follow-up were evaluated. RESULTS: At the 2-year follow-up, the caregiver-care receiver relationship was terminated for any reason in 11 cases (17%) in the intervention group, and in 25 cases (36%) in the control group. After adjusting, the primary outcome (i.e., termination of care giving for any reason) indicated statistical significance (p = 0.04) with a hazard rate of 1.83 (95% confidence interval 1.03-3.29). With a similar adjustment, the difference in mortality and placement to institutional care between the two groups demonstrated a trend towards statistical significance. The caregivers' health, as related to quality of life and depressive symptoms, remained unchanged in both groups at the 1-year follow-up. CONCLUSION: These results indicate that a tailored support programme for caregivers may help the caregiver to continue the caregiver-care receiver relationship and delay institutionalization.

Economic evaluation comparing From Home To Operation same day admission and preoperative admission one day prior to the surgery process: a randomized, controlled trial of laparoscopic cholecystectomy.

OBJECTIVE: A novel preoperative procedure From Home To Operation (FHTO) seeks to combat increasing operation and infection rates. This is the first prospective randomized controlled trial (RCT) comparing the cost-effectiveness and cost-utility of FHTO and conventional ward procedures for standardized Laparoscopic Cholecystectomy (LC). RESEARCH DESIGN AND METHODS: During 12/2004-7/2005, 47 patients with symptomatic gallstones were randomized to receive LC in the FHTO (28 patients) or in a conventional manner (19 patients) in a Finnish hospital setting. The 15D quality of life tool was administered at the baseline and 1 month after. MAIN OUTCOME MEASURES: A stochastic approach over a month interval for hospital costs, length of postoperative stay, infection rate and Quality-Adjusted Life Years (QALY) was employed. RESULTS: Baseline group characteristics were similar. The mean health care costs with FHTO (1695 EUR) were significantly lower (p < 0.001) than in the conventional arm (2234 EUR). The number of patients discharged on the first postoperative day was 27 (96.4%) and 15 (78.9%) with two (7.1%) infections in the FHTO and four (21.1%) in the conventional arm. A difference in QALYs gained (0.0174; p = 0.030) favouring FHTO was observed. According to a cost-effectiveness acceptability curve, the probability of FHTO being cost-effective was 99%. The results were robust to probabilistic sensitivity analyses. CONCLUSIONS: FHTO can introduce substantial cost savings and have a positive impact on both clinical measures and quality of life. Studies with larger numbers of patients are needed to assess whether conventional ward procedure can be a source of infections, which can be avoided with FHTO. CLINICAL TRIAL REGISTRY: ICJME-qualified registry of the Hospital District of Helsinki and Uusimaa (number 217849).

Attitudes towards euthanasia among physicians, nurses and the general public in Finland.

The object of this study was to investigate the attitudes of physicians, nurses and the general public to physician-assisted suicide (PAS), active voluntary euthanasia (AVE) and passive euthanasia (PE) in Finland. Respondents received a postal questionnaire to evaluate the acceptability of euthanasia in five scenarios, which were imaginary patient cases. Age, severity of pain and prognosis of the disease were presented as background factors in these scenarios. This work was carried out in Finland in 1998. The respondents include a random selection of 814 physicians (506 responded, 62%), 800 nurses (582 responded, 68%) and 1000 representatives of the general public (587 responded, 59%).Thirty-four percent of the physicians, 46% of the nurses and 50% of the general public agreed that euthanasia would be acceptable in some situations. Of the scenarios, PE was most often considered acceptable in cases of severe dementia (physicians 88%, nurses 79% and general public 64%). In the same scenario, 8% of physicians, 23% of nurses and 48% of general public accepted AVE. In the scenario of an incurable cancer, 20% of the physicians, 34% of the nurses and 42% of the general public accepted PAS. All forms of euthanasia were generally more acceptable in older, than in younger, scenario patients. This paper conclude that PE was largely accepted among Finnish medical professionals and the general public. Only a minority favored AVE and PAS.

The quantitative risk of violent crime and criminal offending: a case-control study among the offspring of recidivistic Finnish homicide offenders.

OBJECTIVE: To study if later risk of violent offending and criminality among high-risk children can be estimated quantitatively on the basis of parental crimes. METHOD: The criminal and prison records of the offspring (N=11) of homicide recidivists (N=36) were compared with data from controls (N=220) who were matched for sex, domicile of birth and date of birth and death. RESULTS: The risk (odds ratio) was increased up to 24-fold for violent crimes (P=0.01), and up to 17-fold for criminality (P=0.0008) among the offspring of homicide recidivists. CONCLUSION: The quantitative risk of a child for later violent offending and criminality can be estimated on the basis of parental homicide recidivism. This kind of method could be used to choose target groups for early preventive interventions, and to study the effectiveness of prevention.

General practitioners' willingness to request plain lumbar spine radiographic examinations.

OBJECTIVES: To examine general practitioners' attitudes to plain lumbar spine radiographic examinations. DESIGN: A postal questionnaire consisting of questions on background data and doctors' opinions about plain lumbar spine radiographic examinations, as well as eight vignettes (imaginary patient cases) presenting indications for lumbar radiography, and five vignettes focusing on the doctors' willingness to request lumbar radiography on the basis of patients' age and duration of symptoms. The data were analysed according to the doctor's age, sex, workplace and the medical school of graduation. SETTING: Finland. SUBJECTS: Six hundred and fifteen randomly selected physicians working in primary health care (64% of original target group). RESULTS: The vignettes revealed that the use of plain lumbar radiographic examination varied between 26 and 88%. Patient's age and radiation protection were the most prominent factors influencing doctors' decisions to request lumbar radiographies. Only slight differences were observed between the attitudes of male and female doctors, as well as between young and older doctors. Doctors' willingness to request lumbar radiographies increased with the patient's age in most vignettes. The duration of patients' symptoms had a dramatic effect on the doctor's decision: in all vignettes, doctors were more likely to request lumbar radiography when patient's symptoms had exceeded 4 weeks. CONCLUSIONS: General practitioners commonly use plain lumbar spine radiographic examinations, despite its limited value in the diagnosis of low back pain. Further consensus and medical education is needed to clarify the indications for plain lumbar radiographic examination.

Lack of association between the functional variant of the catechol-o-methyltransferase (COMT) gene and early-onset alcoholism associated with severe antisocial behavior.

Addictive drugs, including ethanol, increase the brain's dopaminergic transmission, and catechol-o-methyltransferase (COMT) enzyme has a crucial role in dopamine inactivation. A common functional polymorphism in the COMT gene results in a three- to four-fold variation in enzyme activity. In a previous study, we found an association between type 1 (with late-onset but without prominent antisocial behavior) alcoholism and the low activity allele of the COMT gene. In this work we analyzed whether the COMT polymorphism has any effect on the development of type 2 (with early-onset and habitual impulsive violent behavior) alcoholism. The COMT genotype was determined in 62 impulsive violent recidivist offenders with early-onset (type 2) alcoholism, 123 late-onset nonviolent (type 1) alcoholics, and 267 race and gender-matched controls. The allele and genotype frequencies of these groups were compared with each other and also with previously published data from 3,140 Finnish blood donors. The type 2 alcoholics did not differ from either the blood donors or the controls. The low activity (L) allele frequency was higher among type 1 alcoholics (chi(2) = 4.98, P = 0.026) when compared with type 2 cases. The odds ratio for type 1 alcoholism as compared with type 2 alcoholism for those subjects with the LL genotype versus the HH genotype was 3.0 (95% confidence interval 1.1-8.4, P = 0.017). The results suggest that COMT genotype has no major role in the development of early-onset alcoholism with severe antisocial behavior.

Prioritization attitudes among doctors and nurses examined by a scenario method.

OBJECTIVES: To investigate doctors' and nurses' attitudes toward 14 potential prioritization criteria. METHODS: This study was performed by using the random paired scenario method. The respondents received a questionnaire with 12 pairs of scenarios, imaginary patient cases, each of which contained two to three different prioritization criteria (e.g., child, old patient, poor patient). Respondents were asked which one of each scenario pair they would choose if only one patient could be treated. The scenarios were randomly put into 30 different questionnaire sets. There was a random selection of 241 doctors and 151 nurses in Finland, with response rates of 60.3% and 50.3%, respectively. RESULTS: Doctors prioritized young patients, severe disease, expensive treatments and posteriorized (negatively prioritized) demented or institutionalized patients, and patients having a self-caused disease. Children were strongly prioritized, even over serious diseases. Expensive treatments appeared to be favored by doctors, and this result cannot be explained by severity of disease. Nurses' attitudes were similar to those of doctors. CONCLUSIONS: Children were strongly prioritized. Elderly persons were posteriorized if they had dementia or were living in institutions. Patients having a self-caused disease are posteriorized, more often by nurses than by doctors.

Attitudes to health care prioritisation methods and criteria among nurses, doctors, politicians and the general public.

The aim of this postal questionnaire study was to measure attitudes to health care prioritisation criteria among the Finnish general public (n = 1156), politicians (n = 1096), doctors (n = 803) and nurses (n = 667), altogether 3722 subjects. The questionnaire consisted of questions on background data, a list of seven alternative prioritisation methods and a list of 11 possible criteria for health care prioritisation. The most acceptable prioritisation methods were increased treatment fees and restricting expensive treatments and examinations. Only a few supported administrative prioritisation decisions. One third of the general public indicated that they did not accept any limitations in health care, whereas only 5% of doctors agreed with them. More doctors accepted prioritisation methods than respondents in other groups. Patient is a child, patient is an elderly person, severity of the disease and prognosis of the disease were the most accepted prioritisation criteria. Politicians and the general public also accepted self-induced nature of disease and patient's wealth as prioritisation crieteria. Logistic regression analysis of the general public respondents demonstrated that male gender, higher education and higher personal income were associated with acceptance of most prioritisation criteria. Similarly, older age of the respondent was associated with acceptance of self-induced nature of disease and patient's wealth as prioritisation criteria.

Association between low activity serotonin transporter promoter genotype and early onset alcoholism with habitual impulsive violent behavior.

A common 44-base pair insertion/deletion polymorphism in the promoter region of the human serotonin transporter (5-HTT) gene has been observed to be associated with affective illness and anxiety-related traits. This biallelic functional polymorphism, designated long (L) and short (S), affects 5-HTT gene expression since the S promoter is less active than the L promoter. Since there is strong evidence of a disturbance in brain serotonergic transmission among antisocial, impulsive, and violent type 2 alcoholic subjects, we decided to test the hypothesis that the frequency of the S allele, which is associated with reduced 5-HTT gene expression, is higher among habitually violent type 2 alcoholics when compared with race and gender-matched healthy controls and non-violent late-onset (type 1) alcoholics. The 5-HTT promoter genotype was determined by a PCR-based method in 114 late onset (type 1) non-violent alcoholics, 51 impulsive violent recidivistic offenders with early onset alcoholism (type 2), and 54 healthy controls. All index subjects and controls were white Caucasian males of Finnish origin. The S allele frequency was higher among type 2 alcoholics compared with type 1 alcoholics (chi2 = 4.86, P = 0.028) and healthy controls (chi2 = 8.24, P = 0.004). The odds ratio for SS genotype vs LL genotype was 3.90, 95% Cl 1.37-11.11, P = 0.011 when type 2 alcoholics were compared with healthy controls. The results suggest that the 5-HTT 'S' promoter polymorphism is associated with an increased risk for early onset alcoholism associated with antisocial personality disorder and impulsive, habitually violent behavior.

Association between the functional variant of the catechol-O-methyltransferase (COMT) gene and type 1 alcoholism.

Catechol-O-methyltransferase (COMT) is an enzyme which has a crucial role in the metabolism of dopamine. It has been suggested that a common functional genetic polymorphism in the COMT gene, which results in 3 to 4-fold difference in COMT enzyme activity, may contribute to the etiology of mental disorders such as bipolar disorder and alcoholism. Since ethanol-induced euphoria is associated with the rapid release of dopamine in limbic areas, it is conceivable that subjects who inherit the allele encoding the low activity COMT variant would have a relatively low dopamine inactivation rate, and therefore would be more vulnerable to the development of ethanol dependence. The aim of this study was to test this hypothesis among type 1 (late-onset) alcoholics. The COMT polymorphism was determined in two independent male late onset (type 1) alcoholic populations in Turku (n = 67) and Kuopio (n = 56). The high (H) and low (L) activity COMT genotype and allele frequencies were compared with previously published data from 3140 Finnish blood donors (general population) and 267 race- and gender-matched controls. The frequency of low activity allele (L) was markedly higher among the patients both in Turku (P = 0.023) and in Kuopio (P = 0.005) when compared with the general population. When all patients were compared with the general population (blood donors), the difference was even more significant (P = 0.0004). When genotypes of all alcoholics (n = 123) were compared with genotypes of matched controls, the odds ratio (OR) for alcoholism for those subjects having the LL genotype vs those with HH genotype was 2.51, 95% CI 1.22-5.19, P = 0.006. Also, L allele frequency was significantly higher among alcoholics when compared with controls (P = 0.009). The estimate for population etiological (attributable) fraction for the LL genotype in alcoholism was 13.3% (95% CI 2.3-25.7%). The results indicate that the COMT polymorphism contributes significantly to the development of late-onset alcoholism.

Low diastolic blood pressure and mortality in a population-based cohort of 16913 hypertensive patients in North Karelia, Finland.

OBJECTIVE: To examine the relationship between mortality and diastolic blood pressure during treatment. DESIGN: A prospective follow-up of a population-based dynamic cohort of hypertensive patients. SETTING: Province of North Karelia, eastern Finland. PATIENTS: A cohort of 16 913 North Karelian hypertensive patients in hypertension register of the North Karelia Project, who had been followed up since 1972 until the end of 1985. Most of these patients had been under antihypertensive drug therapy during the follow-up. MAIN OUTCOME MEASURES: Death: all deaths (n = 4490), deaths from cardiovascular disease (n = 2995) and deaths from non-cardiovascular disease (n = 1495). RESULTS: Of all deaths, 17% of those among men and 24% of those among women were of patients with mean diastolic blood pressures less than 90 mmHg. We found a U-shaped relationship between diastolic blood pressure and total, cardiovascular and non-cardiovascular mortalities. We investigated this relationship in more detail using Cox regression model. Low diastolic blood pressure was associated independently with increased mortality for the patients aged 50 years or more at baseline. The occurrence of cardiac failure and other cardiovascular complications of hypertension were more important determinants of mortality than was low diastolic blood pressure alone. CONCLUSIONS: We demonstrated that there is an association between low diastolic blood pressure and mortality for treated hypertensive patients aged 50-69 years. The clinical importance of this relationship for patients without any cardiovascular complications of hypertension seems negligible. For patients with complications, these complications are likely to be primary factors causing greater than normal mortality and low diastolic blood pressure is mostly a secondary phenomenon. Our data do not lend support to speculations that there is overtreatment of hypertension, which would increase mortality through making diastolic blood pressures too low.

Striatal presynaptic dopamine function in type 1 alcoholics measured with positron emission tomography.

Recent in vivo studies have shown low dopamine D2 receptor and dopamine transporter densities among late onset (type 1) alcoholics. We have now studied 6-[18F]-FDOPA (FDOPA) uptake in 10 type 1 alcoholics and eight matched controls to test the hypothesis that striatal presynaptic dopamine function is lower among alcoholics. Markedly low FDOPA uptake (Ki) was observed in the left caudate of two alcoholic patients, but the mean striatal uptake values of the patient group were higher than those of the control group. The greatest difference was observed in the mean FDOPA intake in the left putamen, which was 28% higher in the patient group (t = 3.00, P = 0.008, d.f. = 16, independent samples t-test), and in the right caudate (difference 36%, t = 2.87, P = 0.01). The elevated FDOPA uptake in putamen and caudate correlated with poor Wisconsin Card Sorting Test (WCST) performance (error %) among alcoholics (correlation coefficients from 0.49 to 0.56), which suggests that the magnitude of presynaptic dopamine function alteration correlates with the degree of disability to modify one's behavior. The results do not give support to the hypothesis of generally decreased striatal dopamine turnover in type 1 alcoholism, but on the contrary indicate an increased presynaptic dopamine function. This may represent a compensatory mechanism to low postsynaptic DA function. The low presynaptic DA function observed in the left caudate of two patients suggests that type 1 alcoholism may be a heterogeneous disorder.

Health care priorities as a problem of local resource allocation.

The aim of this study was to examine attitudes to prioritization in health care among the general public, politicians, doctors and nurses. The focus in this paper is on the types of services from a perspective that is 'policy analytical'. This study forms part of the wider 'Prioritization in Health Care Project' carried out at the University of Kuopio exploring patient treatment level prioritizations. Data were collected by a postal questionnaire in 1995. Four groups were established for the study: (1) a general public sample of 2000 subjects, (2) a random sample of 1000 nurses, (3) a random sample of 1500 medical doctors and (4) a sample of 2200 politicians involved in social and health care administration. Respondents were asked to make value choices between specialized and primary health care services in a real budget situation. One of the most salient findings in this study was that attitudes towards priorities are context-dependent. Certain differences were observed between the groups studied. The attitudes of the general public and nurses were quite similar, while similar views were shared by politicians and doctors. The attitudes of the respondents reflect well what has actually happened in Finnish health care, with the exception of psychiatric services which have undergone drastic cuts.

Doctors' willingness to refer elderly patients for elective surgery.

OBJECTIVES: We aimed to examine the relationship between doctors' willingness to refer elderly patients for elective surgical operations and patients' age, comorbidity, institutionalization, living habits and signs of dementia. METHOD: A random selection of 837 medical doctors in Finland (response rate 56%) received a postal questionnaire consisting of 18 vignettes, i.e. imaginary patient cases. Respondents were asked whether they would refer the patient on the vignette for elective surgical operation, treat the patient conservatively, or choose some other alternative. In the vignettes, the age of patients was randomly varied between 65 and 85, at 5-year intervals, to provide eight different questionnaires, and each respondent obtained one of them. RESULTS: The proportion of doctors willing to refer the patients for surgery was inversely related to the patients' age: in all the vignettes, doctors said they would refer fewer patients in the oldest age groups. Almost all the doctors claimed they would refer healthy, home-dwelling persons aged 65-70 years for operations. In the oldest age groups of patients, the doctors' willingness to refer was highest for cataract operations (69%) and hip prosthesis operations (63%), but only 18% of doctors would refer such patients for coronary by-pass operations. Comorbidity and institutionalization were associated with fewer doctors referring the patients: the proportion of doctors willing to refer these patients was about half that of those willing to refer otherwise healthy and home-dwelling patients. Smoking by patients also decreased the proportions of doctors willing to refer, but moderate signs of dementia in an elderly patient with cataract were associated with only a slight decrease in referring. CONCLUSIONS: Doctors are less willing to refer old patients for elective surgery, but comorbidity, patients' lifestyle and institutionalization have a greater effect on referrals than age.

Attitudes to cuts in expenditure and increased fees in health care.

The aim of this postal questionnaire study was to measure attitudes to cuts and increased fees in health care in various Finnish population groups. Four groups were identified; a population sample of 2000 subjects, aged 18-70 y; a random sample of 1500 medical doctors of working age; a random sample of 1000 nurses of working age; and a sample of 2200 politicians involved in health and social care administration, mostly at the municipal level (altogether 6700 subjects). The main questionnaire included, among other things, the following questions: (1) Which of 18 specified medical activities at the primary health care level could be cut without causing severe harm to the population? (2) For which of 13 specified medical activities should clients pay at least 50% of the real cost? All the groups indicated the greatest willingness to cut expenditure on health education, occupational health services, hygiene inspection, substance abuse care, rehabilitation services for war veterans, and family planning. All the groups were least willing to make cuts in home care for disabled and elderly people, maternity services and clinics for under-fives. Most respondents in all groups felt that the activities for which clients should pay at least 50% of the cost were visits to physicians, occupational health services and dental services, whereas clinics for under-five and home care for disabled and elderly persons should be kept free of charge. As a conclusion, primary health care and prevention of diseases for small children, mothers, the elderly and disabled persons, were prioritised by all the groups.

Comparison of doctors', nurses', politicians' and public attitudes to health care priorities.

OBJECTIVES: The aim of this study was to investigate differences in attitudes concerning prioritisation in health care held by doctors, nurses, local politicians and the general public. METHODS: Four groups were established: a population sample of 2000 subjects, aged 18-70 years; a random sample of 1500 doctors of working age; a random sample of 1000 nurses of working age; and a sample of 2200 politicians involved in health and social care administration, mostly at the municipal level (altogether 6700 subjects). The main questionnaire contained, among other things, a list of 12 statements concerning ethical decisions regarding prioritisation in health care. Respondents were asked to indicate their level of agreement with each statement. RESULTS: Most respondents in all the groups felt able to express an opinion on the statements. Despite considerable professional and cultural differences between groups, the views were generally similar. On the whole, respondents supported liberal policies in which the community took responsibility for subsidising health care. When differences between groups occurred, it was usually the doctors who held discordant views. Doctors were less inclined to consider a patient's economic status as a determinant of priority for treatment than the other three groups. Both doctors and nurses were less punitive towards patients with self-induced diseases. And doctors and politicians were more likely to feel further cuts in health care expenditure were possible than was true for nurses and the public. CONCLUSIONS: While considerable uniformity of opinion exists on ethical issues of prioritisation between the principal interested parties, the views of doctors differ substantially on some matters. If prioritisation was left entirely to doctors, health care provision would not reflect the views of other groups in some important ways.