title: Situation testing: the case of health care refusal.
abstract: BACKGROUND
  Situation testing to assess physicians' refusal to provide healthcare is increasingly used in research studies. This paper aims to explain the relevance and limits of this method.
  
  
  METHODS
  Conducted in 2008-2009, this study was designed to assess the rate of healthcare refusal among several categories of private practitioners toward patients covered by the French public means-tested complementary health insurance (CMUc) when they requested a first appointment by phone. The other objectives were to study the determinants of healthcare refusal and assess the method. The study was conducted on a representative sample of Paris-based dentists and physicians in five categories: general practitioners, medical gynecologists, ophthalmologists, radiologists, and dentists.
  
  
  RESULTS
  The method was based on two protocols. In the first scenario, an actor pretended to be a CMUc beneficiary and, in the second one, he did not give information about his health coverage but hinted at a low socioeconomic status. The two protocols were compared and procedures checking the relation between refusal and CMUc coverage were implemented in each of them. In the scenario in which the patient declared being a CMUc beneficiary, the results showed different refusal rates depending on the type of practitioner, physician, or dentist, their specialty, and whether or not, they charge more than the standard set fee. In the second scenario, refusal rates were much lower. The comparison of the two protocols seems to confirm the existence of discrimination based on CMUc affiliation rather than patients' socioeconomic status.
  
  
  CONCLUSIONS
  The discussion presents the limits of situation testing, which remains an experimental instrument because it does not observe reality but reveals behaviors in situation. The findings cannot be extrapolated and are limited in time. The statistical analysis is only valid if the procedure followed is precise and applied consistently using a preset scenario. In addition, the discriminatory nature of the refusal (CMUc coverage) must be confirmed by a validation procedure (unless clearly stated by the interlocutor).
authors.affiliation: IRDES, 10, rue Vauvenargues, 75018 Paris, France. despres@irdes.fr
authors.forename: C
authors.initials: C
authors.lastname: Després
authors.forename: P-E
authors.initials: PE
authors.lastname: Couralet
mesh_terms: D001291:Attitude of Health Personnel; D003815:Dentists / Q000706:statistics & numerical data; D005602:France / Q000453:epidemiology; D058005:General Practitioners / Q000706:statistics & numerical data; D006176:Gynecology / Q000706:statistics & numerical data; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data*; D009885:Ophthalmology / Q000706:statistics & numerical data; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians'; D011331:Private Practice / Q000706:statistics & numerical data*; D011785:Quality Assurance, Health Care; D011871:Radiology / Q000706:statistics & numerical data; D016079:Refusal to Treat / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012494:Sampling Studies; D013997:Time Factors; D019472:Universal Health Insurance / Q000706:statistics & numerical data