Risk tolerance and attitudes among healthcare professionals and patients regarding location of care decision-making

Introduction There has been growing pressure on inpatient hospital beds for many years, and this, along with the risks of inpatient hospitalisation both for patients and health systems, has required the use of alternative care locations for patients, such that only those who require inpatient admission should be admitted to hospitals. However, it is important that this decision about where patients are treated is made appropriately, as all the available care locations have risks and benefits. The purpose of this study, therefore, was to investigate the risk tolerance of patients, staff and carers in hospital front-door and ambulatory care units, and to interview physiotherapists and patients in these same types of departments to explore their views and attitudes towards risk, and how location of care (LoC) decisions for acutely unwell patients are made. Methods This mixed methods study quantitatively investigated risk tolerance and qualitatively explored physiotherapists’ and patients’ views and experiences. Staff, patients and carers in front-door and ambulatory care units completed a series of ‘lotteries’, in which they made hypothetical financial and health choices. They chose between a guaranteed option (e.g. £70) and an option with uncertain outcomes (e.g. 50% chance of £20, 50% chance of £180), the health lotteries’ options were similar, but related to ‘days in full health’. Risk tolerance in each lottery set was determined via multiple means, and compared based on various characteristics. Physiotherapists were interviewed about their views around risk and LoC decisions, and physiotherapists were also asked about their decision-making process, using semi-structured interviews. Interviews were transcribed and analysed using Thematic Analysis, with Fuzzy Trace Theory as the theoretical framework, which states that people reason based on a combination of ‘verbatim’ (specific) and ‘gist’ (interpretation and understanding) representations of information. Results 106 professionals, 197 patients and 35 carers completed the questionnaires, demonstrating a wide range of risk tolerance levels, and patterns within sub-group analyses. They represented people with a diverse range of demographics, including ages from 16 to over 85 years, multiple ethnic backgrounds, and various professions and experience levels. In the interviews, 14 physiotherapists participated, including physiotherapists from all levels of seniority (band 5 to band 8+) with experience ranging from less than two to more than 20 years. Six key themes were identified - Physiotherapist identity, Working with Risk, the Discharge Decision, Considerations for Referrals, Communication, and Wider Context. Discussion This study is the first to have used lottery set questionnaires of this type in the acute care environment, and is one of very few studies to have done so in a healthcare setting. Physiotherapists’ decision-making and attitudes towards risk in this setting has also been under-researched. Collectively, the results of this study can contribute to improving understanding and communication in managing risk and making LoC decisions at the front-door, in a collaborative and patient-centred way