doi: 10.1111/hex.12187
The use of publicly available quality information when choosing a hospital or health-care provider: the role of the GP Nora Doering MSc*† and Hans Maarse PhD‡ *PhD Candidate, ‡Professor, Department of Health Services Research, School for Public Health and Primary Care (Caphri) of the Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands, †PhD Candidate, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
Abstract Correspondence Nora Doering, MSc Department of Public Health Sciences Karolinska Institutet €gen 18A Tomtebodava 171 77 Stockholm Sweden E-mail: [email protected] Accepted for publication 22 February 2014 Keywords: Decision making, patientdoctor communication, quality information
Background Patients barely use publicly available quality information for making a decision concerning secondary health care, but instead rely on information coming from their general practitioner (GP). An intermediate role of GPs has been suggested concerning the use of publicly available quality information. The aim of the study is to quantify and explore GPs’ use of publicly available quality information when referring patients or suggesting secondary health-care provider to them. Methods In this cross-sectional study, an invitation to an electronic questionnaire was sent to 858 GPs in the south of the Netherlands. GPs were asked about their use of and perception towards publicly available quality information through closed-ended and open-ended questions. Differences among subgroups were tested for significance using Pearson’s chi-square tests. Results The majority of respondents (89.5%) never or rarely use publicly available quality information. They perceive them as invalid and unreliable. Distance to the hospital, prior experiences and personal contacts with specialists guide them when advising and referring. Almost 90% of respondents never or rarely suggest quality information as support for decision making to their patients. No significant differences between subgroups were observed. Conclusion This study is among the firsts exploring and quantifying GPs’ use of publicly available quality information. The results suggest that publicly available quality information appears in its current format and application not useful for GPs. GPs have to be aware of their influential role in patients’ decision making and possibly have to take more responsibility in guiding them through the jungle of quality information.
Introduction Traditionally, patients have not played an active and informed role in the decision mak-
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ing on where to receive secondary health care. However, in the last decades one can observe a shift towards so-called patient-centred care1 with increased patient autonomy and patient
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empowerment.2 For informed decision making, patients need objective and freely accessible quality information. Already in the 1980s, in the USA, this type of information was made publicly available to the wider population in the hope and expectation that the mechanism of informed choice would improve the quality of health care. Public reporting is assumed to have the potential of improving the quality of health care in two different ways, namely through the selection mechanism, whereby patients select the health-care provider reported to have better quality and/or through the change mechanism, whereby public reporting helps providers to identify areas of underperformance that require improvement.3 These mechanisms can only work if there are (i) several hospitals to choose from, (ii) if quality information to enable care users to make informed choices is publicly available and (iii) if patients are willing to travel for better quality. These preconditions are met in the Netherlands. Sixty-nine percentage of the Dutch population can reach three hospitals in a radius of a 30-min car ride, 25% can even reach ten or more hospitals within that time. Quality information is also widely available. Since the early 2000s, much attention has been given to the collection of quality information and its public dissemination.4,5 One can roughly differentiate between three types of publicly available quality information: official, popular and patient-based (Table 1). However, the most prominent initiative was the creation of the patient-oriented website www.kiesbeter. nl (meaning ‘choose better’) for public reporting in 2005 by the National Institute for Public Health and the Environment (RIVM)1 . Every citizen can inspect the website for information on the quality of health care of provider organizations. Information originates from the so-called Basic Set Hospitals, set up by the Healthcare Inspectorate, an institution responsible for
1 From January 2014 onwards kiesbeter.nl is integrated in the newly established National Health Care Institute (kwaliteitsinstituut), which will be officially launched in April 2014.
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Table 1 Types of publicly available quality information Type
Example
Organization
Frequency
Official Popular
Kiesbeter.nl AD Ziekenhuis Top 100 Zorgkaartnederland.nl
RIVM AD
On-going Yearly
NPCF
On-going
Patientbased
RIVM, Rijksinstituut voor Volksgezondheid en Milieu (National Institute for Public Health and the Environment); AD, Algemeen Dagblad (Dutch daily newspaper); NPCF, Nederlandse Pati€enten en Consumenten Federatie (The Federation of Patients and Consumer Organisations in the Netherlands).
monitoring and enhancing the quality of care and the Consumer Quality Index (CQI). The indicators reflect quality of care in terms of structure, process and volume. Additionally, the Dutch weekly magazine Elsevier and the Dutch daily newspaper Algemeen Dagblad publish every year the best hospitals in the Netherlands following their assessment based on various indicators. Patient experiences play an increasingly important role in quality measurement. The CQI is a standardized method developed by the Consumer Experience in Health Care (Centrum Klantenervaring Zorg) to measure, analyse and report information on patients’ experiences. As a registered trademark, it certifies that the information is valid, reliable and comparable.6 Patients’ experiences as type of quality information are also reflected on the internet platform Zorgkaartnederland.nl where patients are offered the possibility to mark their health providers and to describe their personal experiences with the provider. The website presents the average grade (1 = very poor and 10 = excellent) and is targeted to both patients and health providers. This great amount of information gives the patients plenty of opportunity to get informed (or overwhelmed) about the quality of care of health-care providers. Furthermore, research in the Netherlands has shown that patients are willing to bypass the nearest hospital for possibly better quality.7 A body of national and international studies show that despite the fact that patients say they wish transparency and public reporting on quality issues, they barely use publicly available
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quality information for decision making on specialist health care.4,8–16 The decision on which provider organization to choose – if there is any choice – is usually based on other grounds, for example, distance to home or prior experiences with the hospital.17,18 However, the main source for quality information is not publicly reported information, but instead, the opinion of the general practitioner (GP), family and friends.18,19 It has been suggested that GPs can play an intermediate role in the use of publicly available quality information. Even though patients hardly make use of quality information, they could still benefit from it through their GP.4,15 This suggestion is based on the assumption that GPs use publicly available quality information. So far, there has been little empirical evidence collected to test this assumption. As part of a large study on patient choice in the UK, Dixon et al. interviewed 25 GPs concerning their opinions on patient choice. GPs reported that their advice to patients is often based on personal experience (e.g. relationships built up or feedback from previous patients) and that they were sceptical about the available quality information supporting our hypothesis that GPs hardly use publicly available quality information.20 The current study aims to quantify and further explore the GPs’ awareness and use of publicly available quality information in their dialogue with patients on the choice of secondary health care. The focus in our study is upon the Netherlands, which can be considered an interesting case because GPs act as ‘gate keeper’ to specialist care: patients need a referral from their GP to visit a specialist provider.21
Methods Questionnaire development The research involves a cross-sectional survey design among GPs in the Netherlands with open-ended and closed questions to explore and quantify their perception and use of publicly available quality information. For the
purpose of the survey, we defined publicly available quality information as ‘information on the quality of hospitals and/or health-care providers, which is accessible to everyone’. The questionnaire was developed following a literature review and prior discussion with experts and GPs. Statements were created in a successive approach. The GPs and experts were firstly provided with the above mentioned working definition on publicly available quality information. In a second step, they were asked: ‘What is your opinion on publicly available quality information?’ The statements were then clustered into topics (i.e. reliability, accuracy, relevance, responsiveness), duplicates removed, reformulated and randomly ordered. To avoid potential acquiescence bias, statements were randomly formulated in a positive, negative and neutral manner. Some statements were both negatively and positively keyed to check for consistency (i.e. ‘quality information entails conflicting results’ and ‘quality information is reliable’). The complete questionnaire consists of five small sections: (i) Simple demographics (sex, age), (ii) Information on location (4-digit postcode) and type of practice (e.g. solo-practice or group practice), (iii) Perception of quality information (based on statements, e.g. quality information entail conflicting information, 5-Point Likert scale, 1 = completely disagree and 5 = completely agree) (iv) attributes necessary for suggestions and referrals (e.g. waiting times, 5-Point Likert scale: 1 = very unimportant and 5 = very important) and (v) actual use of quality information (5-Point Likert scale: 1 = always and 5 = never). Research has indicated that women and younger-aged persons (Digital natives2) tend to consult and use more publicly available quality information than men and older-aged persons.8 The location of the practice sheds light on the availability of hospital choice, resulting from the amount of hospitals in the direct environment. The type of practice may indicate the degree on how 2
‘A person born or brought up during the age of digital technology and so familiar with computers and the Internet from an early age’ (Oxford Dictionary).
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closely GPs work together and/or exchange experience with other GPs and could therefore explain the need for publicly available quality information. After development, the questionnaire was pre-tested among GPs to test completeness, comprehensiveness and time needed, which resulted in minor adjustments in statements and attributes, and methods. Data collection With the help of the Department of General Practice at Maastricht University, we had access to a list of Dutch GPs in the southern part of the Netherlands (provinces of Limburg and North Brabant) (n = 1468), of whom we had 858 email addresses. An email invitation with a personalized link to the electronic survey (SurveyMonkey®) was sent out. Two weeks later, a reminder email was sent to those who had not yet filled in the questionnaire. The data collection took place in April 2012. Statistical analysis Summary statistics with mean and standard deviations for continuous variables and frequency numbers and percentages for categorical variables were used for describing the study population and their perception and use of quality information. To check whether there were significant differences among certain groups, data were analysed with Pearson’s chi-square tests. Results were considered as statistical significant with a P-value smaller than a = 0.05. All statistical analyses have been performed with IBM Statistics 20.
Results Description of the sample A total of 170 GPs completed the questionnaire. The majority of the respondents is male (69.4%), and about half of them (47.1%) is aged between 51 and 60 years (see Table 2). In the sample, women are significantly younger than men (Pearson’s chi-square = 40.32;
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Table 2 Description of the study population (n = 170) (%) Gender Male Female Age 31–40 41–50 51–60 61–70 Type of GP practice Solo Group Health centre Other Region* Limburg North Brabant
69.4 30.6 18.8 23.5 47.1 10.6 17.2 49.7 20.7 12.4 57.3 42.7
*Thirteen missing values (incomplete post-code).
a = 0.00). About half of the respondents (49.7%) work in a group practice with at least one other partner and only 17.2% in a solo practice. The sample is not in each respect representative for the entire country. GPs in the study sample are significantly older, and the gender distribution differs significantly to the GP population of the entire country. Furthermore, GPs from rural areas are over-represented.22 The role of GPs in decision making According to the survey, GPs are commonly asked by their patients for advice on the choice of hospital or other secondary provider. More than 90% of the respondents report that patients sometimes or often ask them for advice concerning secondary health care (see Table 3). In the open questions, respondents emphasize that some patients always follow the opinion (or referral) of their GP without further discussion, while others ask for additional information or question the advice in situations of uncertainty (e.g. treatment opportunities, major medical procedures). Respondents report that patients are often interested in prior experience of the GP him/herself or other patients.
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doi: 10.1111/hex.12187
The use of publicly available quality information when choosing a hospital or health-care provider: the role of the GP Nora Doering MSc*† and Hans Maarse PhD‡ *PhD Candidate, ‡Professor, Department of Health Services Research, School for Public Health and Primary Care (Caphri) of the Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands, †PhD Candidate, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
Abstract Correspondence Nora Doering, MSc Department of Public Health Sciences Karolinska Institutet €gen 18A Tomtebodava 171 77 Stockholm Sweden E-mail: [email protected] Accepted for publication 22 February 2014 Keywords: Decision making, patientdoctor communication, quality information
Background Patients barely use publicly available quality information for making a decision concerning secondary health care, but instead rely on information coming from their general practitioner (GP). An intermediate role of GPs has been suggested concerning the use of publicly available quality information. The aim of the study is to quantify and explore GPs’ use of publicly available quality information when referring patients or suggesting secondary health-care provider to them. Methods In this cross-sectional study, an invitation to an electronic questionnaire was sent to 858 GPs in the south of the Netherlands. GPs were asked about their use of and perception towards publicly available quality information through closed-ended and open-ended questions. Differences among subgroups were tested for significance using Pearson’s chi-square tests. Results The majority of respondents (89.5%) never or rarely use publicly available quality information. They perceive them as invalid and unreliable. Distance to the hospital, prior experiences and personal contacts with specialists guide them when advising and referring. Almost 90% of respondents never or rarely suggest quality information as support for decision making to their patients. No significant differences between subgroups were observed. Conclusion This study is among the firsts exploring and quantifying GPs’ use of publicly available quality information. The results suggest that publicly available quality information appears in its current format and application not useful for GPs. GPs have to be aware of their influential role in patients’ decision making and possibly have to take more responsibility in guiding them through the jungle of quality information.
Introduction Traditionally, patients have not played an active and informed role in the decision mak-
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ing on where to receive secondary health care. However, in the last decades one can observe a shift towards so-called patient-centred care1 with increased patient autonomy and patient
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reluctance as to the reliability and relevance of information. Almost 50% of the respondents agree with the statement that publicly available quality information gives conflicting results. This finding corresponds with the low percentages of respondents who agree or strongly agree with the statement that quality information is reliable (8.4%), that quality information is up-to-date (5.4%) and that publicly available quality information fulfils their information needs (7.2%). Nevertheless, some emphasize the need to differentiate between types of quality information and that not all types of publicly available quality information are of poor quality. Publicly available quality information in the doctor–patient dialogue Almost 90% never or rarely use quality information as support in daily practice (see Table 5). Despite the fact that GPs do not find quality information reliable or up-to-date (see earlier section), 20.6% believe that it fulfils the patients’ needs for information. One fifth of the respondents state that patients sometimes Table 5 Quality Information in daily practice % Do patient approach you with publicly available quality information? Never 35.5 Rarely 42.0 Sometimes 20.7 Often 1.8 Always 0.0 How often do you use publicly available quality information? Never 52.4 Rarely 37.1 Sometimes 9.3 Often 0.0 Always 1.2 Do you suggest your patients to use publicly available quality information as support for decision making? Never 55.0 Rarely 34.3 Sometimes 8.9 Often 1.2 Always 0.6
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or often approach them with publicly available quality information. Interestingly, an additional analysis shows that those doctors who are approached with quality information tend to use publicly available quality information themselves significantly more than those not being approached by their patients (Pearson’s chi-square = 5.574; a = 0.018).
Discussion This study is among the firsts investigating the GPs’ perception and use of publicly available quality information. Our findings do not confirm the hypothesis that even though patients hardly use quality information, they still benefit from this information through their GP who uses it in advising patients or referring them to a hospital or secondary health-care provider.4,15 Acknowledging the complexity of the topic, our results shed light on two key points. Firstly, the results suggest that patients rely on their GPs in decision making on secondary health care: the vast majority of respondents report that patients ask them for advice. Secondly, the results show that a striking majority of GPs (89.5%) never or rarely uses publicly available quality information in daily practice. GPs have mainly negative connotations on this type of information. No significant differences between groups of GPs were observed. These findings confirm the GPs’ pivotal role in the referral process and seriously cast doubt on the role of publicly available quality information in this process. Limitations This study is not without limitations. The response rate in this study is low (19.8%), which may bias our results. Notice, however, that the low response rate is not unexpected, because it generally tends to be low among Dutch health professionals in surveys on nonclinical topics. Two other potential sources of bias are our selection procedure [we only included GPs with (known) email addresses]
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and the composition of our file of addresses, which only includes GPs in the southern part of the Netherlands. The latter bias implicates that GPs working in big cities are underrepresented. Given these sources of biases, our results cannot be generalized to all GPs in the Netherlands. However, the clear-cut results on the use of quality information by GPs make it unlikely that a higher response rate and the inclusion of all GPs in the Netherlands would dramatically alter the general picture of low use. Nevertheless, further research is required to substantiate the generalizability of this explorative study. To be able to quantify and explore GPs’ perception on publicly available quality information, we used both closed-ended and open-ended questions. Despite our efforts to reduce potential acquiescence bias by having a random mix of neutral, positive and negative statements, we cannot exclude the possibility that the pre-formulated statement influenced respondents in their opinions and therefore altered their answers. The role of GPs in the decision-making process Our study confirms that patients rely on the opinion of their GP. The results are in line with most other studies.4,10,13,15,17,19,23 There has been one cross-sectional study showing that 75% of the patients in the study population take the decision on where to receive secondary health care on their own. However, the author nevertheless acknowledged the role of the GP as important source of information.17 Although research has shown that an increasing percentage of patients wants to be involved in the decision-making process on further treatment, patients seem not (yet?) to be able to take up this role as regards the choice of secondary provider.24,25 It remains to debate whether it should it be a patient’s task to make such a decision. However, it appears that participation in the decision-making process is more an intrinsic value than a right they want to make use of. Ill persons still wish to rely on the advice of a trusted health practitioner to choose a provider for secondary care.24
Why are GPs not using publicly available quality information? The vast majority of the GPs reports to never or only rarely use quality information (see earlier section). One explanation for this finding is that they do not trust publicly available quality information. The information does not meet their standards for advising and referring patients. GPs use other sources for quality information, in particular, their own experience with referring patients and the experience of their colleagues. Ikkerheim and Koolman26 found that even if GPs use quality information from report cards, this does not alter their decision significantly compared with GPs who do not use reports cards. A complementary explanation may be that patients do not take an active role in the decision-making process. Our results support this assumption by finding that the majority of the GPs report never or only rarely to be approached by patients with publicly available quality information. Apparently, patients do not put pressure on their GPs. An additional analysis demonstrated that if patients do not use quality information, GPs do neither, or put vice versa: if patients approach their GPs with publicly available quality information, the GPs are more likely to have consulted publicly available quality information themselves. This finding suggests an interaction between the GP’s use of publicly available quality information and the patient’s use of publicly available quality information in the decision-making dialogue with their GP. We however cannot distinguish between what came first, whether it is the behaviour of the GP influencing the patient or the other way around. Coulter’s25 observation that GPs may even be reluctant in making patients aware of publicly available quality sources is confirmed in this study. Almost 90% of GPs in our sample never or rarely suggest publicly available quality information to their patients. At the same time, however, almost 21% of the GPs think that publicly available quality information fulfils the patients’ needs on publicly available quality information. Part of the explanation might be that GPs are reluctant to share
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information, of which they are themselves not familiar with.20
Conclusion It is commonly acknowledged that patients do not use publicly available quality information in their decision making on the choice of a secondary care provider. Our results show that GPs do neither. Patients do not choose the best healthcare provider given the public quality information available, but rather base their choice on other types of (quality) information. Our results suggest that GPs follow a similar logic. Distance to the hospital, prior experiences and personal knowledge on specialists guide them in their advising and referring role. The study confirmed once more the role of GPs in decision making. In times of sickness, patients want to rely on a trusted health professional. GPs have to be aware of their influential role and possibly have to take more responsibility in guiding the patients through the jungle of quality information in order to achieve more patient involvement. In its current format and application, publicly available quality information does not appear useful and cannot fulfil its selection and change role. To increase its use, there is the need for information to be targeted and tailored to GPs’ information needs. It remains however to debate, whether the use of publicly available quality information should be further promoted when neither the GPs nor the patients seem to use these sources of quality information for their decision making.
Funding This paper is the result of research that was requested by the European Commission’s Directorate – General for Health & Consumer and co-funded through the EU’s FP7 Cooperation Work Programme: Health (contract number 242058; contract acronym EUCBCC) 2010–2013 EUCBCC consortium. The European Commission is not responsible for the content of the paper. Responsibility for the facts described in the report and the views expressed rests entirely with the authors. What is already known on this subject? 1. Patients do not use publicly available quality information for deciding where to receive secondary health care. 2. GPs, family and friends are the main sources for information. 3. Studies suggested that patients still benefit from publicly available quality information with the GP as a mediator, but until now there have been no studies on GPs’ attitude towards and use of publicly available quality information. What does this paper add? 1. Results confirm the important role of GPs in patient’s decision making 2. GPs do not use publicly available quality information 3. GPs do not trust information from publicly available sources 4. GPs do not suggest publicly available quality information as decision tool for patients 5. Patients do not approach GPs with publicly available quality information
Acknowledgements We would like to thank Prof. Metsemakers and the Department of General Practice of Maastricht University for providing the contact information of the GPs and Irene A. Glinos for helpful comments on an earlier version of this article.
Conflict of interest All authors declare no conflict of interests
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References 1 Hibbard JH. Moving toward a more patient-centered health care delivery system. Health Affairs, 2004; 23: Suppl Web Exclusive:VAR133–135. 2 Feste C, Anderson RM. Empowerment: from philosophy to practice. Patient Education and Counseling, 1995; 26: 139–144. 3 Berwick DM, James B, Coye MJ. Connections between quality measurement and improvement. Medical Care, 2003; 41: I.
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GPs’ use of quality information, N Doering and H Maarse 4 de Groot IB, Otten W, Smeets HJ, Marang-van de Mheen PJ. Is the impact of hospital performance data greater in patients who have compared hospitals? BMC Health Services Research, 2011; 11: 214. 5 Maarse JA, Ruwaard D, Spreeuwenberg C. The governance of quality management in dutch health care: new developments and strategic challenges. Quality Management in Health Care, 2013; 22: 236–247. 6 Maarse J, Ruwaard D, Spreeuwenberg C. The governance of quality management in dutch health care: new developments and strategic challenges. Quality Management in Health Care, 2012; 22: 236–247. 7 Varkevisser M, van der Geest S. Why do patients bypass the nearest hospital? An empirical analysis for orthopaedic care and neurosurgery in the Netherlands The European Journal of Health Economics, 2007; 8: 287–295. 8 Dijs-Elsinga J, Otten W, Versluijs M et al. Choosing a hospital for surgery: the importance of information on quality of care. Medical Decision Making, 2010; 30: 544–555. 9 Faber M, Bosch M, Wollersheim H, Leatherman H, Grol R. Public reporting in health care: how do consumers use quality-of-care information? A systematic review Medical Care, 2009; 47: 1–8. 10 Marang-van de Mheen P, Dijs-Elsinga J, Otten W et al. The relative importance of quality of care information when choosing a hospital for surgical treatment: a hospital choice experiment. Medical Decision Making, 2010; 31: 816–827. 11 Marshall M, McLoughin V. How do patients use information on health providers? British Medical Journal, 2010; 341: c5272. 12 Marshall M, Shekelle P, Leatherman S, Brooke R. The public release of performance data: what do we expect to gain? A review of the evidence. Journal of the American Medical Association, 2000; 283: 1866– 1874. 13 Moser A, Korstjens I, van der Weijden T, Tange H. Themes affecting health-care consumers’choice of a hospital for elective surgery when receiving webbased comparative consumer information. Patient Education and Counseling, 2010; 78: 365–371. 14 Schneider E, Epstein A. Use of public performance reports: a survey of patients undergoing cardiac
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surgery. Journal of the American Medical Association, 1998; 279: 1638–1642. Schwartz L, Woloshin S, Birkmeyer J. How do elderly patients decide where to go for major surgery? Telephone interview survey British Medical Journal, 2005; 331: 821. Sofaer S, Crofton C, Goldstein E, Hoy E, Crabb J. What do consumers want to know about the quality of care in hospitals? Health Services Research, 2005;40(Pt 2):2018–2036. de Cruppe W, Geraedts M. How do patients choose a hospital for elective surgery? Bundesgesundheitsblatt, Gesundheitsforschung, Gesundheitsschutz, 2011; 54: 951. Harris KM, Buntin MB. Choosing a health care provider: the role of quality information. Policy, 2008; 1: 6. Lako CJ, Rosenau P. Demand-driven care and hospital choice. Dutch health policy toward demand-driven care: results from a survey into hospital choice. Health Care Analysis, 2009; 17: 20– 35. Dixon A, Robertson R, Appleby J, Burge P, Devlin NJ. Patient choice: how patients choose and how providers respond, 2010. Available at: http://www. kingsfund.org.uk/publications/patient-choice, accessed 24 January 2014. Kroneman MW, Maarse H, van der Zee J. Direct access in primary care and patient satisfaction: a European study. Health Policy, 2006; 76: 72–79. NIVEL. Aantal werkzame huisartsen naar leeftijd en geslacht 2012. Available at: http://www.nivel.nl/ databank, accessed 15 July 2013. van de Geest S, Varkevisser M. Zorgconsumenten en kwaliteitsinformatie. Economisch-Statistische Berichten, 2012; 97: 174–175. Fotaki M, Roland M, Boyd A, McDonald R, Scheaff R, Smith L. What benefits will choice bring to patients? Literature review and assessment of implications Journal of Health Services Research & Policy, 2008; 13: 178–184. Coulter A. Do patients want a choice and does it work? British Medical Journal, 2010; 341: c4989. Ikkersheim D, Koolman X. The use of quality information by general practitioners: does it alter choices? A randomized clustered study BMC Family Practice, 2013; 14: 95.
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The use of publicly available quality information when choosing a hospital or health-care provider: the role of the GP Nora Doering MSc*† and Hans Maarse PhD‡ *PhD Candidate, ‡Professor, Department of Health Services Research, School for Public Health and Primary Care (Caphri) of the Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands, †PhD Candidate, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
Abstract Correspondence Nora Doering, MSc Department of Public Health Sciences Karolinska Institutet €gen 18A Tomtebodava 171 77 Stockholm Sweden E-mail: [email protected] Accepted for publication 22 February 2014 Keywords: Decision making, patientdoctor communication, quality information
Background Patients barely use publicly available quality information for making a decision concerning secondary health care, but instead rely on information coming from their general practitioner (GP). An intermediate role of GPs has been suggested concerning the use of publicly available quality information. The aim of the study is to quantify and explore GPs’ use of publicly available quality information when referring patients or suggesting secondary health-care provider to them. Methods In this cross-sectional study, an invitation to an electronic questionnaire was sent to 858 GPs in the south of the Netherlands. GPs were asked about their use of and perception towards publicly available quality information through closed-ended and open-ended questions. Differences among subgroups were tested for significance using Pearson’s chi-square tests. Results The majority of respondents (89.5%) never or rarely use publicly available quality information. They perceive them as invalid and unreliable. Distance to the hospital, prior experiences and personal contacts with specialists guide them when advising and referring. Almost 90% of respondents never or rarely suggest quality information as support for decision making to their patients. No significant differences between subgroups were observed. Conclusion This study is among the firsts exploring and quantifying GPs’ use of publicly available quality information. The results suggest that publicly available quality information appears in its current format and application not useful for GPs. GPs have to be aware of their influential role in patients’ decision making and possibly have to take more responsibility in guiding them through the jungle of quality information.
Introduction Traditionally, patients have not played an active and informed role in the decision mak-
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ing on where to receive secondary health care. However, in the last decades one can observe a shift towards so-called patient-centred care1 with increased patient autonomy and patient
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GPs’ use of quality information, N Doering and H Maarse
empowerment.2 For informed decision making, patients need objective and freely accessible quality information. Already in the 1980s, in the USA, this type of information was made publicly available to the wider population in the hope and expectation that the mechanism of informed choice would improve the quality of health care. Public reporting is assumed to have the potential of improving the quality of health care in two different ways, namely through the selection mechanism, whereby patients select the health-care provider reported to have better quality and/or through the change mechanism, whereby public reporting helps providers to identify areas of underperformance that require improvement.3 These mechanisms can only work if there are (i) several hospitals to choose from, (ii) if quality information to enable care users to make informed choices is publicly available and (iii) if patients are willing to travel for better quality. These preconditions are met in the Netherlands. Sixty-nine percentage of the Dutch population can reach three hospitals in a radius of a 30-min car ride, 25% can even reach ten or more hospitals within that time. Quality information is also widely available. Since the early 2000s, much attention has been given to the collection of quality information and its public dissemination.4,5 One can roughly differentiate between three types of publicly available quality information: official, popular and patient-based (Table 1). However, the most prominent initiative was the creation of the patient-oriented website www.kiesbeter. nl (meaning ‘choose better’) for public reporting in 2005 by the National Institute for Public Health and the Environment (RIVM)1 . Every citizen can inspect the website for information on the quality of health care of provider organizations. Information originates from the so-called Basic Set Hospitals, set up by the Healthcare Inspectorate, an institution responsible for
1 From January 2014 onwards kiesbeter.nl is integrated in the newly established National Health Care Institute (kwaliteitsinstituut), which will be officially launched in April 2014.
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Table 1 Types of publicly available quality information Type
Example
Organization
Frequency
Official Popular
Kiesbeter.nl AD Ziekenhuis Top 100 Zorgkaartnederland.nl
RIVM AD
On-going Yearly
NPCF
On-going
Patientbased
RIVM, Rijksinstituut voor Volksgezondheid en Milieu (National Institute for Public Health and the Environment); AD, Algemeen Dagblad (Dutch daily newspaper); NPCF, Nederlandse Pati€enten en Consumenten Federatie (The Federation of Patients and Consumer Organisations in the Netherlands).
monitoring and enhancing the quality of care and the Consumer Quality Index (CQI). The indicators reflect quality of care in terms of structure, process and volume. Additionally, the Dutch weekly magazine Elsevier and the Dutch daily newspaper Algemeen Dagblad publish every year the best hospitals in the Netherlands following their assessment based on various indicators. Patient experiences play an increasingly important role in quality measurement. The CQI is a standardized method developed by the Consumer Experience in Health Care (Centrum Klantenervaring Zorg) to measure, analyse and report information on patients’ experiences. As a registered trademark, it certifies that the information is valid, reliable and comparable.6 Patients’ experiences as type of quality information are also reflected on the internet platform Zorgkaartnederland.nl where patients are offered the possibility to mark their health providers and to describe their personal experiences with the provider. The website presents the average grade (1 = very poor and 10 = excellent) and is targeted to both patients and health providers. This great amount of information gives the patients plenty of opportunity to get informed (or overwhelmed) about the quality of care of health-care providers. Furthermore, research in the Netherlands has shown that patients are willing to bypass the nearest hospital for possibly better quality.7 A body of national and international studies show that despite the fact that patients say they wish transparency and public reporting on quality issues, they barely use publicly available
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quality information for decision making on specialist health care.4,8–16 The decision on which provider organization to choose – if there is any choice – is usually based on other grounds, for example, distance to home or prior experiences with the hospital.17,18 However, the main source for quality information is not publicly reported information, but instead, the opinion of the general practitioner (GP), family and friends.18,19 It has been suggested that GPs can play an intermediate role in the use of publicly available quality information. Even though patients hardly make use of quality information, they could still benefit from it through their GP.4,15 This suggestion is based on the assumption that GPs use publicly available quality information. So far, there has been little empirical evidence collected to test this assumption. As part of a large study on patient choice in the UK, Dixon et al. interviewed 25 GPs concerning their opinions on patient choice. GPs reported that their advice to patients is often based on personal experience (e.g. relationships built up or feedback from previous patients) and that they were sceptical about the available quality information supporting our hypothesis that GPs hardly use publicly available quality information.20 The current study aims to quantify and further explore the GPs’ awareness and use of publicly available quality information in their dialogue with patients on the choice of secondary health care. The focus in our study is upon the Netherlands, which can be considered an interesting case because GPs act as ‘gate keeper’ to specialist care: patients need a referral from their GP to visit a specialist provider.21
Methods Questionnaire development The research involves a cross-sectional survey design among GPs in the Netherlands with open-ended and closed questions to explore and quantify their perception and use of publicly available quality information. For the
purpose of the survey, we defined publicly available quality information as ‘information on the quality of hospitals and/or health-care providers, which is accessible to everyone’. The questionnaire was developed following a literature review and prior discussion with experts and GPs. Statements were created in a successive approach. The GPs and experts were firstly provided with the above mentioned working definition on publicly available quality information. In a second step, they were asked: ‘What is your opinion on publicly available quality information?’ The statements were then clustered into topics (i.e. reliability, accuracy, relevance, responsiveness), duplicates removed, reformulated and randomly ordered. To avoid potential acquiescence bias, statements were randomly formulated in a positive, negative and neutral manner. Some statements were both negatively and positively keyed to check for consistency (i.e. ‘quality information entails conflicting results’ and ‘quality information is reliable’). The complete questionnaire consists of five small sections: (i) Simple demographics (sex, age), (ii) Information on location (4-digit postcode) and type of practice (e.g. solo-practice or group practice), (iii) Perception of quality information (based on statements, e.g. quality information entail conflicting information, 5-Point Likert scale, 1 = completely disagree and 5 = completely agree) (iv) attributes necessary for suggestions and referrals (e.g. waiting times, 5-Point Likert scale: 1 = very unimportant and 5 = very important) and (v) actual use of quality information (5-Point Likert scale: 1 = always and 5 = never). Research has indicated that women and younger-aged persons (Digital natives2) tend to consult and use more publicly available quality information than men and older-aged persons.8 The location of the practice sheds light on the availability of hospital choice, resulting from the amount of hospitals in the direct environment. The type of practice may indicate the degree on how 2
‘A person born or brought up during the age of digital technology and so familiar with computers and the Internet from an early age’ (Oxford Dictionary).
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closely GPs work together and/or exchange experience with other GPs and could therefore explain the need for publicly available quality information. After development, the questionnaire was pre-tested among GPs to test completeness, comprehensiveness and time needed, which resulted in minor adjustments in statements and attributes, and methods. Data collection With the help of the Department of General Practice at Maastricht University, we had access to a list of Dutch GPs in the southern part of the Netherlands (provinces of Limburg and North Brabant) (n = 1468), of whom we had 858 email addresses. An email invitation with a personalized link to the electronic survey (SurveyMonkey®) was sent out. Two weeks later, a reminder email was sent to those who had not yet filled in the questionnaire. The data collection took place in April 2012. Statistical analysis Summary statistics with mean and standard deviations for continuous variables and frequency numbers and percentages for categorical variables were used for describing the study population and their perception and use of quality information. To check whether there were significant differences among certain groups, data were analysed with Pearson’s chi-square tests. Results were considered as statistical significant with a P-value smaller than a = 0.05. All statistical analyses have been performed with IBM Statistics 20.
Results Description of the sample A total of 170 GPs completed the questionnaire. The majority of the respondents is male (69.4%), and about half of them (47.1%) is aged between 51 and 60 years (see Table 2). In the sample, women are significantly younger than men (Pearson’s chi-square = 40.32;
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Table 2 Description of the study population (n = 170) (%) Gender Male Female Age 31–40 41–50 51–60 61–70 Type of GP practice Solo Group Health centre Other Region* Limburg North Brabant
69.4 30.6 18.8 23.5 47.1 10.6 17.2 49.7 20.7 12.4 57.3 42.7
*Thirteen missing values (incomplete post-code).
a = 0.00). About half of the respondents (49.7%) work in a group practice with at least one other partner and only 17.2% in a solo practice. The sample is not in each respect representative for the entire country. GPs in the study sample are significantly older, and the gender distribution differs significantly to the GP population of the entire country. Furthermore, GPs from rural areas are over-represented.22 The role of GPs in decision making According to the survey, GPs are commonly asked by their patients for advice on the choice of hospital or other secondary provider. More than 90% of the respondents report that patients sometimes or often ask them for advice concerning secondary health care (see Table 3). In the open questions, respondents emphasize that some patients always follow the opinion (or referral) of their GP without further discussion, while others ask for additional information or question the advice in situations of uncertainty (e.g. treatment opportunities, major medical procedures). Respondents report that patients are often interested in prior experience of the GP him/herself or other patients.
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doi: 10.1111/hex.12187
The use of publicly available quality information when choosing a hospital or health-care provider: the role of the GP Nora Doering MSc*† and Hans Maarse PhD‡ *PhD Candidate, ‡Professor, Department of Health Services Research, School for Public Health and Primary Care (Caphri) of the Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands, †PhD Candidate, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
Abstract Correspondence Nora Doering, MSc Department of Public Health Sciences Karolinska Institutet €gen 18A Tomtebodava 171 77 Stockholm Sweden E-mail: [email protected] Accepted for publication 22 February 2014 Keywords: Decision making, patientdoctor communication, quality information
Background Patients barely use publicly available quality information for making a decision concerning secondary health care, but instead rely on information coming from their general practitioner (GP). An intermediate role of GPs has been suggested concerning the use of publicly available quality information. The aim of the study is to quantify and explore GPs’ use of publicly available quality information when referring patients or suggesting secondary health-care provider to them. Methods In this cross-sectional study, an invitation to an electronic questionnaire was sent to 858 GPs in the south of the Netherlands. GPs were asked about their use of and perception towards publicly available quality information through closed-ended and open-ended questions. Differences among subgroups were tested for significance using Pearson’s chi-square tests. Results The majority of respondents (89.5%) never or rarely use publicly available quality information. They perceive them as invalid and unreliable. Distance to the hospital, prior experiences and personal contacts with specialists guide them when advising and referring. Almost 90% of respondents never or rarely suggest quality information as support for decision making to their patients. No significant differences between subgroups were observed. Conclusion This study is among the firsts exploring and quantifying GPs’ use of publicly available quality information. The results suggest that publicly available quality information appears in its current format and application not useful for GPs. GPs have to be aware of their influential role in patients’ decision making and possibly have to take more responsibility in guiding them through the jungle of quality information.
Introduction Traditionally, patients have not played an active and informed role in the decision mak-
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ing on where to receive secondary health care. However, in the last decades one can observe a shift towards so-called patient-centred care1 with increased patient autonomy and patient
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reluctance as to the reliability and relevance of information. Almost 50% of the respondents agree with the statement that publicly available quality information gives conflicting results. This finding corresponds with the low percentages of respondents who agree or strongly agree with the statement that quality information is reliable (8.4%), that quality information is up-to-date (5.4%) and that publicly available quality information fulfils their information needs (7.2%). Nevertheless, some emphasize the need to differentiate between types of quality information and that not all types of publicly available quality information are of poor quality. Publicly available quality information in the doctor–patient dialogue Almost 90% never or rarely use quality information as support in daily practice (see Table 5). Despite the fact that GPs do not find quality information reliable or up-to-date (see earlier section), 20.6% believe that it fulfils the patients’ needs for information. One fifth of the respondents state that patients sometimes Table 5 Quality Information in daily practice % Do patient approach you with publicly available quality information? Never 35.5 Rarely 42.0 Sometimes 20.7 Often 1.8 Always 0.0 How often do you use publicly available quality information? Never 52.4 Rarely 37.1 Sometimes 9.3 Often 0.0 Always 1.2 Do you suggest your patients to use publicly available quality information as support for decision making? Never 55.0 Rarely 34.3 Sometimes 8.9 Often 1.2 Always 0.6
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or often approach them with publicly available quality information. Interestingly, an additional analysis shows that those doctors who are approached with quality information tend to use publicly available quality information themselves significantly more than those not being approached by their patients (Pearson’s chi-square = 5.574; a = 0.018).
Discussion This study is among the firsts investigating the GPs’ perception and use of publicly available quality information. Our findings do not confirm the hypothesis that even though patients hardly use quality information, they still benefit from this information through their GP who uses it in advising patients or referring them to a hospital or secondary health-care provider.4,15 Acknowledging the complexity of the topic, our results shed light on two key points. Firstly, the results suggest that patients rely on their GPs in decision making on secondary health care: the vast majority of respondents report that patients ask them for advice. Secondly, the results show that a striking majority of GPs (89.5%) never or rarely uses publicly available quality information in daily practice. GPs have mainly negative connotations on this type of information. No significant differences between groups of GPs were observed. These findings confirm the GPs’ pivotal role in the referral process and seriously cast doubt on the role of publicly available quality information in this process. Limitations This study is not without limitations. The response rate in this study is low (19.8%), which may bias our results. Notice, however, that the low response rate is not unexpected, because it generally tends to be low among Dutch health professionals in surveys on nonclinical topics. Two other potential sources of bias are our selection procedure [we only included GPs with (known) email addresses]
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and the composition of our file of addresses, which only includes GPs in the southern part of the Netherlands. The latter bias implicates that GPs working in big cities are underrepresented. Given these sources of biases, our results cannot be generalized to all GPs in the Netherlands. However, the clear-cut results on the use of quality information by GPs make it unlikely that a higher response rate and the inclusion of all GPs in the Netherlands would dramatically alter the general picture of low use. Nevertheless, further research is required to substantiate the generalizability of this explorative study. To be able to quantify and explore GPs’ perception on publicly available quality information, we used both closed-ended and open-ended questions. Despite our efforts to reduce potential acquiescence bias by having a random mix of neutral, positive and negative statements, we cannot exclude the possibility that the pre-formulated statement influenced respondents in their opinions and therefore altered their answers. The role of GPs in the decision-making process Our study confirms that patients rely on the opinion of their GP. The results are in line with most other studies.4,10,13,15,17,19,23 There has been one cross-sectional study showing that 75% of the patients in the study population take the decision on where to receive secondary health care on their own. However, the author nevertheless acknowledged the role of the GP as important source of information.17 Although research has shown that an increasing percentage of patients wants to be involved in the decision-making process on further treatment, patients seem not (yet?) to be able to take up this role as regards the choice of secondary provider.24,25 It remains to debate whether it should it be a patient’s task to make such a decision. However, it appears that participation in the decision-making process is more an intrinsic value than a right they want to make use of. Ill persons still wish to rely on the advice of a trusted health practitioner to choose a provider for secondary care.24
Why are GPs not using publicly available quality information? The vast majority of the GPs reports to never or only rarely use quality information (see earlier section). One explanation for this finding is that they do not trust publicly available quality information. The information does not meet their standards for advising and referring patients. GPs use other sources for quality information, in particular, their own experience with referring patients and the experience of their colleagues. Ikkerheim and Koolman26 found that even if GPs use quality information from report cards, this does not alter their decision significantly compared with GPs who do not use reports cards. A complementary explanation may be that patients do not take an active role in the decision-making process. Our results support this assumption by finding that the majority of the GPs report never or only rarely to be approached by patients with publicly available quality information. Apparently, patients do not put pressure on their GPs. An additional analysis demonstrated that if patients do not use quality information, GPs do neither, or put vice versa: if patients approach their GPs with publicly available quality information, the GPs are more likely to have consulted publicly available quality information themselves. This finding suggests an interaction between the GP’s use of publicly available quality information and the patient’s use of publicly available quality information in the decision-making dialogue with their GP. We however cannot distinguish between what came first, whether it is the behaviour of the GP influencing the patient or the other way around. Coulter’s25 observation that GPs may even be reluctant in making patients aware of publicly available quality sources is confirmed in this study. Almost 90% of GPs in our sample never or rarely suggest publicly available quality information to their patients. At the same time, however, almost 21% of the GPs think that publicly available quality information fulfils the patients’ needs on publicly available quality information. Part of the explanation might be that GPs are reluctant to share
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information, of which they are themselves not familiar with.20
Conclusion It is commonly acknowledged that patients do not use publicly available quality information in their decision making on the choice of a secondary care provider. Our results show that GPs do neither. Patients do not choose the best healthcare provider given the public quality information available, but rather base their choice on other types of (quality) information. Our results suggest that GPs follow a similar logic. Distance to the hospital, prior experiences and personal knowledge on specialists guide them in their advising and referring role. The study confirmed once more the role of GPs in decision making. In times of sickness, patients want to rely on a trusted health professional. GPs have to be aware of their influential role and possibly have to take more responsibility in guiding the patients through the jungle of quality information in order to achieve more patient involvement. In its current format and application, publicly available quality information does not appear useful and cannot fulfil its selection and change role. To increase its use, there is the need for information to be targeted and tailored to GPs’ information needs. It remains however to debate, whether the use of publicly available quality information should be further promoted when neither the GPs nor the patients seem to use these sources of quality information for their decision making.
Funding This paper is the result of research that was requested by the European Commission’s Directorate – General for Health & Consumer and co-funded through the EU’s FP7 Cooperation Work Programme: Health (contract number 242058; contract acronym EUCBCC) 2010–2013 EUCBCC consortium. The European Commission is not responsible for the content of the paper. Responsibility for the facts described in the report and the views expressed rests entirely with the authors. What is already known on this subject? 1. Patients do not use publicly available quality information for deciding where to receive secondary health care. 2. GPs, family and friends are the main sources for information. 3. Studies suggested that patients still benefit from publicly available quality information with the GP as a mediator, but until now there have been no studies on GPs’ attitude towards and use of publicly available quality information. What does this paper add? 1. Results confirm the important role of GPs in patient’s decision making 2. GPs do not use publicly available quality information 3. GPs do not trust information from publicly available sources 4. GPs do not suggest publicly available quality information as decision tool for patients 5. Patients do not approach GPs with publicly available quality information
Acknowledgements We would like to thank Prof. Metsemakers and the Department of General Practice of Maastricht University for providing the contact information of the GPs and Irene A. Glinos for helpful comments on an earlier version of this article.
Conflict of interest All authors declare no conflict of interests
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