Target Journal: BMJ

Type of piece: Rapid response to an article/letter to the editor

Title: How do patients choose their preferred healthcare provider? A series of case studies from Europe

Michela Tinellia, Zlatko Nikoloskia, Stephanie Kumpunena, Radivoje Pribakovic Brinovec c, Emily Warrenb, Katharina Wittgensa, Petra Dickmanna

a: LSE Health and Social Care, The LondonSchool of Economics and Political Sciences, United Kingdom

b: Department of Health Services Research and Policy, LondonSchool of Hygiene and Tropical Medicine, United Kingdom

c: National Institute of Public Health, Slovenia

Corresponding author: Michela Tinelli, LSE Health and Social Care, The London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK; Tel + 44 (0)20 7955 7668; fax + 44 (0) 20 7955 6803.

Acknowledgments: This work was supported by the European Union 7th Framework Programme EU Cross Border Care Collaboration (ECAB). Contract no: 242058. Sole responsibility lies with the authors and the European Commission is not responsible for any use that may be made of the information contained therein. The funder played no role in the design of the study, the interpretation of the findings, the writing of the paper, or the decision to submit. The infographic was designed by Chiara Comiotto, London College of Communication, as part of the LCC-LSE Visual Rhetoric Collaboration Project (2011-2012). Authors’ contribution: MT contributed to the conception and design of the study, to the establishment of the team, to study management, to planning on the analysis, some of the analysis, interpretation of the results, and drafting and revision of the paper. ZN contributed to data collection, data entering and cleaning, data analysis, interpretation of the results, anddrafting and revision of the paper; SK contributed to the design and development of the survey, data collection, interpretation of the results, and revision of the paper; RP contributed to the design of the survey, interpretation of the results and revision of the paper; EW contributed to the design of the survey, interpretation of the results and revision of the paper; KW contributed to the development of the survey; data collection, data entering, and revision of the paper; PD contributed to the design of the survey, interpretation of the results and revision of the paper.

Conflicts of interest: none declared

Word number: 778(max no: 1000)

Patients have become demanding consumers of healthcare services who want to exercise their rights of choice on a number of issues regarding disease and treatment1.At the same time, they have more information at their disposal than ever before, and greater confidence and competence to use that information to improve their own and others’ wellbeing. However it should be acknowledgedthat too much information can sometimes be confusing, and the search for information based on evidence from good quality study can be challenged by the large-scale presence of poor quality evidencelooking at question irrelevant to patients, derived from studies designed using inappropriatemethodologies, or based on biased and incomplete reporting2.

Whether patientsare able to navigate through the amount of public available information, and access the quality information they need, is crucial to support patient-centredhealthcare decision making. Richards and colleagues made clear (reporting a series of examples from Europe and USA)thatpatients can help improvinghealthcare,and healthcare innovations should be based on a deeper understanding of patients’ experiences and needs3.

The Making choices in healthcaresurvey investigated how patients across Europe make healthcare choices4. It was administered to a sample of three EU countries (Germany, Slovenia, and England) and asked respondents about their needs for, and access to, healthcare information when making choices in healthcare. The purpose was to bring to the attention of policypatient experiencesand provide evidence on which information should be shared with the public to offer them the support they need, and facilitate their choice of healthcare providers.

Most patients reported having an active role when selecting a general practitioner (GP; over 80% in all three countries); and 90% when selectinga hospital in Englandand Germany and 60% in Slovenia. In order to choose their healthcare professionals, patients used various sources of information (see Figure 1). In all three countries, selection of a GP predominantly relied on recommendations from family members and friends (and to a lesser extent, from the Internet). Factors influencing their choice included the GP’s performance rating and practice location (e.g. distance from home/work). In contrast, when selecting a hospital, patients reported relying most on a health professional’s recommendation. Hospital performance, availability of specialist doctors and rates of infections were also reported to influence patients’ final decision in hospital selection.

The preferences revealed by patients in the Germany,Slovenia and Englandare similar to those in other countries at comparable income levels (e.g. USA and Australia). For example, choice of hospital provider in many other countries is equally supported by professionals’ opinions3.Patients also value information on structural and process-related factors of care (e.g. location and accessibility or medical qualifications and specialists’ friendliness) more than measurable health outcomes, like mortality rates5,6.

Overall, most patients across the EU rely on similar sources and types of information when selecting healthcare providers in their own country5. Their choice of care appears to be driven by experience factors more than generic information on safety and quality standards readily available from the media. Interactions with providers as well as discussions with trusted members of the community matter most to patients3.

In light of the recent policy developments on cross-border healthcare in Europe, and the imminent implementation of the Directive on the application of patients’ rights in cross-border healthcare7(coming into force by October 20138) it is crucial to reflect whether they same can be said about patients seeking care across borders. To overcome some of the challenges related to access and use of information, whilst promoting cross-country cooperation on healthcare, the Directive encourages Member States to create National Contact Points for both resident and cross-border patients9. Their function willbe to provide clear and accessible information on treatments, providers, and levels of reimbursement across the EU. This applies to both primary and secondary care, although the bulk of the planned cooperation is mainly related to secondary care10.

If personal experiences do matter to patientsgreatly11, careful consideration needs to be placed on the possibility togather direct experience frompatients, and their trusted members of the community, and shape thepublicly-available information on national and cross-border care accordingly.The National Contact Points, envisaged by the Directive, could be used as vehicle for the publicto share their views with other individuals (mobile or resident), and support their choice of healthcare in their country and across borders.As indicated by Richards et al3successful examples of online patient communities, aimed at sharing other people's experiences of health and illness, supporting, informing and coaching each other, can be found in some of the countries where the usage of internet is fairly high (see for instance in the UK).

References

  1. Health Consumer Powerhouse. The Empowerment of the European Patient - Options and Implications. Health Consumer Powerhouse, Brussels 2009.
  2. Chalmers I, Glasziou P. Avoidable waste in the production and reporting of research evidence.Lancet 2009; 374: 86-89.
  3. Richards T, Montori MV, Godlee F, et al. Let the patient revolution begin. The British Medical Journal 2013;346:f2614.
  4. EUCBCC, European Union Cross Border Care Collaborations project website; available at [last visited May 2013].
  5. Victoor A, Delnoij DM, Friele RD et al. Determinants of patient choice of healthcare providers: a scoping review BMC Health Services Research 2012;12:272.
  6. Howell M.A 37-Year-Old Man Trying to Choose a High-QualityHospital: Review of Hospital Quality Indicators, The Journal of the American Medical Association 2009; 302:2353-2360.
  7. European Union. Directive 2011/24/EU of the European Parliament and the EU Council. Official Journal of the European Union, 2011.
  8. Greer S. Avoiding another directive: the unstable politics of European Union cross-border health law. Health Economics, Policy and Law 2013:1-7. [Epub ahead of print].
  9. Delnoij D, Sauter W. Patient information under the EU patients’ rights Directive. EuropeanJournal of Public Health 2011:21;271–274.
  10. GlinosIA, Baeten R, Helble M, Maarse H. A typology of cross-border patient mobility. Health & Place. 2010;16:1145-55.
  11. Coulter A. What do patients and the public want from primary care? British Medical Journal 2005;331:1199-201.
  12. European Union Cross Border Care Collaborations project WP5 - Work package on patient choice and public reporting on quality of care submitted to the EU Commission, LSE Health and Social Care mimeo, April 2013.

Figure 1: Making choices in healthcaresurvey results on source and type of information accessed

Note: Total number of respondents: England235; Germany 128; Slovenia 335. Ethical approval was provided by the London School of Economics Research Ethics Committee, the NHS Research Ethics Committee in England (REC 11/LO/0866), and the National Medical Ethics Committee of the Republic of Slovenia (129/06/12). Source of data: European Union Cross Border Care Collaborations project WP5 (2013)12.

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