Which factors decided general practitioners’ choice of hospital on behalf of their patients in an area with free choice of public hospital? A questionnaire study

Responsibility for choice of hospital

Among the 240 respondents 183 (76%) reported that in their view they chose the hospital on behalf of the latest patient referred to hospital, 35 (15%) reported that the patient made the choice, two (1%) reported that the patients’ relatives made the choice, and 20 (8%) did not state, who chose the hospital or ticked off several categories. Several of these GPs commented that they chose the hospital in cooperation with the patient or that the patient agreed with the GP. One GP commented that he always asked whether the patient wanted to be referred to another hospital than the one proposed by the GP, and another GP reported that he asked whether the patient wanted to be referred to a specific department.

Reasons for GPs’ choice of hospital

Ninety-two percent of the respondents (220 of 240) reported that they had chosen the hospital on behalf of one patient or more, while 20 GPs attributed all patients’ choice to the patients, their relatives or referral guidelines limiting free choice of hospital for the specific patients (these guidelines did not interfere with patient’ rights to choose a hospital in another county). The 220 respondents did not differ significantly from the study population with regard to county, gender or number of years since graduation. Four GPs did not tick off any reasons for choice of hospital and were excluded from this part of the study. Eighty-seven of the 216 GPs (40%) reported that a single factor decided their choice for the patient, short distance to the hospital being the decisive factor for 75 of the 87 GPs (86%). Ninety-five GPs reported that 2–5 factors were very important for their choice, 25 quoted 6–9 factors, and nine GPs quoted ten or more factors.

Short distances to hospital, the department’s serious consideration of referrals from the GP, and comments from previous patients referred to the department were the most common factors behind GPs’ choice of hospital on behalf of patients (Table 1).

The importance of each factor behind choice of hospital was not associated with the GP’s gender (data not shown), and multiple regression analysis showed no significant association between the number of reasons for choice and the number of years since the GP’s graduation (β = 0.109, p = 0.26) or gender (p = 0.96). In univariate analysis of each factor and the number of years since graduation, GPs who based their choice on their personal experience with the department as employees were significantly younger (on average 20.1 years since graduation) than GPs who did not (on average 24.2 years since graduation) (p < 0.05).

One GP commented that problems associated with transport and rehabilitation after hospitalisation posed greater challenges than waiting time, and therefore patients were only referred out of the county if the quality of care within the county was very bad.

Sources of information on quality or service

The most frequently used sources of information on quality at hospital departments were reports from patients referred to the department or the hospital by the GP previously (Table 2), and other GPs’ comments on the department. Univariate analysis showed that female GPs were significantly more likely than male GPs to consider official information from departments an important source of information, and younger GPs were significantly more likely than older GPs to quote their experience as trainees at a department (average number of years since graduation 19.2 and 25.1 respectively, p < 0.001) or a hospital (average number of years since graduation 21.4 and 24.7 years respectively; p < 0.05) or comments from patients previously referred to a department (average number of years since graduation 23.2 and 25.3 years respectively; p < 0.05) as important sources of information on quality. Multivariate analyses confirmed that there were statistically significant negative associations between the number of years after the GPs’ graduation and GPs’ utilisation of information from previously referred patients (β = −0.05; p < 0.05), and an association between gender and use of official information from the department (odds ratio 0.37; p < 0.01) or the hospital (odds ratio 0.35; p < 0.01), female GPs being more likely to quote official information as a source of information. Multivariate analysis found no association between GPs’ age or gender and their quoting experience from employment at department or hospital as sources of information on quality (data not shown).

One GP commented pointedly that she spent her scarce time on the patients rather than reading official information about quality at various departments. Several GPs repeated in their response to this question their answers to another question that previous patients’ reports were the most important sources of information on quality, two GPs underscoring that they attributed greater weight to 20 years’ experience with a hospital than to the hospital’s description of its quality, one GP contrasting “action” with “words”.

The hospitals’ letters of confirmation of referrals were the GPs’ most important source of information on waiting times (Table 3). Information available from websites was used less often than information on paper. Univariate analysis found no association between GPs’ age or gender and their utilisation of various sources of information, but multiple, logistical regression analyses showed that male (p < 0.01) and younger GPs (p < 0.01) were especially likely to use the counties’ waiting time prognoses on the internet.

Eight GPs reported that they often asked patients to call the county’s patient advisor to discuss which department they would like to be referred to, one GP adding that in some cases she recommended accepting a long waiting time if the department was an especially good one. One GP commented that in her opinion it was a task for the hospital to inform the patients about waiting times, while another GP had delegated collecting of and information about data on waiting times to her secretary. Two GPs reported that if patients wanted a shorter waiting time, they asked the patients to look for waiting time data elsewhere. One GP likewise stated that she informed the patient about the right to free choice but asked them to investigate the opportunities on their own. One GP reported that she did not use any official information about expected waiting times, because waiting time prognoses were outdated as early as at the time of publishing. Several GPs described an intention to utilize data on the web in the future, although some GPs found that utilization of data on the internet was a very time consuming and complicated process. One GP found that calling departments likewise was time consuming because it usually took a long time to find somebody who could answer questions on expected waiting time.

Responsibility for choice of hospital

In the present study the GPs reported that they chose the hospital on behalf of 76% of patients. This result appears to contradict results from national Danish surveys of patients’ experience with hospitals: in 2004 46% of in-patients treated in the study area reported, that they chose the hospital; among elective in-patients 89% were aware before being hospitalised that they were free to choose, and 52% of these patients chose the hospital by themselves [26]. The divergent findings may be interpreted as an indicator of shared decision making. When 30% of patients reported that their GP’s recommendation influenced their own choice of hospital [26], the GPs may have perceived that they chose the hospital on behalf of the patient.

The results indicate that patients choose the hospital to a lesser degree than policy makers (politicians and administrators) want them to do to improve management of the public health care sector by introducing a proxy for the market mechanism. Other studies have found that GPs appear to question whether choice is valuable to patients [29], and whether patients really want to choose the hospital [4]. GPs’ choice behaviour varies by GP [29] and by the patients’ diagnoses [39], English GPs being more likely to offer choice to patients, who are in need of a routine intervention, elective patients, and patients who are relatively healthy [4].

One study distinguished between ‘choice enthusiasts’, ‘choice sceptics’ and ‘choice paternalists’ [29]. The present study did not enable us to divide GPs into such subgroups, but confirming results from other studies [4, 30] several GPs expressed reluctance to provide advice to patients, because they did not consider this task a part of their job [30, 40]; considered this task too time-consuming for a consultation [4], or distrusted data published by the providers [29] and wanted to forestall blame for presenting faulty data [23]. This behaviour may reflect an attempt to minimize the length of each visit to the GP. However, at a more general level GPs’ behaviour may reflect a ‘logic of care’ rather than a ‘logic of choice’ [41] - GPs making choices based on their professional views on patients’ needs and wants, rather than as agents acting in a market place enabling patients to make informed choices in line with the neoclassical standard model.

Factors determining GPs’ choice of hospital on behalf of patients

Short distance to hospital was the most important factor behind GPs’ choice of hospital. Numerous other studies of GPs’ actual referral pattern and patients’ choices in structurally different health care systems likewise indicate that short distance strongly influences patients’ and GPs’ choice of hospital [26, 33, 42]. Studies of GPs’ hypothetical referrals and patients’ hypothetical choices have led to other results with GPs emphasizing the importance of short waiting time and the GP’s impression of quality at the alternative departments [35, 43], while patients facing a hypothetical choice emphasized the importance of data on structure quality and attributed little weight to waiting time [44].

Different findings in studies of GPs’ and patients’ choice behaviour may reflect differences between how GPs and patients think they ought to choose the hospital and how they actually make the choice, one study finding significant differences between GPs’ response to hypothetical case stories and their actual referral pattern [45]. Another reason could be international institutional differences with regard to subsidization of transport costs and the length of waiting times.

The small influence of waiting time on choice may be considered to be remarkable, as the media and politicians at the national level consistently focus on waiting times as a major performance measure and challenge, but other studies of choice of hospital likewise found only a small influence of waiting time on choice. Cataract patients generally accepted waiting times of three months and less, while waiting times of six months or more were perceived as too long [46, 47]. In a hypothetical study patients reported that for each additional hour of travel time they would, on average, require a reduction of in the waiting time of 2.3 months [48]. The results of these studies and the present study may partly explain why differences between waiting times at hospitals persisted more than a decade after the introduction of free choice of hospital, but they may also reflect, that a minority of patients are treated as elective patients.

In the present study we focused on the influence of GPs’ sources of information about departments/hospitals and factors commonly found to influence the GPs’ choices. However, GPs’ choices on behalf of patients may be influenced by other agendas independent of the individual patient, i.e. GPs may refer patients to a local hospital to contribute to its continuing existence [30].

GPs’ use of sources of information on quality and service

In the present study GPs were less likely to use official information on quality and waiting time than proxy-measures from informal sources like their own and other GPs’ and patients’ experience with regard to quality and waiting time. This result was consistent with other studies of GPs’ or patients’ utilisation of sources of information, which have found very little utilisation of such sources [49] and refer to GPs as having “a sort of ‘mental filing cabinet’ of informal information or soft intelligence”[28]. The GPs’ experience with cooperation with various departments or hospitals was very important for the GPs’ choice. GPs’ responses indicated that their experience with specific departments was the most important factor, but many GPs attributed their choice to their experience with a hospital in general rather than the individual department, thereby indicating that they generalised their experience from one or more departments at a hospital to other departments at the hospital as a whole – a kind of ‘halo’-effect.

The strong influence of informal data sources like patients’ previous experience on choice and advice on choice may reflect lack of official information on quality or waiting time or that GPs are suspicious of published data on performance, viewing such data as “spin” [29]. Several respondents commented that use of web-based information was too time-consuming compared to data on paper; their memory of previous referrals, and asking the patient to call one or more hospitals or the county’s patient’s advisors for information.

Some GPs wrote that they intended to use web-based information more in the future. Such statements may reflect expectations that more experience and improved IT will ease their access to the web or lack of experience. When the present study was performed approx. 86% of Danish general practices had access to the internet, and a little less than half of the practices used the access each day [50].

Implications

Further research is warranted on the interaction between GP and patient in choice of hospital, preferably by direct observation of the referral process followed by interviews with the GP as well as the patient about their views on the referral process including their experience of responsibility for the choice.

The findings in the present study support results from studies of patients’ choice behaviour which indicate that patients and their agents do not act as the autonomous customers assumed in market-resembling models for management of the public sector. When agents act on patients’ behalf they tend to utilise informal sources of information – even when systematically collected and published information on service is available. One implication of the major influence of previous experience with hospital departments may be a tendency to inertia in referral patterns.

Limitations of the study

The response rate in the present study was 52%, which appears to be quite normal for studies performed in general practice.

The choice of study method meant that we did not observe the process of choice, and only reasons we were aware of beforehand were included in the study, but the questionnaire was validated, and the respondents were offered the opportunity to comment on the reasons and did not refer to reasons not mentioned in the questionnaire.

The respondents could report any number of reasons and we did not ask them to quantify the importance of each reason, because this would complicate the data collection and probably reduce the response rate. We assumed that the cumulative importance of a reason for choice of hospital was proportional to the frequency it was quoted by the GPs, but this may not necessarily be the case: a comparison of two Dutch studies published recently may indicate that frequency of reporting may give results which differ from estimations of importance by way of a choice experiment [25, 44].

Respondents did not differ from non-respondents with regard to age, gender or county, but GPs with a stronger than average interest in subjects concerning choice of hospital may be especially likely to participate in the study. Therefore the study may exaggerate the impact of each individual factor on choice of hospital.

Usually studies should be performed prospectively to reduce bias, but in the present study we chose a retrospective design in order not to influence the GPs’ choice behaviour. Our choice of design increased the risk of recall bias, and the GPs may have reported factors which they thought ought to have influenced their choices rather than the decisive factors. For example GPs may have hesitated to quote media reports as an important source of information. GPs probably are very conscious about their use of some sources of information like websites, while the importance of some sources may be underestimated, because their utilisation is more nebulous, like feedback from patients or media reports. Presumably patient characteristics influenced the GPs’ choices but not their willingness to participate. Therefore patient characteristics presumably did not introduce bias in the study.

The study included a large number of statistical tests. Some of the statistically significant associations in univariate analysis may be due to mass significance rather than causality.

The study was performed thirteen years after the introduction of free choice of public hospital within the study area and eleven years after the introduction of free choice of public hospital at the national level. Patients’ awareness of their right to choose was high. Therefore, even though the study was performed at a specific time in the process of introducing free choice of hospital, we find it most likely that studies performed a few years before or after the present study would not have led to results which were very different from those of the present study.