Patient choice modelling: how do patients choose their hospitals?

Sociodemographic and health system factors associated with variations in hospitalization costs for rheumatic diseases in adults aged 45 years and older: A cross-sectional study of provincial health accounts in Jiangsu Province, China

AIM

To report the cost of hospitalization and the associated risk factors for rheumatic diseases in middle-aged and elderly patients in China.

METHODS

The study participants included inpatients from hospitals of various levels in the Jiangsu Province Health Account database in 2016. Participants were selected by using a multistage sampling method. Patients <45 years of age were excluded, and patients hospitalized for rheumatic diseases were identified according to the 10th edition of the International Classification of Diseases. Generalized linear models were used to analyze the sociodemographic characteristics related to the hospitalization costs of patients with rheumatic diseases.

RESULTS

The study included 3696 patients. The average cost of hospitalization for patients with rheumatic diseases was USD 4038.63. Female sex, a long length of stay, age between 65 and 74 years, free medical care, not being covered by the Urban-Rural Residents Basic Medical Insurance, and a high hospital level were associated with high hospitalization costs.

CONCLUSION

This study examined hospitalization costs and relevant influencing factors in middle-aged and elderly patients with rheumatic disease in China. Our findings are useful for further research on costs of disease and the economic evaluation of strategies to prevent rheumatic disease.

Social Medical Insurances, Choices of Medical Institutions and the 'Siphon Effect' in the Health Service Market: Evidence from 2021 Yangtze River Delta Region of China

Purpose

The siphon effect in the health service market is notably pronounced in many countries. How to measure and identify the determinants contributing to the siphon effect presents a substantial challenge. This study aimed to analyse the effect of two different social medical insurances, the Basic Medical Insurance System for Urban Employees (BMISUE), and the Basic Medical Insurance System for Urban and Rural Residents (BMISURR), on the siphon effect in the health services market.

Methods

The data used in this study were from the 2021 Health Life Satisfaction Survey of Yangtze River Delta (HLSSYRD) conducted by Shanghai Jiao Tong University. The logistic model was used to evaluate the association between social medical insurances and individual choices of medical institutions, and the Propensity Score Matching method (PSM) was used to check the robustness of basic results.

Results

Residents covered by BMISUE were more likely to choose a general hospital when they first sought medical treatment (OR = 5.377, 95% CI: 4.887, 5.915) relative to those insured by BMISURR. Further analysis showed that BMISUE would accelerate the siphon effect of general hospitals, people insured by BMISUE were still more likely to choose general hospitals despite being close to primary hospitals compared to those insured by BMISURR (OR = 3.240, 95% CI: 2.945, 3.565). Heterogeneity analysis indicated BMISUE had a greater impact on residents aged 15-59 years and those with high income compared to older people and individuals with low income.

Conclusion

Different social medical insurances can substantially affect residents' first choice of medical institutions. BMISUE with higher benefits level could exacerbate the siphon effect in the health service market. More equitable medical security system should be strengthened to bridge the benefits gap between BMISUE and BMISURR.

Driving time drives the hospital choice: choice models for pelvic organ prolapse surgery in Italy

OBJECTIVE

The Italian healthcare jurisdiction promotes patient mobility, which is a major determinant of practice variation, thus being related to the equity of access to health services. We aimed to explore how travel times, waiting times, and other efficiency- and quality-related hospital attributes influenced the hospital choice of women needing pelvic organ prolapse (POP) surgery in Tuscany, Italy.

METHODS

We obtained the study population from Hospital Discharge Records. We duplicated individual observations (n = 2533) for the number of Tuscan hospitals that provided more than 30 POP interventions from 2017 to 2019 (n = 22) and merged them with the hospitals' list. We generated the dichotomous variable "hospital choice" assuming the value one when hospitals where patients underwent surgery coincided with one of the 22 hospitals. We performed mixed logit models to explore between-hospital patient choice, gradually adding the women's features as interactions.

RESULTS

Patient choice was influenced by travel more than waiting times. A general preference for hospitals delivering higher volumes of interventions emerged. Interaction analyses showed that poorly educated women were less likely to choose distant hospitals and hospitals providing greater volumes of interventions compared to their counterpart. Women with multiple comorbidities more frequently chose hospitals with shorter average length of stay.

CONCLUSION

Travel times were the main determinants of hospital choice. Other quality- and efficiency-related hospital attributes influenced hospital choice as well. However, the effect depended on the socioeconomic and clinical background of women. Managers and policymakers should consider these findings to understand how women behave in choosing providers and thus mitigate equity gaps.

How to direct patients to high-volume hospitals: exploring the influencing drivers

BACKGROUND

During the last decade, planning concentration policies have been applied in healthcare systems. Among them, attention has been given to guiding patients towards high-volume hospitals that perform better, acccording to the volume-outcome association. This paper analyses which factors drive patients to choose big or small hospitals (with respect to the international standards of volumes of activity).

METHODS

We examined colon cancer surgeries performed in Piedmont (Italy) between 2004 and 2018. We categorised the patient choice of the hospital as big/small, and we used this outcome as main dependent variable of descriptive statistics, tests and logistic regression models. As independent variables, we included (i) patient characteristics, (ii) characteristics of the closest big hospital (which should be perceived as the most immediate to be chosen), and (iii) territorial characteristics (i.e., characteristics of the set of hospitals among which the patient can choose). We also considered interactions among variables to examine which factors influence all or a subset of patients.

RESULTS

Our results confirm that patient personal characteristics (such as age) and hospital characteristics (such as distance) play a primary role in the patient decision process. The findings seem to support the importance of closing small hospitals when they are close to big hospitals, although differences emerge between rural and urban areas. Other interesting insights are provided by examining the interactions between factors, e.g., patients affected by comorbidities are more responsive to hospital quality even though they are distant.

CONCLUSIONS

Reorganising healthcare services to concentrate them in high-volume hospitals emerged as a crucial issue more than forty years ago. Evidence suggests that concentration strategies guarantee better clinical performance. However, in healthcare systems in which patients are free to choose where to be treated, understanding patients' behaviour and what drives them towards the most effective choice is of paramount importance. Our study builds on previous research that has already analysed factors influencing patients' choices, and takes a step further to enlighten which factors drive patients to choose between a small or a big hospital (in terms of volume). The results could be used by decision makers to design the best concentration strategy.

Preferences of patients with diabetes mellitus for primary healthcare institutions: a discrete choice experiment in China

OBJECTIVES

To quantify the preference of patients with diabetes mellitus (DM) for primary healthcare (PHC) institutions in China to redirect the patient flow and improve health outcomes.

DESIGN

Cross-sectional study. Discrete choice experiment (DCE) surveys asked patients with DM to choose between hypothetical institutions that differed in the medical service capacity, out-of-pocket (OOP) medical costs per month, travel time, the attitude of medical staff and the availability of diabetes drugs.

SETTING

Shandong province, China.

PARTICIPANTS

The participants were 887 patients with DM from 36 urban communities and 36 rural villages in Shandong province. One participant did not provide any DCE answers and a further 57 patients failed the internal consistency test. 829 fully completed surveys were included in the final data analysis.

MAIN OUTCOMES AND MEASURES

A mixed logit model was used to calculate the willingness to pay and predict choice probabilities for PHC institution attributes. Preference heterogeneity was also investigated.

RESULTS

All five attributes were associated with the preferences of patients with DM. The OOP medical costs and the medical service capacity were the most influential attributes. Improvements simultaneously in the attitude of medical staff, drug availability and travel time increased the likelihood of a patient's PHC institution choice. Preferences differed by region, annual household income and duration of diabetes.

CONCLUSIONS

Our patient preference data may help policymakers improve health services and increase acceptance of choosing PHC institutions. The OOP medical costs and medical service capacity should be regarded as a priority in decision-making.

Health service behaviors of migrants: A conceptual framework

Universal health coverage is vital to the World Health Organization's (WHO's) efforts to ensure access to health as a human right. However, it has been reported that migrants, including both international immigrants and internal migrants, underuse health services. Establishing a conceptual framework to facilitate research on the health service behaviors (HSB) of migrants is particularly important. Many theoretical frameworks explaining the general population's HSB have been published; however, most theoretical frameworks on migrants' HSB only focus on international immigrants without the inclusion of internal migrants. Of note, internal migrants are much more abundant than immigrants, and this group faces similar barriers to HSB as immigrants do. Based on theoretical frameworks of immigrants' HSB and Anderson's behavior model, the author proposes a new conceptual framework of migrants' HSB that includes both immigrants and internal migrants. The new conceptual framework divides the determinants into macro-structural or contextual factors, health delivery system characteristics, and characteristics of the population at risk and describes subgroup-specific factors. The author added some variables and reclassified variables in some dimensions, including characteristics of health delivery systems and access to healthcare. The characteristics of health delivery systems comprise the volume, organization, quality, and cost of the health delivery system, while the characteristics of access to healthcare include time accessibility, geographic accessibility, and information accessibility. The outcomes of HSB have been expanded, and relationships between them have been reported. The mediating effects of some variables have also been described. This conceptual framework can facilitate a deep and comprehensive understanding of the HSB determination process for migrants, including internal migrants.

"Shopping around" for treatment is not a solution to cancer backlog

Ajay Aggarwal and colleagues argue that relying on patient choice to cut waiting times is oversimplistic and likely to widen inequalities

Stable Two-Sided Satisfied Matching for Hospitals and Patients Based on the Disappointment Theory

With the global spread of COVID-19 and the shortage of medical resources, the key to improve the quality of medical services is to solve the problem of hospital–patient matching. This paper constructs a two-sided matching (TSM) model based on the psychological perceptions of hospitals and patients to realize effective matching that maximizes the satisfaction of hospitals and patients. First, we determine the influencing factors of mutual choice between hospitals and patients through investigation and literature and establish a TSM evaluation system to obtain the preference order of hospitals and patients. Then, using disappointment theory, the preference order value is transformed into preference utility, and the preference utility of hospitals and patients is transformed into the perceived utility of hospital and patient satisfaction. Finally, under the constraint of stable matching, a multiobjective optimization model of TSM is established with the goal of maximizing the sum of the perceived utility of hospitals and patients. The optimal TSM results are obtained by solving the model, and an example is given to verify the practicability and effectiveness of the model. The results show that the stable bilateral satisfaction matching model considering the psychological factors of both sides can fully meet the expectations of hospitals and patients and has certain practical value.

Use of hospitals in the New York City Metropolitan Region, by race: how separate? How equal in resources and quality?

BACKGROUND

Although racial and ethnic minorities disproportionately use some hospitals, hospital-based racial and ethnic composition relative to geographic region and its association with quality indicators has not been systematically analyzed.

METHODS

We used four race and ethnicity categories: non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and Asian/Pacific Islander/Alaskan Native/American Indian (API/AIAN), as well as a combined non-NHW category, from the 2010 (latest year publicly available) Medicare Institutional Provider & Beneficiary Summary public use file for 84 hospitals in the New York City region. We assessed the relative distribution of race and ethnicity across hospitals grouped at different geographic levels (region, county, hospital referral region [HRR], or hospital service areas [HSA]) using the dissimilarity index. Hospital characteristics included quality star ratings, essential professional services and diagnostic/treatment equipment, bed size, total expenses, and patients with dual Medicare and Medicaid enrollment. We assessed Spearman's rank correlation between hospital-based racial and ethnic composition and quality/structural measures.

RESULTS

Dissimilarity Index decreases from region (range 30.3-40.1%) to county (range 13.7-23.5%), HRR (range 10.5-27.5%), and HSA (range 12.0-16.9%) levels. Hospitals with larger non-NHW patients tended to have lower hospital ratings and higher proportions of dually-enrolled patients. They were also more likely to be safety net hospitals and non-federal governmental hospitals.

CONCLUSIONS

In the NYC metropolitan region, there is considerable hospital-based racial and ethnic segregation of Medicare patients among non-NHW populations, extending previous research limited to NHB. Availability of data on racial and ethnic composition of hospitals should be made publicly available for researchers and consumers.

3D Differential Equation Model for Patients' Choice of Hospital in China

The number of patients in a hospital is a direct indicator of patients' choice of hospital, which is a complex process affected by many factors. Based on the national medical system and patients' preference for high-grade hospitals in China, this study establishes a three-dimensional differential equation model for calculating the time variation of the number of visits to three grades of hospitals. We performed a qualitative analysis of the system. We carried out a subsequent numerical simulation to analyze the impact on the system when the rate of leapfrog treatment and the maximum capacity of doctors and treatments changed. The results show that the sustainability of China's three levels of hospitals mainly depends on the level of hospital development. The strength of comprehensive health improvement at specific levels is the key to increasing the service efficiency of medical resources.

Effect of hospital attributes on patient preference among outpatient attendants in Wolaita Zone, Southern Ethiopia: discrete choice experiment study

BACKGROUND

Patient preference has preceded the use of health care services, and it has been affected by different hospital attributes. Meanwhile, the number of patients receiving vital health intervention is particularly low in Ethiopia. Therefore, this study aimed to determine the effect of hospital attributes on patient preference for outpatients in the Wolaita area in September 2020.

METHODS

A discrete choice experimental study was applied to determine the effect of hospital attributes on patient preference with a sample size of 1077. The experimental survey was conducted among outpatient attendants selected through a systematic random sampling approach. Six key attributes (competence of healthcare providers; availability of medical equipment and supplies; cost of service; wait time; distance; and hospital reputation) deduced from various hospital attributes were used to elicit the patient preferences. The data was collected from participants through the Open Data Kit application. A random effect probit model with marginal willingness to pay measure and partially log-likelihood analysis was applied to extract important attributes. We used STATA version 15 software for analysis, and the fitness of the model was verified by the calculated p-value for the Wald chi-square with a cut-point value of 0.05.

RESULT

One thousand forty-five patients who received outpatient care participated in the study. The random effect probit results have shown that all hospital attributes included in the study were significantly valued by patients while choosing the hospital (p-value < 0.001). Meanwhile, based on marginal willingness to pay and partial log-likelihood analysis, the competence of health care providers was identified as the most important attribute followed by the availability of medical equipment and supplies in hospitals.

CONCLUSION AND RECOMMENDATION

The results suggested that the quality of health care providers and availability of medical equipment and supply in hospitals would be primary interventional points for improving the patient preference of hospitals. Assessment, education, and training are recommended for enhancing the quality of health care providers. And stock balance checks, inspections, and accreditation are believed to be valuable for improving the availability of equipment and supply in hospitals.

Using Discrete Choice Methodology to Explore the Impact of Patient Room Window Design on Hospital Choice

Evidence-based design has been fundamental to designing healthcare environments for patient outcomes and experience, yet few studies have studied how design factors drive patient choice. 652 patients who recently received care at hospitals across the United States were administered an online discrete choice survey to investigate the factors playing into their choice between hypothetical hospitals. Discrete choice models are widely used to model patient preferences among treatment alternatives, but few studies have utilized this approach to investigate healthcare design alternatives. In the current study, respondents were asked to choose between hypothetical hospitals that differed in patient room design, window features of the room, appointment availability, distance from home, insurance coverage, and HCAHPS ratings. The results demonstrate that patient room design that allowed unobscured access to daylight and views through windows, in-network insurance coverage, closer distance from home, and one-star higher patient experience rating increased the likelihood of a patient's hospital choice. The study broadly explores discrete choice model's applicability to healthcare design and its ability to quantify patient perceptions with a metric meaningful for hospital administrators.

Predictors of patients' choice of hospitals under universal health coverage: a case study of the Nicaraguan capital

BACKGROUND

This study looks at the factors that can shape patients' choice of healthcare providers. Understanding this process can help with making high quality healthcare more accessible for all. We focus on distance, patient's health status, (perceived) quality of healthcare facility, and referrals to investigate how these factors compete in shaping patients' choice of hospitals.

METHODS

This study was carried out in Managua, the capital of Nicaragua. Utilizing an exit-survey, patients were interviewed across five public hospitals in 2017 and then six in 2019 when a new highly-equipped hospital was added to the system. We used a multinomial logit model to investigate patients' preference of a specific hospital over the rest within each wave.

RESULTS

Our results show that being referred to a hospital is the strongest predictor and in some cases, it can increase the relative risk ratio of choosing a facility by a factor of 49 (p < 0.01; 95% CI: 27.39-87.17). For the remaining factors, the hierarchy of importance was less clear-cut yet all these factors remained significantly important at various levels.

CONCLUSIONS

Overall, our results highlight the importance of referral systems in making quality healthcare more equitable. Moreover, with distance also being a key predictor and in the absence of an organized referral system, those with low-income would either be further deprived by having to settle with locally available healthcare (regardless of its quality) or face high amounts of out-of-pocket expenditure when seeking help from the private sector.

Predicting the Travel Distance of Patients to Access Healthcare Using Deep Neural Networks

OBJECTIVE

Improving geographical access remains a key issue in determining the sufficiency of regional medical resources during health policy design. However, patient choices can be the result of the complex interactivity of various factors. The aim of this study is to propose a deep neural network approach to model the complex decision of patient choice in travel distance to access care, which is an important indicator for policymaking in allocating resources.

METHOD

We used the 4-year nationwide insurance data of Taiwan and accumulated the possible features discussed in earlier literature. This study proposes the use of a convolutional neural network (CNN)-based framework to make predictions. The model performance was tested against other machine learning methods. The proposed framework was further interpreted using Integrated Gradients (IG) to analyze the feature weights.

RESULTS

We successfully demonstrated the effectiveness of using a CNN-based framework to predict the travel distance of patients, achieving an accuracy of 0.968, AUC of 0.969, sensitivity of 0.960, and specificity of 0.989. The CNN-based framework outperformed all other methods. In this research, the IG weights are potentially explainable; however, the relationship does not correspond to known indicators in public health.

CONCLUSIONS

Our results demonstrate the feasibility of the deep learning-based travel distance prediction model. It has the potential to guide policymaking in resource allocation. Clinical and Translational Impact Statement- Deep learning technology is feasible in investigating the distance that patients would travel while accessing care. It is a tool that integrates complex interactive variables with highly imbalanced data distributions.

Hospital volume allocation: integrating decision maker and patient perspectives

Planning problems in healthcare systems have received greater attention in the last decade, especially because of the concerns recently raised about the scattering of surgical interventions among a wide number of different facilities that can undermine the quality of the outcome due to the volume-outcome association. In this paper, an approach to plan the amount of surgical interventions that a facility has to perform to assure a low adjusted mortality rate is proposed. The approach explicitly takes into account the existing interaction among patients’ choices and decision makers’ planning decisions. The first objective of the proposed approach is to find a solution able to reach quality in health outcomes and patients’ adherence. The second objective is to investigate the difference among solutions that are identified as optimal by either only one of the actors’ perspective, i.e., decision makers and patients, or by considering both the perspectives simultaneously. Following these objectives, the proposed approach is applied to a case study on Italian colon cancer interventions performed in 2014. Results confirm a variation in the hospital planned volumes when considering patients’ behaviour together with the policy maker plan, especially due to personal preferences and lack of information about hospital quality.

Residential Area Sociodemographic and Breast Cancer Screening Venue Location Built Environmental Features Associated with Women's Use of Closest Venue in Greater Sydney, Australia

Understanding environmental predictors of women’s use of closest breast screening venue versus other site(s) may assist optimal venue placement. This study assessed relationships between residential-area sociodemographic measures, venue location features, and women’s use of closest versus other venues. Data of 320,672 Greater Sydney screening attendees were spatially joined to residential state suburbs (SSCs) (n = 799). SSC-level sociodemographic measures included proportions of: women speaking English at home; university-educated; full-time employed; and dwellings with motor-vehicles. A geographic information system identified each woman’s closest venue to home, and venue co-location with bus-stop, train-station, hospital, general practitioner, and shop(s). Multilevel logistic models estimated associations between environmental measures and closest venue attendance. Attendance at closest venue was 59.4%. Closest venue attendance was positively associated with SSC-level women speaking English but inversely associated with SSC-level women university-educated, full-time employed, and dwellings with motor-vehicles. Mobile venue co-location with general practitioner and shop was positively, but co-location with bus-stop and hospital was inversely associated with attendance. Attendance was positively associated with fixed venue co-location with train-station and hospital but inversely associated with venue co-location with bus-stop, general practitioner, and shop. Program planners should consider these features when optimising service locations to enhance utilisation. Some counterintuitive results necessitate additional investigation.

Choice, quality and patients' experience: evidence from a Finnish physiotherapy service

We study the relationship between patient choices and provider quality in a rehabilitation service for disabled patients who receive the service frequently but do not have access to quality information. Previous research has found a positive relationship between patient choices and provider quality in health services that patients typically do not have previous experience or use frequently. We contribute by examining choices of new patients and experienced patients who were either forced to switch or actively switched their provider. In the analysis, we combine register data on patients' choices and switches with provider quality data from a competitive bidding, and estimate conditional logit choice models. The results show that all patients prefer high-quality providers within short distances. We find that the willingness to travel for quality is highest among new patients and active switchers. These results suggest that new patients and active switchers compare different alternatives more thoroughly, whereas forced switchers choose their new provider in limited time leading into poorer choices.

Experiences of Outpatient Clinics and Opinions of Telehealth by Caucasian and South Asian Patients' With Celiac Disease

Outpatient clinics are an important part of chronic disease management, including that of celiac disease. During the coronavirus disease 2019 (COVID-19) global pandemic, telephone and online video consultations with health care professionals have substantially increased. This study aimed to explore the experience and opinions of adults, with celiac disease, toward face-to-face clinic appointments and alternatives, such as telehealth. Semistructured qualitative interviews with 37 patients were undertaken (75% White Caucasians, 25% South Asians; 29 patients were not adhering to the gluten-free diet). Interviews were recorded, transcribed, and analyzed by NVivo. Frequently reported issues with face-to-face appointments included travel and car parking costs, needing to take time off work, and frequent changes to appointment time. In addition, South Asian patients highlighted issues with linguistics barriers. Telephone consultations were considered acceptable and practical by the majority of patients based on ease and convenience. Online video consultations were favored by just 9 patients, however it is acknowledged that since the COVID-19 pandemic, there has been a greater exposure to this type of technology. These patient experiences can inform health care service development and are not biased by external health concerns connected with in-person visits during the pandemic.

Does the type of health insurance enrollment affect provider choice, utilization and health care expenditures?

BACKGROUND

Two of the objectives of Universal Health Coverage are equity in access to health services and protection from financial risks. This paper seeks to examine whether the type of health insurance enrollment affects the utilization of health services, choice of provider and financial protection of households in Togo.

METHODS

Data were obtained from a cross-sectional, representative household survey involving 1180 insured households that had reported either illness in the household in the 4 weeks preceding the survey or hospitalization in the 12 months preceding the survey. A nested logit model was used to account for the utilization of health services and provider choice, and methods of assessing catastrophic health care expenditures were used to analyze the level of household financial protection.

RESULTS

Policyholders of private health insurance use private health care facilities more than policyholders of public health insurance. The main reasons for not using health centers among households with public insurance were out-of-pocket payments (49.19%), waiting time (36.80%), and distance to the nearest health center (36.76%). Furthermore, on average, households with public insurance spent a higher proportion of their total monthly nonfood expenditures on health care than those with private insurance. We find that the type of insurance, share of expenditures allocated to food, distance to the nearest health center, and waiting time significantly impact the choice of provider. Regardless of the type of health insurance, elderly individuals avoid using private health centers and referral hospitals due to the high cost.

CONCLUSION

We found that a multiple health insurance system results in a multilevel health system that is not equitable for everyone. The capacity of the health insurance system to provide equitable health care services and protect its members from catastrophic health care expenditures should be at the core of health care reform. This study recommends raising awareness of the criteria for the reimbursement of medical procedures within the framework of public insurance and promoting specific health insurance mechanisms for elderly individuals. Careful attention should be paid to ensuring universal education and literacy as a means of improving access to and the use of health care.

Patient Views on Religious Institutional Health Care

IMPORTANCE

Federal protections allow health facilities to limit options to patients on the basis of religious values. Little is known about whether US adults consider religious affiliation when selecting facilities and whether they agree with such limitations.

OBJECTIVE

To understand patient views on religious institutional care.

DESIGN, SETTING, AND PARTICIPANTS

This is a population-based, cross-sectional survey study of US adults recruited from the probability-based AmeriSpeak Omnibus panel available from NORC (formerly the National Opinion Research Center) at the University of Chicago. Surveys were administered via internet or telephone during a 3-day fielding period in November 2017. Data analysis was performed from January 2018 to October 2019.

EXPOSURES

Participant characteristics, including religiosity measures.

MAIN OUTCOMES AND MEASURES

Whether patients consider religious affiliation when selecting a health care facility and their views on whether an institution's religious values should take precedence over their health choices. Responses were compared by gender. When gender differences existed, regression models were performed, and thematic content analysis was applied to open-ended responses.

RESULTS

There were 1446 participants (745 [51.5%] male; mean [SD] age, 46 [17] years), for a survey completion rate of 24.5% and weighted cumulative response weight of 7.3%. Most respondents (62.6%) were white, and the most common religion was Protestant (28.2%). When specifically asked, only 6.4% reported that they considered religious affiliation when selecting a health care facility; most participants (71.3%) reported when selecting a health care facility that they did not care whether it is religiously affiliated, 13.4% preferred a religious affiliation, and 15.3% preferred no religious affiliation. There were no gender differences. Most participants (71.4%) believed that their health choices should take priority over an institution's religious affiliation in services offered, and this was more common for women than for men (74.9% vs 68.1%; difference, 6.8%; 95% CI, 5.6%-8.2%; P = .005), who more commonly endorsed concerns for personal choice and autonomy over one's own body.

CONCLUSIONS AND RELEVANCE

This study suggests that most patients value their personal choices, yet do not consider an institution's religious affiliation when choosing their source of health care. Women placed greater emphasis on their autonomy in comparison with an institution's right to invoke religious restrictions to care. Given the growth in ownership of health care facilities by religious entities in the United States and increasing attention to conscientious objections, these findings point to a need for advocacy and legislation that effectively balances protections for religious institutions with protections for patients.

Migration status and healthcare seeking behaviours among the Chinese labor-force: a nationally representative study

OBJECTIVES

We aimed to analyse the healthcare seeking behaviours (HSB) of populations with different migration status and examine the relationship between migration status and HSB.

DESIGN

A secondary analysis of cross-sectional data of China Labor-force Dynamics Survey wave 2016, which was conducted by the Sun Yat-sen University every 2 years since 2010.

SETTING

29 provinces/cities/autonomous regions in mainland China, excluding Tibet and Hainan province.

PARTICIPANTS

3522 respondents in a condition in the previous 2 weeks or during the last 12 months were analysed.

MAIN OUTCOME MEASURES

The migration status included internal migrants (IMs), returned population, rural residents and urban residents. The HSB including health services utilisation and choice of health facilities for their health services. Multivariable logistic regressions were used to examine the association between migration status and HSB.

RESULTS

2193 and 1898 of 3522 respondents were in need of outpatient services (having a condition in the previous 2 weeks) or inpatient services (being asked to use the inpatient services during the last 12 months). Compared with urban residents, the returned population (OR=0.66, 95% CIs 0.49 to 0.89) and rural residents (OR=0.65, 95% CIs 0.51 to 0.82) were less likely to have an unmet need for outpatient services. The latter tended to choose lower-level hospitals, while the IMs preferred the lowest-level healthcare facilities for health services. After controlling for confounding factors, the results above did not reach any statistical significance.

CONCLUSION

Association between migration status and HSB might be through enabling resource and needs. Returned population, IMs and rural residents tended to choose low-level hospitals for their health service needs, but this association was mainly associated with their poorer social and economic resources. Improving their social and economic resources would be helpful for reducing the barriers of HSB.

Evaluating nuanced practices for initiating decision-making in neurology clinics: a mixed-methods study

Background

We report follow-on research from our previous qualitative analysis of how neurologists offer patients choice in practice. This focus reflects the NHS’s emphasis on ‘patient choice’ and the lack of evidence-based guidance on how to enact it. Our primary study identified practices for offering choice, which we called ‘patient view elicitors’ (PVEs) and ‘option-listing’. However, that study was not designed to compare these with recommendations or to analyse the consequences of selecting one practice over another.

Objectives

To (1) map out (a) the three decision-making practices – recommending, PVEs and option-listing – together with (b) their interactional consequences; (2) identify, qualitatively and quantitatively, interactional patterns across our data set; (3) statistically examine the relationship between interactional practices and self-report data; and (4) use the findings from 1–3 to compare the three practices as methods for initiating decision-making.

Design

A mixed-methods secondary analysis of recorded neurology consultations and associated questionnaire responses. We coded every recommendation, PVE and option-list together with a range of variables internal (e.g. patients’ responses) and external to the consultation (e.g. self-reported patient satisfaction). The resulting matrix captured the qualitative and quantitative data for every decision.

Setting and participants

The primary study was conducted in two neurology outpatient centres. A total of 14 neurologists, 223 patients and 114 accompanying others participated.

Results

Distribution of practices – recommending was the most common approach to decision-making. Patient demographics did not appear to play a key role in patterning decisional practices. Several clinical factors did show associations with practice, including (1) that neurologists were more likely to use option-lists or PVEs when making treatment rather than investigation decisions, (2) they were more certain about a diagnosis and (3) symptoms were medically explained. Consequences of practices – option-lists and PVEs (compared with recommendations) – were strongly associated with choice by neurologists and patients. However, there was no significant difference in overall patient satisfaction relating to practices employed. Recommendations were strongly associated with a course of action being agreed. Decisions containing PVEs were more likely to end in rejection. Option-lists often ended in the decision being deferred. There was no relationship between length of consultation and the practice employed.

Limitations

A main limitation is that we judged only outcomes based on the recorded consultations and the self-report data collected immediately thereafter. We do not know what happened beyond the consultation.

Conclusions

Patient choice is harder to enact than policy directives acknowledge. Although there is good evidence that neurologists are seeking to enact patient choice, they are still more likely to make recommendations. This appears to be partly due to concerns that ‘choice’ might conflict with doctors’ duty of care. Future guidance needs to draw on evidence regarding choice in practice to support doctors and patients to achieve the wider goal of shared decision-making.

Future research

To advance understanding of how interactional practices might have effects beyond the clinic, a priority is to investigate associations between decision-making practices and external outcomes (such as adherence).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.