Where would you go for your next hospitalization?

Assessment of health system performance in Germany: Survey-based insights into the perspective of people with private health insurance

INTRODUCTION

The World Health Organization (WHO) defined intermediate and overall goals to assess the performance of health systems. As the population perspective becomes more important for improving health systems, the aim of this study was to gain insights into the perspective of people with private health insurance (PHI) in Germany along the predefined WHO goals.

METHODS

A cross-sectional survey was conducted in 2018 among people with PHI in Germany. The questionnaire included items on all intermediate (access, coverage, quality, and safety) and overall WHO goals (improved health, responsiveness, social and financial risk protection, and improved efficiency). Descriptive analyses were conducted for the total sample and subgroups (gender, age, income, and health status).

RESULTS

In total, 3601 respondents (age 58.5 ± 14.6; 64.7% male) assessed the German health system. For example, 3.3%-7.5% of the respondents with subjective needs reported forgone care in the past 12 months due to waiting time, distance, or financial reasons and 14.4% suspected medical errors in their care. During the last physician visit 94.2% experienced respectful treatment but only 60.6% perceived coordination of care as good. Unnecessary health services were perceived by 24.2%. For many items significant subgroup differences were found, particularly for age groups (18-64 vs. 65+).

CONCLUSION

Conducting a health system performance assessment from the population perspective gained new and unique insights into the perception of people with PHI in Germany. Areas to improve the health system were seen in, for example, coordination of care, financial risk protection, and quality of care, and inequalities between subgroups were identified.

Quality provision in hospital markets with demand inertia: The role of patient expectations

Switching costs and persistent preferences generate demand inertia and link current and future choices of hospital. Using a model of hospital competition with demand inertia, we investigate the effect of patient expectations on quality. We consider three types of expectations. Myopic patients choose a hospital based on current variables alone, forward-looking but naïve patients consider the future but assume that quality remains constant, and forward-looking and rational patients foresee the evolution of quality. We rank quality provision and show that it is higher under naïve than myopic expectations, while quality under rational expectations may be highest or lowest. This result also holds for patients' health gains, suggesting that rationality may hurt patients. Additionally, policies to reduce switching costs lead to lower quality, possibly unless patients are rational and cost substitutability between output and quality is sufficiently strong. Finally, we show how optimal price regulation depends on expectations and switching costs.

Designing Payment Contracts for Healthcare Services to Induce Information Sharing: The Adoption and the Value of Health Information Exchanges (HIEs)

Recent initiatives to improve healthcare quality and reduce costs have centered around payment mechanisms and IT-enabled health information exchanges (HIEs). Such initiatives profoundly influence both providers’ choices in terms of healthcare effort levels and HIE adoption and patients’ choice of providers. Using a game-theoretical model of a healthcare setup, we examine the role of payment models in aligning providers’ and patients’ incentives for realizing socially optimal (i.e., first-best) choices. We show that the traditional fee-for-service (FFS) payment model does not necessarily induce the first-best solution. The pay-for-performance (P4P) model may induce the first-best solution under some conditions if provider switching by patients during a health episode is socially suboptimal, making provider coordination less of an issue. We identify an episode-based payment (EBP) model that can always induce the first-best solution. The proposed EBP model reduces to the P4P model if the P4P model induces the first-best solution. In other cases, the first-best inducing EBP model is multilateral in the sense that the payment to a provider depends not only on the provider’s own efforts and outcomes but also on those of other providers. Furthermore, the payment in this EBP model is sequence dependent in the sense that payment to a provider is contingent upon whether the patient visits a given provider first or second. We show that the proposed EBP model achieves the lowest healthcare cost, not necessarily at the expense of care quality or provider payment, relative to FFS and P4P. Although our proposed contract is complex, it sets an optimality baseline when evaluating simpler contracts and also characterizes aspects of payment that need to be captured for socially desirable actions. We further show that the value of HIEs depends critically on the payment model as well as on the social desirability of patient switching. Under all three payment models, the HIE value is higher when switching by at least some patients is desirable than when switching by any patient is undesirable. Moreover, the HIE value is highest under the FFS model and lowest under the P4P model. Hence, assessing the value of HIEs in isolation from the underlying payment mechanism and patient-switching behavior may result in under- or overestimation of the HIE value. Therefore, as payment models evolve over time, there is a real need to reevaluate the HIE value and the government subsidies that induce providers to adopt HIEs.

Demographics matter: the potentially disproportionate effect of COVID-19 on hospital ratings

Objective

To identify how features of the community in which a hospital serves differentially relate to its patients' experiences based on the quality of that hospital.

Design

A Finite Mixture Model (FMM) is used to uncover a mix of two latent groups of hospitals that differ in quality. In the FMM, a multinomial logistic equation relates hospital-level factors to the odds of being in either group. A multiple linear regression relates the characteristics of communities served by hospitals to the patients' expected ratings of their experiences at hospitals in each group. Thus, this association potentially varies with hospital quality. The analysis was conducted via Stata.

Setting

Hospital ratings are measured by Hospital Compare using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a patient satisfaction survey required by the Centers for Medicare and Medicaid Services for hospitals in the USA.

Participants

2,816 Medicare-certified acute care hospitals across all US states.

Intervention

None.

Main Outcome Measure

Differences in the marginal impacts of key community demographics on patient experiences between the two groups of hospitals.

Results

We provide evidence that low-rated hospitals have much more variability in patient experience ratings than high-rated ones. Moreover, the experiences at low-rated hospitals are more sensitive to county demographic factors, which means exogenous shocks, like coronavirus disease-2019 (COVID-19), will likely affect these hospitals differently, as such shocks are known to disproportionately affect their communities.

Conclusions

Our results imply that low-rated hospitals with more variability in their HCAHPS responses are more likely to face adverse patient experiences due to COVID-19 than high-rated hospitals. Pandemics like COVID-19 create conditions that intensify the already high demands placed on hospitals and care providers and make it even more challenging to deliver quality care.

The impact of quality on hospital choice. Which information affects patients' behavior for colorectal resection or knee replacement?

Quality competition among hospitals, induced by patients freely choosing their hospital in a price regulated market, can only be realized if quality differences between hospitals are transparent, understandable, and thus influence patients' hospital choice. We use data from ~145,000 German patients and ~ 900 hospitals for colorectal resections and knee replacements to investigate whether patients value quality and specialization when choosing their hospital. Using a random utility choice model, we estimate patients' marginal utilities, willingness to travel and change in hospital demand for quality improvements. Patients respond to service quality and specialization and thus, quality competition seems to be present. Colorectal resection patients are willing to travel longer for more specialized hospitals (+9% for procedure volume, +9% for certification). Knee replacement patients travel longer for hospitals with better service quality (+6%) and higher procedure volume (+12%). However, clinical quality indicators, often difficult to access and interpret, barely play a role in patients' hospital choice. Furthermore, we find that competition on quality for colorectal resection is rather local, whereas for knee replacement we observe regional competition patterns.

Provider-patient communication and hospital ratings: perceived gaps and forward thinking about the effects of COVID-19

Objectives

To highlight clinical and operational issues, identify factors that shape patient responses in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and test the correlations between composite measures and overall hospital ratings.

Design

Responses to HCAHPS surveys were used in a partial correlation analysis to ascertain those HCAHPS composite measures that most relate to overall hospital ratings. The linear mean scores for the composite measures and individual and global items were analyzed with descriptive analysis and correlation analysis via JMP and SPSS statistical software.

Setting

HCAHPS is a patient satisfaction survey required by the Centers for Medicare and Medicaid Services for hospitals in the USA. The survey is for adult inpatients, excluding psychiatric patients.

Participants

3382 US hospitals.

Intervention

None.

Main Outcome Measure

Pearson correlation coefficients for the six composite measures and overall hospital rating.

Results

The partial correlations for overall hospital rating and three composite measures are positive and moderately strong for care transition (0.445) and nurse communication (0.369) and weak for doctor communication (0.066).

Conclusions

From a health policy standpoint, it is imperative that hospital administrators stress open and clear communication between providers and patients to avoid problems ranging from misdiagnosis to incorrect treatment. Additional research is needed to determine how the coronavirus of 2019 pandemic influences patients’ perceptions of quality and willingness to recommend hospitals at a time when nurses and physicians show symptoms of burnout due to heavy workloads and inadequate personal protective equipment.

Consumers' Association of Hospital Reputation With Healthcare Quality

Why consumers consistently rank hospital reputation as one of the most important factors when selecting health care services remains unknown. We hypothesized that this is explained by consumers associating reputation with objective quality. We performed a cross-sectional, US population-based survey of consumers (N = 23,410) exploring this association. A Spearman rank order correlation was used to measure the strength of this relationship. Subgroups of consumers more likely to associate the two was explored with multivariable logistic regression. Consumers commonly agree (56%) that a hospital's reputation is the same as its quality of health care. Consumers also associate hospital reputation with the belief that they will be less like to suffer a complication (ρ = 0.509) or die (ρ = 0.441), although the strength of these relationships were modest (all p < 0.01). Consumers who were male (OR: 0.84), Hispanic (OR: 0.82), African American (OR: 0.86), married (OR: 0.85), self-reported as healthy (OR: 0.67), and had a recent hospitalization (OR: 0.70) were less likely to believe that reputation and quality were equivalent (all p < 0.01). This data suggests that consumers link the construct of hospital reputation with objective health care quality, but this pattern of behavior is of concern, particularly when reputation does not align with objective data.

Subjective and objective quality and choice of hospital: Evidence from maternal care services in Germany

We study patient choice of healthcare provider based on both objective and subjective quality measures in the context of maternal care hospital services in Germany. Objective measures are obtained from publicly reported clinical indicators, while subjective measures are based on satisfaction scores from a large and nationwide patient survey. We merge both quality metrics to detailed hospital discharge records and quantify the additional distance expectant mothers are willing to travel to give birth in maternity clinics with higher reported quality. Our results reveal that patients are on average willing to travel 0.1-2.7 additional kilometers for a one standard deviation increase in quality. Patients respond to both objective and subjective quality measures, suggesting that patient satisfaction scores may constitute important complements to clinical indicators when choosing provider.

Exploring the association between sick child healthcare utilisation and health facility quality in Malawi: a cross-sectional study

OBJECTIVE

Increasing the availability of basic healthcare services in low-and middle-income countries is not sufficient to meet the Sustainable Development Goal target for child survival in high-mortality settings, where healthcare utilisation is often inconsistent and quality of care can be poor. We assessed whether poor quality of sick child healthcare in Malawi is associated with low utilisation of sick child healthcare.

DESIGN

We measured two elements of quality of sick child healthcare: facility structural readiness and process of care using data from the 2013 Malawi Service Provision Assessment. Overall quality was defined as the average of these metrics. We extracted demographic data from the 2013-2014 Malawi Multiple Indicator Cluster Survey and linked households to nearby facilities using geocodes. We used logistic regression to examine the association of facility quality with utilisation of formal health services for children under 5 years of age suffering diarrhoea, fever or cough/acute respiratory illness, controlling for demographic and socioeconomic characteristics. We conducted sensitivity analyses (SAs), modifying the travel distance and population-facility matching criteria.

SETTING AND POPULATION

568 facilities were linked with 9701 children with recent illness symptoms in Malawi, of whom 69% had been brought to a health facility.

RESULTS

Overall, facilities showed gaps in structural quality (62% readiness) and major deficiencies in process quality (33%), for an overall quality score of 48%. Better facility quality was associated with higher odds of utilisation of sick child healthcare services (adjusted ORs (AOR): 1.66, 95% CI: 1.04 to 2.63), as was structural quality alone (AOR: 1.33, 95% CI: 0.95 to 1.87). SAs supported the main finding.

CONCLUSION

Although Malawi's health facilities for curative child care are widely available, quality and utilisation of sick child healthcare services are in short supply. Improving facility quality may provide a way to encourage higher utilisation of healthcare, thereby decreasing preventable childhood morbidity and mortality.

Quality-based ratings in Medicare and trends in kidney transplantation

OBJECTIVE

To assess the relationship between the 2007 Medicare regulation enforcing quality standards for transplant centers and trends in kidney transplantation.

DATA SOURCES

Transplant centers' biannual reports and the national registry for kidney transplantation from 2003 to 2010.

STUDY DESIGN

Non-compliant (low-performing) centers were compared with centers in compliance with quality standards according to: number of transplants, waiting-list registrations, and rates of graft failures, transfers, and deaths. Multivariate regressions were estimated to evaluate the association between the regulation and transplantation outcomes.

DATA EXTRACTION METHODS

Patient characteristics and outcomes were aggregated to six-month periods and linked to centers' reports.

PRINCIPAL FINDINGS

Relative to average-performing centers, 12 percent of transplants shifted away from low-performing centers and high-performing centers captured 6 percent of this decline. Low-performing centers experienced a 2-percentage point per period decline in 1-year graft failure rates and a 15-percent decrease in registrations post-regulation, whereas high-performing centers incurred a 5-percent decrease in registrations relative to average-performing centers.

CONCLUSIONS

Government oversight in kidney transplantation was associated with a small downward shift in overall kidney transplants. Reductions in graft failure rates at low-performing centers may imply an increase in quality or a decline in transplantation of either marginal organs or riskier patients; whereas reductions in registrations may indicate risk aversion toward high-risk patients. Policy makers should consider making less punitive requirements for programs, which employ new transplantation techniques to expand access.

Hospital Choice for Cataract Treatments: The Winner Takes Most

Background: Transparency in quality of care is an increasingly important issue in healthcare. In many international healthcare systems, transparency in quality is crucial for health insurers when purchasing care on behalf of their consumers, for providers to improve the quality of care (if necessary), and for consumers to choose their provider in case treatment is needed. Conscious consumer choices incentivize healthcare providers to deliver better quality of care. This paper studies the impact of quality on patient volume and hospital choice, and more specifically whether high quality providers are able to attract more patients.

Methods: The dataset covers the period 2006-2011 and includes all patients who underwent a cataract treatment in the Netherlands. We first estimate the impact of quality on volume using a simple ordinary least squares (OLS), second we use a mixed logit to determine how patients make trade-offs between quality, distance and waiting time in provider choice.

Results: At the aggregate-level we find that, a one-point quality increase, on a scale of one to a hundred, raises patient volume for the average hospital by 2-4 percent. This effect is mainly driven by the hospital with the highest quality score: the effect halves after excluding this hospital from the dataset. Also at the individual-level, all else being equal, patients have a stronger preference for the hospital with the highest quality score, and appear indifferent between the remaining hospitals.

Conclusion: Our results suggest that the top performing hospital is able to attract significantly more patients than the remaining hospitals. We find some evidence that a small share of consumers may respond to quality differences, thereby contributing to incentives for providers to invest in quality and for insurers to take quality into account in the purchasing strategy.

Women's Preferences for Birthing Hospital in Denmark: A Discrete Choice Experiment

BACKGROUND

Free choice of hospital has been introduced in many healthcare systems to accommodate patient preferences and incentivize hospitals to compete; however, little is known about what patients actually prefer.

OBJECTIVES

This study assessed women's preferences for birthing hospital in Denmark by quantifying the utility and trade-offs of hospital attributes.

METHODS

We conducted a discrete-choice experiment survey with 12 hypothetical scenarios in which women had to choose between three hospitals characterized by five attributes: continuity of midwifery care, availability of a neonatal intensive care unit (NICU), hospital services offered, level of specialization to handle rare events, and travel time. A random parameter logit model was used to estimate the utility and marginal willingness to travel (WTT) for improvements in other hospital attributes.

RESULTS

A total of 517 women completed the survey. Significant preferences were expressed for all attributes (p < 0.01), with the availability of a NICU being the most important driver of women's preferences; women were willing to travel 30 more minutes (95% confidence interval 28-32) to reach a hospital with a highly specialized NICU. The subgroup analyses revealed differences in WTT, with substantial heterogeneity due to prior experience with giving birth and regarding risk attitude and health literacy.

CONCLUSION

A high specialization level was the most influential factor for women without previous birth experience and for risk-averse individuals but not for women with a high health literacy score. Hence, more information about the woman's risk profile and services required could play a role in affecting hospital choice.

Impact of network size and demand on cost performance for high- and low-quality healthcare service organizations

Purpose

Healthcare networks are becoming ubiquitous, yet it is unclear how hospitals with varying quality capabilities would fare by being affiliated with large healthcare networks. The purpose of this paper is to first consider the deductive configuration perspective and distinguish high and low quality hospitals by using clinical and experiential quality as two dimensions of quality capability. Next, it examines the impact of healthcare network size on operating costs of hospitals. Additionally, the paper investigates the interaction effect of hospital demand and healthcare network size on operating costs.

Design/methodology/approach

The paper uses a dataset that was created by combining five separate sources. Cluster analysis technique is used to classify hospitals into four groups – holistic quality leaders (high clinical and experiential quality capability), experiential quality focusers (low clinical quality capability and high experiential quality capability), clinical quality focusers (high clinical capability and low experiential quality capability), and quality laggards (low clinical and experiential quality capability). The authors test the research hypotheses by means of regression analyses after controlling for several contextual characteristics.

Findings

The results show that affiliation with large healthcare networks reduces operating costs for quality laggards, but increases these costs for experiential quality focusers and clinical quality focusers. The hypothesized positive relationship between healthcare network size and costs is not supported for holistic quality leaders. The authors find that clinical quality focusers and holistic quality leaders can complement higher utilization levels in their operations due to increased demand and healthcare network size to reduce their operating costs per day.

Originality/value

There has been increasing evidence suggesting that hospitals must carefully manage both clinical and experiential quality. By focusing on both clinical and experiential quality, unlike experiential quality focusers and clinical quality focusers, holistic quality leaders are not adversely affected by the size of their network. The results suggest that experiential quality focusers and clinical quality focusers should either embrace holistic quality management or restrict the size of their networks to maintain their quality level and to reduce coordination costs.

Pregnant women's choice of birthing hospital: A qualitative study on individuals' preferences

OBJECTIVE

To investigate pregnant women's decision making in relation to their choice of birthing hospital and, in particular, their priorities regarding hospital characteristics.

METHODS

The focus of this study was the choice of birthing hospital among pregnant women. A qualitative interview design was used and women were recruited during their first pregnancy-related visit to a general practitioner. The interviews were conducted using a semi-structured interview guide, and a thematic analysis of the data was carried out.

RESULTS

Women made their hospital choice decision independently and they relied extensively on their own or peers' experiences. Travel distance played a role, but some women were willing to incur longer travel times to give birth at a specialized hospital in order to try to reduce the risks (in case of unexpected events). The women associated the presence of specialized services and staff that were more qualified and experienced with increased safety. Other priorities included continuity of care (i.e., being seen by the same midwife) as well as service availability, which in this case referred to the possibility of a water birth and postnatal hoteling services.

CONCLUSIONS

The choice of hospital provider appears to be strongly influenced by experience, whether personal experience or the experience of peers. However, there appears to be room for more information to be provided on safety and service attributes as an instrument for making an informed decision.

Discrete Choice Experiments: A Guide to Model Specification, Estimation and Software

We provide a user guide on the analysis of data (including best-worst and best-best data) generated from discrete-choice experiments (DCEs), comprising a theoretical review of the main choice models followed by practical advice on estimation and post-estimation. We also provide a review of standard software. In providing this guide, we endeavour to not only provide guidance on choice modelling but to do so in a way that provides a 'way in' for researchers to the practicalities of data analysis. We argue that choice of modelling approach depends on the research questions, study design and constraints in terms of quality/quantity of data and that decisions made in relation to analysis of choice data are often interdependent rather than sequential. Given the core theory and estimation of choice models is common across settings, we expect the theoretical and practical content of this paper to be useful to researchers not only within but also beyond health economics.

Hospital Compare and Hospital Choice: Public Reporting and Hospital Choice by Hip Replacement Patients in Texas

The Centers for Medicare & Medicaid Services publicizes comparative performance data on Hospital Compare, a website maintained to support consumer decision making. Given the agency’s goal, this study investigates the relationship between public reporting and hospital choices of hip replacement patients in Texas. Estimating individual-level valuations of provider characteristics allowing for heterogeneity across patients, we find consumer selections and hospitals’ displayed performance vary together in time. Comparing associations involving public reporting with those associated with more readily observable hospital attributes, we conclude relationships coinciding with release of comparative performance data are modest, but not inconsequential. Our use of an empirical strategy novel for evaluation of public reporting has methodological implications, while the study’s affirmative result is of potential interest to policy makers and administrators.

Choice of hospital: Which type of quality matters?

The implications of hospital quality competition depend on what type of quality affects choice of hospital. Previous studies of quality and choice of hospitals have used crude measures of quality such as mortality and readmission rates rather than measures of the health gain from specific treatments. We estimate multinomial logit models of hospital choice by patients undergoing hip replacement surgery in the English NHS to test whether hospital demand responds to quality as measured by detailed patient reports of health before and after hip replacement. We find that a one standard deviation increase in average health gain increases demand by up to 10%. The more traditional measures of hospital quality are less important in determining hospital choice.

The Effect of Publicized Quality Information on Home Health Agency Choice

We examine consumers' use of publicized quality information in Medicare home health care markets, where consumer cost sharing and travel costs are absent. We report two findings. First, agencies with high quality scores are more likely to be preferred by consumers after the introduction of a public reporting program than before. Second, consumers' use of publicized quality information differs by patient group. Community-based patients have slightly larger responses to public reporting than hospital-discharged patients. Patients with functional limitations at the start of their care, at least among hospital-discharged patients, have a larger response to the reported functional outcome measure than those without functional limitations. In all cases of significant marginal effects, magnitudes are small. We conclude that the current public reporting approach is unlikely to have critical impacts on home health agency choice. Identifying and releasing quality information that is meaningful to consumers may help increase consumers' use of public reports.

Is Anyone Paying Attention to Physician Report Cards? The Impact of Increased Availability on Consumers' Awareness and Use of Physician Quality Information

OBJECTIVE

To determine if the release of health care report cards focused on physician practice quality measures leads to changes in consumers' awareness and use of this information.

PRIMARY DATA SOURCES

Data from two rounds of a survey of the chronically ill adult population conducted in 14 regions across the United States, combined with longitudinal information from a public reporting tracking database. Both data were collected as part of the evaluation for Aligning Forces for Quality, a nationwide quality improvement initiative funded by the Robert Wood Johnson Foundation.

STUDY DESIGN

Using a longitudinal design and an individual-level fixed effects modeling approach, we estimated the impact of community public reporting efforts, measured by the availability and applicability of physician quality reports, on consumers' awareness and use of physician quality information (PQI).

PRINCIPAL FINDINGS

The baseline level of awareness was 12.6 percent in our study sample, drawn from the general population of chronically ill adults. Among those who were not aware of PQI at the baseline, when PQI became available in their communities for the first time, along with quality measures that are applicable to their specific chronic conditions, the likelihood of PQI awareness increased by 3.8 percentage points. For the same group, we also find similar increases in the uses of PQI linked to newly available physician report cards, although the magnitudes are smaller, between 2 and 3 percentage points.

CONCLUSIONS

Specific contents of physician report cards can be an important factor in consumers' awareness and use of PQI. Policies to improve awareness and use of PQI may consider how to customize quality report cards and target specific groups of consumers in dissemination.

Modern Management Practices and Hospital Admissions

We investigate whether the modern management practices and publicly reported performance measures are associated with choice of hospital for patients with acute myocardial infarction (AMI). We define and measure management practices at approximately half of US cardiac care units using a novel survey approach. A patient's choice of a hospital is modeled as a function of the hospital's performance on publicly reported quality measures and the quality of its management. The estimates, based on a grouped conditional logit specification, reveal that higher management scores and better performance on publicly reported quality measures are positively associated with hospital choice. Management practices appear to have a direct correlation with admissions for AMI--potentially through reputational effects--and indirect association, through better performance on publicly reported measures. Overall, a one standard deviation change in management practice scores is associated with an 8% increase in AMI admissions.

Patient satisfaction in cardiology after cardiac catheterization : Effects of treatment outcome, visit characteristics, and perception of received care

BACKGROUND

Patient satisfaction is a key indicator for quality of care. However, recent data on determinants of satisfaction in invasive cardiology are lacking. Hence this study was conducted to identify determinants of patient satisfaction after hospitalization for cardiac catheterization.

PATIENTS AND METHODS

Data were obtained from 811 randomly selected patients discharged from ten hospitals responding to a mailed post-visit questionnaire. The satisfaction dimension was measured with a validated 42-item inventory assessing demographic and visit characteristics as well as medical, organizational, and service aspects of received care. Bivariate and multivariate statistical analyses were performed to identify predictors of satisfaction.

RESULTS

Patients were most satisfied with the kindness of medical practitioners and nurses. The lowest ratings were observed for discharge procedures and instructions. Multivariate analysis revealed five predictors of satisfaction: treatment outcome (OR, 2.14), individualized medical care (OR, 1.64), clear reply to patient's inquiries by physicians (OR, 1.63), kindness of nonmedical professionals (OR, 3.01), and room amenities (OR, 2.02). No association between demographic data and overall satisfaction was observed.

CONCLUSION

Five key determinants that can be addressed by health-care providers in order to improve patient satisfaction were identified. Our findings highlight the importance of the communicational behavior of health-care professionals and the transparency of discharge management.

An empirical study on hospital selection in India

PURPOSE

The purpose of this paper is to understand the different factors patients consider in choosing a hospital in a major city in India, prior to admission.

DESIGN/METHODOLOGY/APPROACH

A 20-item scale to identify various factors a patient considers in choosing a hospital was developed. A field survey was conducted on patients who were discharged in the recent past from a public or a private hospital. The data collected were analysed using multivariate techniques.

FINDINGS

The data analysis highlighted several factors in the hospital choice selection process, namely quality of treatment, referral, transport convenience, cost, and safety and services.

RESEARCH LIMITATIONS/IMPLICATIONS

This research study was carried out in one of the four major metropolitan cities of India. Nonetheless, the study provides valuable insights into the hospital selection process in a developing country like India.

PRACTICAL IMPLICATIONS

Hospital managers, in general, can use the study findings to improve the operating performance of their hospitals so that they are able to attract more patients in the future. Additionally, the information can be useful to the marketing managers for developing appropriate marketing strategies for their hospitals.

ORIGINALITY/VALUE

Majority of the empirical research on hospital choice process has been conducted in Europe and North America. Limited knowledge exists on the same in a developing nation like India. This research illustrates a comprehensive study to address that concern.

The volume-outcome relationship and minimum volume standards--empirical evidence for Germany

For decades, there is an ongoing discussion about the quality of hospital care leading i.a. to the introduction of minimum volume standards in various countries. In this paper, we analyze the volume-outcome relationship for patients with intact abdominal aortic aneurysm and hip fracture. We define hypothetical minimum volume standards in both conditions and assess consequences for access to hospital services in Germany. The results show clearly that patients treated in hospitals with a higher case volume have on average a significant lower probability of death in both conditions. Furthermore, we show that the hypothetical minimum volume standards do not compromise overall access measured with changes in travel times.

Adapting Scott and Bruce's General Decision-Making Style Inventory to Patient Decision Making in Provider Choice

OBJECTIVE

Research testing the concept of decision-making styles in specific contexts such as health care-related choices is missing. Therefore, we examine the contextuality of Scott and Bruce's (1995) General Decision-Making Style Inventory with respect to patient choice situations.

METHODS

Scott and Bruce's scale was adapted for use as a patient decision-making style inventory. In total, 388 German patients who underwent elective joint surgery responded to a questionnaire about their provider choice. Confirmatory factor analyses within 2 independent samples assessed factorial structure, reliability, and validity of the scale.

RESULTS

The final 4-dimensional, 13-item patient decision-making style inventory showed satisfactory psychometric properties. Data analyses supported reliability and construct validity. Besides the intuitive, dependent, and avoidant style, a new subdimension, called "comparative" decision-making style, emerged that originated from the rational dimension of the general model.

CONCLUSIONS

This research provides evidence for the contextuality of decision-making style to specific choice situations. Using a limited set of indicators, this report proposes the patient decision-making style inventory as valid and feasible tool to assess patients' decision propensities.

Concentration of gynaecology and obstetrics in Germany: is comprehensive access at stake?

Financial soundness will become more and more difficult in the future for all types of hospitals. This is particularly relevant for gynaecology and obstetrics departments: while some disciplines can expect higher demand due to demographic changes and progress in medicine and medical technology, the inpatient sector for gynaecology and obstetrics is likely to lose patients in line with these trends. In this paper we estimate future demand for gynaecology and obstetrics in Germany and develop a cost model to calculate the average profitability in this discipline. The number of inpatient cases in gynaecology and obstetrics can be expected to decrease by 3.62% between 2007 and 2020 due to the demographic change and a potential shift from inpatient to outpatient services. Small departments within the fields of gynaecology and obstetrics are already incurring heavy losses, and the anticipated decline in cases should increase this financial distress even more. As such, the further centralisation of services is indicated. We calculate travel times for gynaecology and obstetrics patients and estimate the anticipated changes in travel times by simulating different scenarios for this centralisation process. Our results show that the centralisation of hospital services in gynaecology and obstetrics may be possible without compromising comprehensive access as measured by travel times.

Competition and the impact of online hospital report cards

Information on the quality of healthcare gives providers an incentive to improve care, and this incentive should be stronger in more competitive markets. We examine this hypothesis by studying Pennsylvanian hospitals during the years 1995-2004 to see whether those hospitals located in more competitive markets increased the quality of the care provided to Medicare patients after report cards rating the quality of their Coronary Artery Bypass Graft programs went online in 1998. We find that after the report cards went online, hospitals in more competitive markets used more resources per patient, and achieved lower mortality among more severely ill patients.

Is there a Medicaid penalty? The effect of hospitals' Medicaid population on their private payer market share

This study examines whether privately insured patients avoid hospitals with large Medicaid populations. I use a conditional logit model of hospital choice to determine whether the size of a hospital's Medicaid population affects the probability that a privately insured patient will choose that hospital. I focus on the metropolitan area of Tampa, Florida, in the years 1994-1996. I control for hospital fixed effects, hospital-specific time trends, patients' driving time to the hospital, and interactions between patient and hospital characteristics. I also instrument for the Medicaid population using the predicted Medicaid population. The results show that privately insured patients are less likely to choose a hospital if it served a larger number of Medicaid patients who were admitted through the emergency department in the previous 6 months. The effect persists over time-an additional 6-month lag cuts the effect in half. Capacity constraints do not seem to be the reason for the effect. I show that the Medicaid effect size could have a moderate effect on the profits of some hospitals. Although limited in scope, this study suggests that hospitals may experience a negative effect on their private revenues when they admit a large population of Medicaid patients.

Patient choice in the selection of hospitals by 9-1-1 emergency medical services providers in trauma systems

OBJECTIVES

Reasons for undertriage (transporting seriously injured patients to nontrauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis.

METHODS

This was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and nontrauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. "Serious injury" was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings.

RESULTS

A total of 176,981 injured patients were evaluated and transported by EMS over the 3-year period, of whom 5,752 (3.3%) had ISS ≥ 16 and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21- to 30-year-olds to 75.8% among those older than 90 years. This trend paralleled undertriage rates and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols.

CONCLUSIONS

Emergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age and involves inherent differences in patient prognosis.

The multiple causal pathways between performance measures' use and effects

In recent decades, there has been a growing interest in the design and implementation of systems using public reporting of performance measures to improve performance. In their simplest form, such interventions rest on the market-based logic of consumers using publicly released information to modify their behavior, thereby penalizing poor performers. However, evidence from large-scale efforts to use public reporting of performance measures as an instrumental performance improvement tool suggests that the causal mechanisms involved are much more complex. This article offers a typology of four different plausible causal pathways linking public reporting of performance measures and performance improvement. This typology rests on a variety of conceptual models and a review of available empirical evidence. We then use this typology to discuss the core elements that need to be taken into account in efforts to use public reporting of performance measures as a performance improvement tool.

A Unifying Framework of the Demand for Transnational Medical Travel

Transnational medical travel has gained attention recently as a strategy for patients to obtain care that is higher quality, costs less, or offers improved access relative to care provided within their home countries. This article examines institutional environments in the European Union and United States that influence transnational medical travel, describes the conceptual model of demand for medical travel, and illustrates individual dimensions in the conceptual model of medical travel using a series of case studies. The conceptual model of medical travel is predicated on Andersen's behavioral model of health services. Transnational medical travel is a heterogeneous phenomenon that is influenced by a number of patient-related factors and by the institutional environment in which the patient resides. While cost, access, and quality are commonly cited factors that influence a patient's decision regarding where to seek care, multiple factors may simultaneously influence the decision about the destination for care, including culture, social factors, and the institutional environment. The conceptual framework addresses the patient-related factors that influence where a patient seeks care. This framework can help researchers and regulatory bodies to evaluate the opportunities and the risks of transnational medical travel and help providers and governments to develop international patient programs.

The impact of profitability of hospital admissions on mortality

BACKGROUND

Fiscal constraints faced by Medicare are leading to policies designed to reduce expenditures. Evidence of the effect of reduced reimbursement on the mortality of Medicare patients discharged from all major hospital service lines is limited.

METHODS

We modeled risk-adjusted 30-day mortality of patients discharged from 21 hospital service lines as a function of service line profitability, service line time trends, and hospital service line and year-fixed effects. We simulated the effect of alternative revenue-neutral reimbursement policies on mortality. Our sample included all Medicare discharges from PPS-eligible hospitals (1997, 2001, and 2005).

RESULTS

The results reveal a statistically significant inverse relationship between changes in profitability and mortality. A $0.19 average reduction in profit per $1.00 of costs led to a 0.010-0.020 percentage-point increase in mortality rates (p < .001). Mortality in newly unprofitable service lines is significantly more sensitive to reduced payment generosity than in service lines that remain profitable. Policy simulations that target service line inequities in payment generosity result in lower mortality rates, roughly 700-13,000 fewer deaths nationally.

CONCLUSIONS

The policy simulations raise questions about the trade-offs implicit in universal reductions in reimbursement. The effect of reduced payment generosity on mortality could be mitigated by targeting highly profitable services only for lower reimbursement.