Public views on healthcare performance indicators and patient choice

Are patients willing to accept longer travel times to decrease their risk associated with surgical procedures? A systematic review

Background

Distance to a hospital is an influencing factor for patients´ decision making when choosing a hospital for surgery. It is unclear whether patients prefer to travel further to regional instead of local hospitals if the risk associated with elective surgery is lower in the farther hospital. The aim of our systematic review was to investigate patient preferences for the location of care, taking into consideration surgical outcomes and hospital distance.

Methods

MEDLINE (PubMed), EconLit, PsycInfo and EMBASE were searched until November 2019. We included experimental choice studies in which participants were asked to make a hypothetical decision where to go for elective surgery when surgical risk and/or distance to the hospitals vary. There was no restriction on the type of intervention or study. Reviewers independently extracted data using a standardized form. The number and proportion of participants willing to accept additional risk to obtain surgery in the local hospital was recorded. We also extracted factors associated with the decision.

Results

Five studies exploring participants´ preferences for local care were included. In all studies, there were participants who, independently of a decreased mortality risk or a higher survival benefit in the regional hospital, adhered to the local hospital. The majority of the patients were willing to travel longer to lower their surgical risk. Older age and fewer years of formal education were associated with a higher risk tolerance in the local hospital.

Conclusions

Whether patients were willing to travel for a lower surgery-associated risk could not be answered in a straightforward manner. The studies we identified showed that decision making also relies on factors other than on rational information on risk or distance to hospital.

Trial registration

International prospective register of ongoing systematic reviews (PROSPERO): CRD42016033655. Registered 1 January 2016.

To what degree do patients actively choose their healthcare provider at the point of referral by their GP? A video observation study

BACKGROUND

Many countries in Europe have implemented managed competition and patient choice during the last decade. With the introduction of managed competition, health insurers also became an important stakeholder. They purchase services on behalf of their customers and are allowed to contract healthcare providers selectively. It has, therefore, become increasingly important to take one's insurance into account when choosing a provider. There is little evidence that patients make active choices in the way that policymakers assume they do. This research aims to investigate, firstly, the role of patients in choosing a healthcare provider at the point of referral, then the role of the GP and, finally, the influence of the health insurer/insurance policies within this process.

METHODS

We videotaped a series of everyday consultations between Dutch GPs and their patients during 2015 and 2016. In 117 of these consultations, with 28 GPs, the patient was referred to another healthcare provider. These consultations were coded by three observers using an observation protocol which assessed the role of the patient, GP, and the influence of the health insurer during the referral.

RESULTS

Patients were divided into three groups: patients with little or no input, patients with some input, and those with a lot of input. Just over half of the patients (56%) seemed to have some, or a lot of, input into the choice of a healthcare provider at the point of referral by their GP. In addition, in almost half of the consultations (47%), GPs inquired about their patients' preferences regarding a healthcare provider. Topics regarding the health insurance or insurance policy of a patient were rarely (14%) discussed at the point of referral.

CONCLUSIONS

Just over half of the patients appear to have some, or a lot of, input into their choice of a healthcare provider at the point of referral by their GP. However, the remainder of the patients had little or no input. If more patient choice continues to be an important aim for policy makers, patients should be encouraged to actively choose the healthcare provider who best fits their needs and preferences.

Spatial analysis of factors influencing choice of paediatric practice for mothers from low-income and minority populations

AIM

Publicly reported quality data theoretically enable parents to choose higher-performing paediatric practices. However, little is known about how parents decide where to seek paediatric care. We explored the relationship between geographic factors, care quality and choice of practice to see if the decision-making process could be described in terms of a 'gravity model' of spatial data.

METHODS

In the context of a randomised controlled trial, we used a geographic information system to calculate flow volume between practice locations and participants' homes, to locate subjects within a census tract, to determine distances between points and to perform exploratory mapping. Generalised linear modelling was then used to determine whether the data fit a gravity model, which is a spatial model that evaluates factors impacting travel from one set of locations to another.

RESULTS

A total of 662 women and 52 paediatric practices were included in the analysis. Proximity of a practice to home was the most important factor in choosing a practice (Z = -15.01, P < 0.001). Practice size was important to a lesser extent, with larger practices more likely to be chosen (Z = 8.96, P < 0.001). A practice's performance on quality measures was associated with choice only for women who had received an intervention to increase use of quality data (Z = 2.51, P < 0.05).

CONCLUSIONS

The gravity model and the concept of flow can help explain the choice of paediatric practice in a predominantly low-income, racially ethnic minority (non-White) urban population. This has important ramifications for the potential impact of publicly reported quality data.

Feedback preferences of patients, professionals and health insurers in integrated head and neck cancer care

Background

Audit and feedback on professional practice and health care outcomes are the most often used interventions to change behaviour of professionals and improve quality of health care. However, limited information is available regarding preferred feedback for patients, professionals and health insurers.

Objective

Investigate the (differences in) preferences of receiving feedback between stakeholders, using the Dutch Head and Neck Audit as an example.

Methods

A total of 37 patients, medical specialists, allied health professionals and health insurers were interviewed using semi‐structured interviews. Questions focussed on: “Why,” “On what aspects” and “How” do you prefer to receive feedback on professional practice and health care outcomes?

Results

All stakeholders mentioned that feedback can improve health care by creating awareness, enabling self‐reflection and reflection on peers or colleagues, and by benchmarking to others. Patients prefer feedback on the actual professional practice that matches the health care received, whereas medical specialists and health insurers are interested mainly in health care outcomes. All stakeholders largely prefer a bar graph. Patients prefer a pie chart for patient‐reported outcomes and experiences, while Kaplan‐Meier survival curves are preferred by medical specialists. Feedback should be simple with firstly an overview, and 1‐4 times a year sent by e‐mail. Finally, patients and health professionals are cautious with regard to transparency of audit data.

Conclusions

This exploratory study shows how feedback preferences differ between stakeholders. Therefore, tailored reports are recommended. Using this information, effects of audit and feedback can be improved by adapting the feedback format and contents to the preferences of stakeholders.

Functionality and feedback: a realist synthesis of the collation, interpretation and utilisation of patient-reported outcome measures data to improve patient care

Background

The feedback of patient-reported outcome measures (PROMs) data is intended to support the care of individual patients and to act as a quality improvement (QI) strategy.

Objectives

To (1) identify the ideas and assumptions underlying how individual and aggregated PROMs data are intended to improve patient care, and (2) review the evidence to examine the circumstances in which and processes through which PROMs feedback improves patient care.

Design

Two separate but related realist syntheses: (1) feedback of aggregate PROMs and performance data to improve patient care, and (2) feedback of individual PROMs data to improve patient care.

Interventions

Aggregate – feedback and public reporting of PROMs, patient experience data and performance data to hospital providers and primary care organisations. Individual – feedback of PROMs in oncology, palliative care and the care of people with mental health problems in primary and secondary care settings.

Main outcome measures

Aggregate – providers’ responses, attitudes and experiences of using PROMs and performance data to improve patient care. Individual – providers’ and patients’ experiences of using PROMs data to raise issues with clinicians, change clinicians’ communication practices, change patient management and improve patient well-being.

Data sources

Searches of electronic databases and forwards and backwards citation tracking.

Review methods

Realist synthesis to identify, test and refine programme theories about when, how and why PROMs feedback leads to improvements in patient care.

Results

Providers were more likely to take steps to improve patient care in response to the feedback and public reporting of aggregate PROMs and performance data if they perceived that these data were credible, were aimed at improving patient care, and were timely and provided a clear indication of the source of the problem. However, implementing substantial and sustainable improvement to patient care required system-wide approaches. In the care of individual patients, PROMs function more as a tool to support patients in raising issues with clinicians than they do in substantially changing clinicians’ communication practices with patients. Patients valued both standardised and individualised PROMs as a tool to raise issues, but thought is required as to which patients may benefit and which may not. In settings such as palliative care and psychotherapy, clinicians viewed individualised PROMs as useful to build rapport and support the therapeutic process. PROMs feedback did not substantially shift clinicians’ communication practices or focus discussion on psychosocial issues; this required a shift in clinicians’ perceptions of their remit.

Strengths and limitations

There was a paucity of research examining the feedback of aggregate PROMs data to providers, and we drew on evidence from interventions with similar programme theories (other forms of performance data) to test our theories.

Conclusions

PROMs data act as ‘tin openers’ rather than ‘dials’. Providers need more support and guidance on how to collect their own internal data, how to rule out alternative explanations for their outlier status and how to explore the possible causes of their outlier status. There is also tension between PROMs as a QI strategy versus their use in the care of individual patients; PROMs that clinicians find useful in assessing patients, such as individualised measures, are not useful as indicators of service quality.

Future work

Future research should (1) explore how differently performing providers have responded to aggregate PROMs feedback, and how organisations have collected PROMs data both for individual patient care and to improve service quality; and (2) explore whether or not and how incorporating PROMs into patients’ electronic records allows multiple different clinicians to receive PROMs feedback, discuss it with patients and act on the data to improve patient care.

Study registration

This study is registered as PROSPERO CRD42013005938.

Funding

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

Protocol for using mixed methods and process improvement methodologies to explore primary care receptionist work

INTRODUCTION

The need to cope with an increasingly ageing and multimorbid population has seen a shift towards preventive health and effective management of chronic disease. This places general practice at the forefront of health service provision with an increased demand that impacts on all members of the practice team. As these pressures grow, systems become more complex and tasks delegated across a broader range of staff groups. These include receptionists who play an essential role in the successful functioning of the surgery and are a major influence on patient satisfaction. However, they do so without formal recognition of the clinical implications of their work or with any requirements for training and qualifications.

METHODS AND ANALYSIS

Our work consists of three phases. The first will survey receptionists using the validated Work Design Questionnaire to help us understand more precisely the parameters of their role; the second involves the use of iterative focus groups to help define the systems and processes within which they work. The third and final phase will produce recommendations to increase the efficiency and safety of the key practice processes involving receptionists and identify the areas and where receptionists require targeted support. In doing so, we aim to increase job satisfaction of receptionists, improve practice efficiency and produce better outcomes for patients.

ETHICS AND DISSEMINATION

Our work will be disseminated using conferences, workshops, trade journals, electronic media and through a series of publications in the peer reviewed literature. At the very least, our work will serve to prompt discussion on the clinical role of receptionists and assess the advantages of using value streams in conjunction with related tools for process improvement.

Patient Navigators and Parent Use of Quality Data: A Randomized Trial

BACKGROUND

Consumers rarely use publicly reported health care quality data. Despite known barriers to use, few studies have explored the effectiveness of strategies to overcome barriers in vulnerable populations.

METHODS

This randomized controlled trial tested the impact of a patient navigator intervention to increase consumer use of publicly reported quality data. Patients attending an urban prenatal clinic serving a vulnerable population enrolled between May 2013 and January 2015. The intervention consisted of 2 in-person sessions in which women learned about quality performance and viewed scores for local practices on the Massachusetts Health Quality Partners Web site. Women in both the intervention and control arms received a pamphlet about health care quality. Primary study outcomes were mean clinical quality and patient experience scores of the practices women selected (range 1-4 stars).

RESULTS

Nearly all (726/746; 97.3%) women completed the study, 59.7% were Hispanic, and 65.1% had a high school education or less. In both unadjusted and adjusted models, women in the intervention group chose practices with modestly higher mean clinical quality (3.2 vs 3.0 stars; P = .001) and patient experience (3.0 vs 2.9 stars; P = .05) scores. When asked to rate what factors mattered the most in their decision, few cited quality scores.

CONCLUSIONS

An intervention to reduce barriers to using publicly reported health care quality data had a modest effect on patient choice. These findings suggest that factors other than performance on common publicly reported quality metrics have a stronger influence on which pediatric practices women choose.

Functionality and feedback: a protocol for a realist synthesis of the collation, interpretation and utilisation of PROMs data to improve patient care

INTRODUCTION

The feedback and public reporting of PROMs data aims to improve the quality of care provided to patients. Existing systematic reviews have found it difficult to draw overall conclusions about the effectiveness of PROMs feedback. We aim to execute a realist synthesis of the evidence to understand by what means and in what circumstances the feedback of PROMs data leads to the intended service improvements.

METHODS AND ANALYSIS

Realist synthesis involves (stage 1) identifying the ideas, assumptions or 'programme theories' which explain how PROMs feedback is supposed to work and in what circumstances and then (stage 2) reviewing the evidence to determine the extent to which these expectations are met in practice. For stage 1, six provisional 'functions' of PROMs feedback have been identified to structure our review (screening, monitoring, patient involvement, demand management, quality improvement and patient choice). For each function, we will identify the different programme theories that underlie these different goals and develop a logical map of the respective implementation processes. In stage 2, we will identify studies that will provide empirical tests of each component of the programme theories to evaluate the circumstances in which the potential obstacles can be overcome and whether and how the unintended consequences of PROMs feedback arise. We will synthesise this evidence to (1) identify the implementation processes which support or constrain the successful collation, interpretation and utilisation of PROMs data; (2) identify the implementation processes through which the unintended consequences of PROMs data arise and those where they can be avoided.

ETHICS AND DISSEMINATION

The study will not require NHS ethics approval. We have secured ethical approval for the study from the University of Leeds (LTSSP-019). We will disseminate the findings of the review through a briefing paper and dissemination event for National Health Service stakeholders, conferences and peer reviewed publications.

Are patients' preferences regarding the place of treatment heard and addressed at the point of referral: an exploratory study based on observations of GP-patient consultations

Background

Today, in several north-western European countries, patients are encouraged to choose, actively, a healthcare provider. However, patients often visit the provider that is recommended by their general practitioner (GP). The introduction of patient choice requires GPs to support patients to be involved, actively, in the choice of a healthcare provider. We aim to investigate whether policy on patient choice is reflected in practice, i.e. what the role of the patient is in their choices of healthcare providers at the point of referral and to what extent GPs’ and patients’ healthcare paths influence the role that patients play in the referral decision.

Methods

In 2007–2008, we videotaped Dutch GP-patient consultations. For this study, we selected, at random, 72 videotaped consultations between 72 patients and 39 GPs in which the patient was referred to a healthcare provider. These were analysed using an observation protocol developed by the researchers.

Results

The majority of the patients had little or no input into the choice of a healthcare provider at the point of referral by their GP. Their GPs did not support them in actively choosing a provider and the patients often agreed with the provider that the GP proposed. Patients who were referred for diagnostic purposes seem to have had even less input into their choice of a provider than patients who were referred for treatment.

Conclusions

We found that the GP chooses a healthcare provider on behalf of the patient in most consultations, even though policy on patient choice expects from patients that they choose, actively, a provider. On the one hand, this could indicate that the policy needs adjustments. On the other hand, adjustments may be needed to practice. For instance, GPs could help patients to make an active choice of provider. However, certain patients prefer to let their GP decide as their agent. Even then, GPs need to know patients’ preferences, because in a principal-agent relationship, it is necessary that the agent is fully informed about the principal’s preferences.

Does the use of a visualised decision board by undergraduate students during shared decision-making enhance patients' knowledge and satisfaction? - A randomised controlled trial

OBJECTIVES

Aim of this RCT was to evaluate whether the added use of a decision board (DB) during shared decision-making improves patients' knowledge as for different treatment options and overall satisfaction with the consultation.

METHODS

Forty-nine undergraduate students were trained in shared decision-making (SDM) and evaluated by an Objective Structured Clinical Examination (OSCE). According to their test results, all participants were randomly allocated to either the test- (DB) or the control-group (Non-DB). Both groups performed SDM with patients showing a defect in a posterior tooth (Class-II defect). Prior to the interview, patients of the DB group were given the decision aid for review. In the Non-DB group, patients were consulted without additional aids. After treatment decision, a questionnaire was completed by all patients to measure knowledge (costs, survival rate, characteristics and treatment time) and overall satisfaction with the consultation. Fifty DB patients and 31 Non-DB patients completed the questionnaire.

RESULTS

DB patients (n = 50) demonstrated a statistically significant increase in knowledge compared to the Non-DB group (n = 31) (Mann-Whitney U-test; DB group = 10.04; Non-DB group = 4.16; P = 0.004). There was no significant difference between groups regarding satisfaction with the consultation (t-test; P > 0.05).

CONCLUSIONS

During the shared decision-making process, the use of a decision board yielding information about Class-II treatment options leads to a significantly higher patient knowledge compared to knowledge gained through consultation alone. It is therefore desirable to provide DBs for dental diagnoses with several treatment options to increase transparency for the patient.

Patients' and clinicians' views of comparing the performance of providers of surgery: a qualitative study

OBJECTIVES

Comparison of providers' outcomes is intended to encourage patient choice and stimulate clinicians to improve the quality of their services. Given that success will depend on how patients and clinicians respond, our aim was to explore their views of using outcome data to compare providers.

METHOD

Qualitative data from six focus groups with patients (n = 45) and seven meetings with surgical clinicians (n = 107) were collected during autumn 2010. Discussions audio-taped, transcribed and a thematic analysis carried out.

RESULTS

Patients and clinicians confirmed the value of making comparisons of the outcomes of providers publicly available. However, both groups harboured three principal concerns: the validity of the data; fears that the data would be misinterpreted by the media, politicians and commissioners, and the focus should not just be on providers but also on the performance of individual surgeons. In addition, patients felt that information on providers' outcomes would only ever have a limited impact on their choice because there were other important factors to be taken into account: accessibility, waiting time, the size of the provider and the quality of other aspects such as cleanliness and nursing. Also patients acknowledged the importance of friends' and relatives' experiences and that they would seek their GP's advice.

CONCLUSIONS

While comparisons of providers' outcomes should be available to patients to stimulate improvements in performance, information should be directed principally to hospital clinicians and to GPs. Impact may be enhanced by providing data on individual clinicians rather than providers. The extent to which these findings are generalizable to other areas of health care is uncertain.

Priorities for young adults when accessing UK primary care: literature review

This literature review focuses on what matters to young adults when they access primary care services in the United Kingdom. Patients' access to and experience of primary care services differs across age groups. Existing research has largely focused on the needs and experiences of children, adolescents, and adults. There is some evidence to suggest the views of young adults (aged 18-25 years) that may differ from the views of other age groups, and research has not previously reported specifically on the views of this group of the population. The literature was reviewed to identify the views and priorities of young UK adults regarding primary healthcare provision, and furthermore, to identify those related topics that would benefit from further research. Relevant academic publications and grey literature published from 2000 onwards was reviewed and synthesised. We identified and reported emerging themes that were of importance to young adults in respect of the UK primary care provision. A total of 19 papers met our inclusion criteria. Young adults access primary care services less frequently than other age groups; this may be because of their experience of primary care throughout childhood and adolescence. Five aspects of primary care provision emerged as being of importance to young adults--the accessibility and availability of services, the confidentiality of health-related information, issues relating to communication with healthcare professionals, continuity of care, and behaviours and attitudes expressed towards young adults by healthcare professionals. There is a lack of focus of current research on the expectations, needs, and primary healthcare experiences of young adults. Young adults may hold views that are distinct from other age groups. Further research is needed to better understand the needs of a young adult population as their needs may impact the future use of services.

Can patients really make an informed choice? An evaluation of the availability of online information about consultant surgeons in the United Kingdom

OBJECTIVES

The National Health Service (NHS) 'Choose and Book' online scheme, which allows patients to select the location and time of hospital appointments, has now been extended to include the option for patients to select a specific consultant to carry out any necessary treatment. The aim of this study was to determine whether there is sufficient online information about consultants or consultant-led teams for patients to make an informed choice regarding a specific consultant.

DESIGN

A web-based analysis of the availability of information.

SETTING

North of England.

PARTICIPANTS

Two hundred websites of orthopaedic surgeons.

MAIN OUTCOME MEASURES

The websites were analysed using a bespoke template that took into account recommendations of the 2010 UK Government white paper. Each website was scored in relation to the availability of specific content relating to each surgeon.

RESULTS

The majority of websites detailed authorship information (73.2%), level of professional qualification (98.5%) and area of general (73.7%) and specialist (93.3%) interest. However, approximately 50% of websites provided no information in relation to update cycle, involvement in teaching or research and patient satisfaction. Only five (2.6%) of the websites presented death rates, and none indicated morbidity rates.

CONCLUSIONS

For patients to be able to make informed choices about their healthcare, surgeons need to ensure that sufficient information is available online, according to the identified limitations of the websites investigated in this study.

Determinants of patient choice of healthcare providers: a scoping review

BACKGROUND

In several northwest European countries, a demand-driven healthcare system has been implemented that stresses the importance of patient healthcare provider choice. In this study, we are conducting a scoping review aiming to map out what is known about the determinants of patient choice of a wide range of healthcare providers. As far as we know, not many studies are currently available that attempt to draw a general picture of how patients choose a healthcare provider and of the status of research on this subject. This study is therefore a valuable contribution to the growing amount of literature about patient choice.

METHODS

We carried out a specific type of literature review known as a scoping review. Scoping reviews try to examine the breadth of knowledge that is available about a particular topic and therefore do not make selections or apply quality constraints. Firstly, we defined our research questions and searched the literature in Embase, Medline and PubMed. Secondly, we selected the literature, and finally we analysed and summarized the information.

RESULTS

Our review shows that patients' choices are determined by a complex interplay between patient and provider characteristics. A variety of patient characteristics determines whether patients make choices, are willing and able to choose, and how they choose. Patients take account of a variety of structural, process and outcome characteristics of providers, differing in the relative importance they attach to these characteristics.

CONCLUSIONS

There is no such thing as the typical patient: different patients make different choices in different situations. Comparative information seems to have a relatively limited influence on the choices made by many patients and patients base their decisions on a variety of provider characteristics instead of solely on outcome characteristics. The assumptions made in health policy about patient choice may therefore be an oversimplification of reality. Several knowledge gaps were identified that need follow-up research.

Public release of performance data in changing the behaviour of healthcare consumers, professionals or organisations

BACKGROUND

It is becoming increasingly common to release information about the performance of hospitals, health professionals or providers, and healthcare organisations into the public domain. However, we do not know how this information is used and to what extent such reporting leads to quality improvement by changing the behaviour of healthcare consumers, providers and purchasers, or to what extent the performance of professionals and providers can be affected.

OBJECTIVES

To determine the effectiveness of the public release of performance data in changing the behaviour of healthcare consumers, professionals and organisations.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, MEDLINE Ovid (from 1966), EMBASE Ovid (from 1979), CINAHL, PsycINFO Ovid (from 1806) and DARE up to 2011.

SELECTION CRITERIA

We searched for randomised or quasi-randomised trials, interrupted time series and controlled before-after studies of the effects of publicly releasing data regarding any aspect of the performance of healthcare organisations or individuals. The papers had to report at least one main outcome related to selecting or changing care. Other outcome measures were awareness, attitude, views and knowledge of performance data and costs.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for eligibility and extracted data. For each study, we extracted data about the target groups (healthcare consumers, healthcare providers and healthcare purchasers), performance data, main outcomes (choice of healthcare provider and improvement by means of changes in care) and other outcomes (awareness, attitude, views, knowledge of performance data and costs).

MAIN RESULTS

We included four studies containing more than 35,000 consumers, and 1560 hospitals. Three studies were conducted in the USA and examined consumer behaviour after the public release of performance data. Two studies found no effect of Consumer Assessment of Healthcare Providers and Systems information on health plan choice in a Medicaid population. One interrupted time series study found a small positive effect of the publishing of data on patient volumes for coronary bypass surgery and low-complication outliers for lumbar discectomy, but these effects did not persist longer than two months after each public release. No effects on patient volumes for acute myocardial infarction were found.One cluster-randomised controlled trial, conducted in Canada, studied improvement changes in care after the public release of performance data for patients with acute myocardial infarction and congestive heart failure. No effects for the composite process-of-care indicators for either condition were found, but there were some improvements in the individual process-of-care indicators. There was an effect on the mortality rates for acute myocardial infarction. More quality improvement activities were initiated in response to the publicly-released report cards. No secondary outcomes were reported.

AUTHORS' CONCLUSIONS

The small body of evidence available provides no consistent evidence that the public release of performance data changes consumer behaviour or improves care. Evidence that the public release of performance data may have an impact on the behaviour of healthcare professionals or organisations is lacking.

Are waiting times for hospital admissions affected by patients' choices and mobility?

BACKGROUND

Waiting times for elective care have been considered a serious problem in many health care systems. A topic of particular concern has been how administrative boundaries act as barriers to efficient patient flows. In Norway, a policy combining patient's choice of hospital and removal of restriction on referrals was introduced in 2001, thereby creating a nationwide competitive referral system for elective hospital treatment. The article aims to analyse if patient choice and an increased opportunity for geographical mobility has reduced waiting times for individual elective patients.

METHODS

A survey conducted among Norwegian somatic patients in 2004 gave information about whether the choice of hospital was made by the individual patient or by others. Survey data was then merged with administrative data on which hospital that actually performed the treatment. The administrative data also gave individual waiting time for hospital admission. Demographics, socio-economic position, and medical need were controlled for to determine the effect of choice and mobility upon waiting time. Several statistical models, including one with instrument variables for choice and mobility, were run.

RESULTS

Patients who had neither chosen hospital individually nor bypassed the local hospital for other reasons faced the longest waiting times. Next were patients who individually had chosen the local hospital, followed by patients who had not made an individual choice, but had bypassed the local hospital for other reasons. Patients who had made a choice to bypass the local hospitals waited on average 11 weeks less than the first group.

CONCLUSION

The analysis indicates that a policy combining increased opportunity for hospital choice with the removal of rules restricting referrals can reduce waiting times for individual elective patients. Results were robust over different model specifications.

Consumers' interpretation and use of comparative information on the quality of health care: the effect of presentation approaches

BACKGROUND

Public reports about health-care quality have not been effectively used by consumers thus far. A possible explanation is inadequate presentation of the information.

OBJECTIVE

To assess which presentation features contribute to consumers' correct interpretation and effective use of comparative health-care quality information and to examine the influence of consumer characteristics.

DESIGN

Fictitious Consumer Quality Index (CQI) data on home care quality were used to construct experimental presentation formats of comparative information. These formats were selected using conjoint analysis methodology. We used multilevel regression analysis to investigate the effects of presenting bar charts and star ratings, ordering of the data, type of stars, number of stars and inclusion of a global rating.

SETTING AND PARTICIPANTS

Data were collected during 2 weeks of online questioning of 438 members of an online access panel.

RESULTS

Both presentation features and consumer characteristics (age and education) significantly affected consumers' responses. Formats using combinations of bar charts and stars, three stars, an alphabetical ordering of providers and no inclusion of a global rating supported consumers. The effects of the presentation features differed across the outcome variables.

CONCLUSIONS

Comparative information on the quality of home care is complex for consumers. Although our findings derive from an experimental situation, they provide several suggestions for optimizing the information on the Internet. More research is needed to further unravel the effects of presentation formats on consumer decision making in health care.

The risk of risk-adjustment measures for perioperative spine infection after spinal surgery

STUDY DESIGN

Cross-sectional data analysis of the Nationwide Inpatient Sample (NIS).

OBJECTIVE

To develop a risk-adjustment index specific for perioperative spine infection and compare this specific index to the Deyo Comorbidity Index. Assess specific mortality and morbidity adjustments between teaching and nonteaching facilities.

SUMMARY OF BACKGROUND DATA

Risk-adjustment measures have been developed specifically for mortality and may not be sensitive enough to adjust for morbidity across all diagnosis.

METHODS

This condition-specific index was developed by using the NIS in a two-step process to determine confounders and weighting. Crude and adjusted point estimates for the Deyo and condition-specific index were compared for routine discharge, death, length of stay, and total hospital charges and then stratified by teaching hospital status.

RESULTS

A total of 23,846 perioperative spinal infection events occurred in the NIS database between 1988 and 2007 of 1,212,241 procedures. Twenty-three diagnoses made up this condition-specific index. Significant differences between the Deyo and the condition-specific index were seen among total charges and length of stay at nonteaching hospitals (P < 0.001) and death, length of stay, and total charges (P < 0.001) for teaching hospitals.

CONCLUSION

This study demonstrates several key points. One, condition-specific measures may be useful when morbidity is of question. Two, a condition-specific perioperative spine infection adjustment index appears to be more sensitive at adjusting for comorbidities. Finally, there are inherent differences in hospital disposition characteristics for perioperative spine infection across teaching and nonteaching hospitals even after adjustment.

Why do general practitioners abandon the local hospital? An analysis of referral decisions related to elective treatment

AIM

The right to choose a hospital was granted to Norwegian elective patients through the Patients' Rights Act of 2001. The Act assumes that hospital choice will be executed by patients and general practitioners (GPs) at the point of referral. This study examined the probability of referring patients away from the nearest hospitals for three common elective diagnoses: hip replacement, knee surgery, and back pain treatment.

METHODS

Data describing referral rates and individual characteristics with the GP were collected by a self-administered questionnaire to Norwegian GPs in 2004 and 2006. These were combined with data on interactions between the GP and the local hospital from a database describing the hospital's internal organisation, variables describing needs (demand) at local government level from Statistics Norway, variables describing waiting times from the Norwegian Patient Register, and variables describing travelling distances to the nearest hospital and hospital characteristics. The probability of referring patients away from the nearest hospital was analysed using a cross-section regression model with fixed effects for region, years, and hospital type.

RESULTS

GPs were on average more reluctant to send patients away for hip surgery and back pain than they were for knee surgery. Formal coordinative mechanisms between the hospitals and the GPs - meeting places and arenas for information exchange - significantly reduced the likelihood of referring patients away from the local hospital. Long waiting times and long distances to the local hospital also increased the probability of abandoning the local hospital.

CONCLUSION

Hospital managers could attract elective patients by developing arenas for communication and collaboration with local GPs.

Patient's need for choice and information across the interface between primary and secondary care: a survey

OBJECTIVE

Hospitals in The Netherlands have recently made certain performance data public, allowing patients to choose the location of their care. The objective of this study is to assess (a) patient preferences and experiences concerning the transition between primary and secondary health care, (b) patients' needs for choice and information and how these are influenced by personal and morbidity factors.

METHODS

Two different types of questionnaires were used. The first questionnaire concerns the importance that patients attach to the care provided. The second questionnaire concerns the actual experiences of the patient with the care provided. For the selection of patients, we used the databases of the registration networks of the Departments of General Practice of the Universities of Groningen and Leiden. The questionnaires were returned by 513 patients (Importance 69%) and 1404 patients (Experience 65%).

RESULTS

Many patients prefer the GP advising them regarding which hospital or specialist they should be referred to: a quarter of the patients preferred that the GP decided for them. Patients with a curable condition and patients aged between 25 and 65, highly educated and with stable personal characteristics as measured by a purposive scale, more often wished to use information from internet or newspapers to make a decision. The amount of information that was needed on illness or treatment varied greatly. Young people, older people, and those with less stable personal characteristics more often desired only practical information.

CONCLUSIONS

In spite of making performance data of different health care institutions public, only a limited number of patients want to use this information on a limited number of health problems.

PRACTICE IMPLICATIONS

Care providers should take differences into account concerning patients' need for information on their illness.

New labour and reform of the English NHS: user views and attitudes

BACKGROUND

The British National Health Service has undergone significant restructuring in recent years. In England this has taken a distinctive direction where the New Labour Government has embraced and intensified the influence of market principles towards its vision of a 'modernized' NHS. This has entailed the introduction of competition and incentives for providers of NHS care and the expansion of choice for patients.

OBJECTIVES

To explore how users of the NHS perceive and respond to the market reforms being implemented within the NHS. In addition, to examine the normative values held by NHS users in relation to welfare provision in the UK.

DESIGN AND SETTING

Qualitative interviews using a quota sample of 48 recent NHS users in South East England recruited from three local health economies.

RESULTS

Some NHS users are exhibiting an ambivalent or anxious response to aspects of market reform such as patient choice, the use of targets and markets and the increasing presence of the private sector within the state healthcare sector. This has resulted in a sense that current reforms, are distracting or preventing NHS staff from delivering quality of care and fail to embody the relationships of care that are felt to sustain the NHS as a progressive public institution.

CONCLUSION

The best way of delivering such values for patients is perceived to involve empowering frontline staffs who are deemed to embody the same values as service users, thus problematizing the current assumptions of reform frameworks that market-style incentives will necessarily gain public consent and support.

Online assessment of patients' views on hospital performances using Rasch model's KIDMAP diagram

Background

To overcome the drawback of individual item-by-item box plots of disclosure for patient views on healthcare service quality, we propose to inspect interrelationships among items that measure a common entity. A visual diagram on the Internet is developed to provide thorough information for hospitals.

Methods

We used the Rasch rating scale model to analyze the 2003 English inpatient questionnaire data regarding patient satisfactory perception, which were collected from 169 hospitals, examined model-data fit, and developed a KIDMAP diagram on the Internet depicting the satisfaction level of each hospital and investigating aberrant responses with Z-scores and MNSQ statistics for individual hospitals. Differential item functioning (DIF) analysis was conducted to verify construct equivalence across types of hospitals.

Results

18 of the 45 items fit to the model's expectations, indicating they jointly defined a common construct and an equal-interval logit scale was achieved. The most difficult aspect for hospitals to earn inpatients' satisfaction were item 29 (staff told you about any medication side effects to watch when going home). No DIF in the 18-item questionnaire was found between types of hospitals, indicating the questionnaire measured the same construct across hospitals. Different types of hospitals obtained different levels of satisfaction. The KIDMAP on the Internet provided more interpretable and visualized message than traditional item-by-item box plots of disclosure.

Conclusion

After removing misfit items, we find that the 18-item questionnaire measures the same construct across types of hospitals. The KIDMAP on the Internet provides an exemplary comparison in quality of healthcare. Rasch analysis allows intra- and inter-hospital performances to be compared easily and reliably with each other on the Internet.

Willingness of patients to change surgeons for a shorter waiting time for joint arthroplasty

BACKGROUND

To improve access to care, many jurisdictions have proposed waiting-time benchmarks and guarantees. We assessed the willingness of patients to consider changing their surgeon to one with a shorter waiting time for arthroplasty.

METHODS

We mailed a questionnaire to 2 random samples of patients who either were awaiting hip or knee replacement arthroplasty or had had one of these procedures within the preceding 3-12 months. We used logistic regression to assess the determinants of patients' likelihood to consider changing surgeons.

RESULTS

Of 1200 responses from a sample of 2000, 557 (46%) were from patients awaiting surgery and 643 (54%) were from people who had undergone surgery. The mean age of respondents was 69.9 years (standard deviation 10.8), and 682 (57%) were women. The median waiting time for surgery was 8 months. Overall, 753 (63%) of the patients were unlikely to consider changing surgeons. Increased likelihood of changing surgeons was associated with male sex (adjusted odds ratio [OR] 1.49, 95% confidence interval [CI] 1.10-2.02), a high school education or higher (OR 1.73, 95% CI 1.15-2.62) and having already undergone surgery (OR 1.71, 95% CI 1.19-2.46). Decreased likelihood was associated with preference for a particular surgeon before referral (OR 0.57, 95% CI 0.42-0.79), a better score on the EuroQol (EQ-5D) index (a measure of health-related quality of life) (OR 0.39, 95% CI 0.24-0.66), perception that the waiting time to see the surgeon was acceptable (OR 0.50, 95% CI 0.36-0.70), perception that the waiting time to surgery was acceptable (OR 0.62, 95% CI 0.43-0.91) and perceived fairness of treatment (OR 0.53, 95% CI 0.36-0.78).

INTERPRETATION

Despite long waits for surgery, most patients, if given the choice, would be unlikely to change their surgeon to one with a shorter waiting time.

Barriers to patient involvement in health service planning and evaluation: an exploratory study

OBJECTIVE

Patient involvement in health service planning and evaluation is considered important yet not widely practiced. This study explored stakeholder beliefs about patient participation in performance indicator selection to better understand hypothesized barriers.

METHODS

Interviews with 30 cancer patients and health professionals from two teaching hospitals were analyzed qualitatively.

RESULTS

All groups believed patients, not members of the public, should be involved in the selection of indicators. Ongoing, interactive methods such as committee involvement, rather than single, passive efforts such as surveys were preferred. Health professionals recommended patients assume a consultative, rather than decision-making role. Older patients agreed with this.

CONCLUSION

Variable patient interest, health professional attitudes, and a lack of insight on appropriate methods may be limiting patient involvement in this, and other service planning and evaluation activities. More research is required to validate expressed views among the populations these stakeholders represent, and to establish effective methods for engaging patients.

PRACTICE IMPLICATIONS

Efforts to encourage a change in health professional attitude may be required, along with dedicated organizational resources, coordinators and training. Methods to engage patients should involve deliberation, which can be achieved through modified Delphi panel or participatory research approaches.

A fair range of choice: justifying maximum patient choice in the British National Health Service

In this paper I put forward an ethical argument for the provision of extensive patient choice by the British National Health Service. I base this argument on traditional liberal rights to freedom of choice, on a welfare right to health care, and on a view of health as values-based. I argue that choice, to be ethically sustainable on this basis, must be values-based and rational. I also consider whether the British taxpayer may be persuadable with regard to the moral acceptability of patient choice, making use of Rawls' theory of political liberalism in this context. I identify issues that present problems in terms of public acceptance of choice, and also identify a boundary issue with regard to public health choices as against individual choices.

Data sources and performance measurement

Measuring outcomes is necessary but difficult to get right

Raising the benchmark for the 21st century--the 1000 cataract operations audit and survey: outcomes, consultant-supervised training and sourcing NHS choice

PURPOSE

Clinical outcomes for phacoemulsification surgery are still compared with the almost 10-year-old benchmark of the 1997-98 National Cataract Surgery Survey (NCSS) published in this journal. Extraneous to the peer-reviewed research literature, more recent databases suggest much better results may be being obtained. This offered the rare opportunity to perform an audit as research investigating if this was indeed the case and a new benchmark is needed, with the additional standard of rigorous study peer review by independent senior ophthalmologists. At this pilot centre for Patient Choice provision, all cataract surgery was performed on Consultant-supervised training lists, a novel extension in-sourcing care using public resources rather than to an independent sector that may not be supervised by NHS Consultants. Patient satisfaction was also surveyed. We asked whether the NCSS is out-of-date, and whether good outcomes on Choice schemes are compatible with Consultant-led training within the National Health Service?

METHODS

An audit of 1000 consecutive patients undergoing cataract surgery on Patient Choice at the Western Eye Hospital between October 2002 and September 2004. All subjects were scheduled for phacoemulsification. A novel policy was extending "choice" onto training list slots for this period. A validated questionnaire assessed patient satisfaction.

RESULTS

A best corrected visual acuity of 6/12 or better was obtained in 93% of cases. Over 80% of cases were +/-1 D of target refraction (65.7% within 0.5 D). The total incidence of complications was 8.7%. Overall incidence of major complications was 2.4%. Incidence of vitreous loss was 1.1% and that of endophthalmitis 0.1%. Complications rates were lowest for consultants (less than 1%). User satisfaction with having cataract surgery on "patient choice" was high.

CONCLUSIONS

Cataract surgery under patient choice on supervised training lists is associated with a visual outcome and an incidence of complications at least as good as the published national average. User satisfaction is high. Cataract surgery under patient choice is compatible with training activity in receiving hospitals. The improvement in outcomes since the 1997-98 NCSS suggest that the accepted standards for complication rates should be updated to reflect the fact that phacoemulsification has become an established procedure.

Development of an information source for patients and the public about general practice services: an action research study

OBJECTIVE

The publication of information about the performance of health-care providers is regarded as central to promoting greater accountability and empowering patients to exercise choice. The evidence suggests that the public is not very interested in accessing or using current sources of information. This study aimed to explore the information needs of patients in the context of UK primary care and to develop an information source about general practice services, designed to be usable by and useful to patients.

DESIGN

An action research study making use of data from formal and informal interviews, focus groups, participant observation and document review.

SETTING

The geographical areas covered by two Primary Care Trusts in the north of England and two Local Health Boards in south Wales.

PARTICIPANTS

A partnership between 103 members of the public, general practice staff from 19 practices, NHS managers from four Primary Care Organizations and the research team.

RESULTS

The public would like to know more about the quality and range of general practice services but current sources of information do not meet their needs. The public do not like league tables comparing the performance of practices and only a small number of people want to use comparative information to choose between practices. They seem to be more interested in the context and availability of services and the willingness of practices to improve, than in the practice's absolute or relative performance. They want to be clear about the source of the information so that they can make personal judgements about its veracity. Information is most likely to be useful if it adheres to the basic principles of cognitive science in terms of its structure, content and presentation format. Using these findings, paper and electronic prototype versions of a guide to general practice services have been developed.

CONCLUSIONS

In order to maximize the potential use of performance information by the public it is necessary to move beyond provider-led and professionally constructed approaches to information provision and ensure that the public is actively involved in the development of information sources. Such involvement produces a different kind of information to that currently available to the public. The findings of this study have important implications for policy. Most importantly, it seems that the traditional consumerist model underlying a policy of making comparative performance information available to the public to enable them to exercise choice between primary care providers may not be appropriate. An alternative model of information provision, which recognizes the public's commitment to their practice and is integrated with 'soft' sources of knowledge is more likely to engage and be of use to the public.

Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals' perceptions

BACKGROUND

Shared decision-making is advocated because of its potential to improve the quality of the decision-making process for patients and ultimately, patient outcomes. However, current evidence suggests that shared decision-making has not yet been widely adopted by health professionals. Therefore, a systematic review was performed on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals.

METHODS

Covering the period from 1990 to March 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched for studies in English or French. The references from included studies also were consulted. Studies were included if they reported on health professionals' perceived barriers and facilitators to implementing shared decision-making in their practices. Shared decision-making was defined as a joint process of decision making between health professionals and patients, or as decision support interventions including decision aids, or as the active participation of patients in decision making. No study design was excluded. Quality of the studies included was assessed independently by two of the authors. Using a pre-established taxonomy of barriers and facilitators to implementing clinical practice guidelines in practice, content analysis was performed.

RESULTS

Thirty-one publications covering 28 unique studies were included. Eleven studies were from the UK, eight from the USA, four from Canada, two from The Netherlands, and one from each of the following countries: France, Mexico, and Australia. Most of the studies used qualitative methods exclusively (18/28). Overall, the vast majority of participants (n = 2784) were physicians (89%). The three most often reported barriers were: time constraints (18/28), lack of applicability due to patient characteristics (12/28), and lack of applicability due to the clinical situation (12/28). The three most often reported facilitators were: provider motivation (15/28), positive impact on the clinical process (11/28), and positive impact on patient outcomes (10/28).

CONCLUSION

This systematic review reveals that interventions to foster implementation of shared decision-making in clinical practice will need to address a broad range of factors. It also reveals that on this subject there is very little known about any health professionals others than physicians. Future studies about implementation of shared decision-making should target a more diverse group of health professionals.

ASSESSING SURGEONS' DISCLOSURE OF RISK INFORMATION BEFORE CAROTID ENDARTERECTOMY

BACKGROUND

To make an informed decision about treatment, patients need accurate information about the benefits and risks of treatment and 'non-treatment' options. A survey was conducted to determine patients' recall of the extent and effect of preoperative disclosure by surgeons to patients of risks about carotid endarterectomy (CEA).

METHODS

A self-administered questionnaire was given to 133 patients undergoing elective CEA in New South Wales. The primary outcome measures were patient recall of preoperative discussion, self-assessed estimates of stroke risk with and without surgery and receipt of written information before CEA.

RESULTS

A significantly higher proportion of patients recalled that their surgeon discussed the short-term stroke risk (i.e. within 30 days) if they decided to undergo CEA (86.2%) than if they decided not to have the procedure (76.9%) (P = 0.04). Of those patients who recalled the surgeon discussing their short-term stroke risk with CEA, only 24 (18.0%) were accurately able to quantify this risk. Patients were significantly more likely to recall their surgeon discussing their long-term stroke risk (i.e. within 2 years) if they decided not to have CEA (72.4%) than if they decided to have the CEA (31.5%) (P < 0.0001).

CONCLUSIONS

Patients recalled discussions with their surgeon about short-term stroke risk. Only a minority, however, accurately quantified their postoperative stroke risk. In view of variable patient recall, decision aids could assist.

What do patients and the public want from primary care?

The government hopes that getting patients' views on their priorities for primary care will ensure support for its plans. It is likely to find patients care more about quality of care than structural or financial reform

How do elderly patients decide where to go for major surgery? Telephone interview survey

OBJECTIVE

To learn how patients in Medicare, the US medical insurance programme that covers elderly patients, made decisions about where to undergo major surgery and how they would make future decisions.

DESIGN

National telephone interview study.

SETTING

United States.

PARTICIPANTS

510 randomly selected Medicare beneficiaries who had undergone an elective, high risk procedure about 3 years earlier--abdominal aneurysm repair (n = 103), heart valve replacement surgery (n = 96), or resection of the bladder (n = 119), lung (n = 128), or stomach (n = 64) for cancer. Response rates were 48% among eligible survivors and 68% among those able to participate.

RESULTS

Although all participants could choose where to have surgery, only 55% said there was an alternative hospital in their area where they could have gone. Overall, only 10% of respondents seriously considered going elsewhere for surgery. Few respondents (11%) looked for information to compare hospitals. Almost all respondents thought their hospital and surgeon had good reputations (94% and 88%, respectively), beliefs mostly determined by what their referring doctors said. When asked how much various factors would influence their advice to a friend about choosing where to go for major surgery, surgeon reputation was the most influential (78% said it would influence their advice "a lot"), followed by the hospital having "nationally recognised" surgeons (63%), and then various performance data (surgeon volume (58%), nurse:patient ratios (49%), number of operations carried out by the hospital (48%), and hospital operative mortality (45%)). Forty per cent said they would act on mortality data, indicating that they would switch from their initial choice of hospital to a different one if its mortality was a percentage point lower (that is, 3% v 4%).

CONCLUSION

Some respondents claimed they would switch hospital for elective surgery on the basis of mortality data. Since most respondents relied on their referring physician's opinion to decide where to have surgery, surgical performance data ought to be accessible to referring physicians.

The factors that influence patients' choice of hospital and treatment

The Government has published a series of papers that aim to turn the NHS into a patient-led service. One aspect of this change is to allow patients choice in their selection of a hospital for elective surgery. This programme hopes eventually to extend choice to other areas of care. This article reviews the literature surrounding patient choice and identifies the issues that affect how patients will reach a decision. Although there is limited information on the subject, a clear difference has been identified between those with acute conditions and those with chronic conditions. Nurses need to be aware of both the policy and the underpinning concepts and patients' views of the topic because it will bring about a major change in the culture of the NHS.

Feeding back survey research findings within palliative care. Findings from qualitative research

The feedback of research findings to practitioners and policy makers is an important component of palliative care research. Little is, however, understood about professionals' views on the ways research findings should be fed back. This study used semi-structured telephone interviews with a vignette to understand professionals' views on the feedback of survey research findings within palliative care. Content analysis of data uncovered a range of issues professionals emphasised as important to consider. These issues are discussed within the context of existing literature in order to raise the profile of research feedback within palliative care.