Why patients may not exercise their choice when referred for hospital care:An exploratory study based on interviews with patients

Background Various north-western European health-care systems encourage patients to make an active choice of health-care provider. This study explores, qualitatively, patients' hospital selection processes and provides insight into the reasons why patients do or do not make active choices. Methods Semi-structured individual interviews were conducted with 142 patients in two departments of three Dutch hospitals. Interviews were recorded, transcribed and analysed in accordance with the grounded theory approach. Results Three levels of choice activation were identified – passive, semi-active and active. The majority of the patients, however, visited the default hospital without having used quality information or considered alternatives. Various factors relating to patient, provider and health-care system characteristics were identified that influenced patients' level of choice activation. On the whole, the patients interviewed could be classified into five types with regard to how they chose, or ‘ended up at’ a hospital. These types varied from patients who did not have a choice to patients who made an active choice. Conclusions A large variation exists in the way patients choose a hospital. However, most patients tend to visit the default without being concerned about choice. Generally, they do not see any reason to choose another hospital. In addition, barriers exist to making choices. The idea of a patient who actively makes a choice originates from neoclassical microeconomic theory. However, policy makers may try in vain to bring principles originating from this theory into health care. Even so, patients do value the opportunity of attending ‘their’ own hospital

On exceptional Lie geometries

Parapolar spaces are point-line geometries introduced as a geometric approach to (exceptional) algebraic groups. We characterize a wide class of Lie geometries as parapolar spaces satisfying a simple intersection property. In particular, many of the exceptional Lie incidence geometries occur. In an appendix, we extend our result to the locally disconnected case and discuss the locally disconnected case of some other well-known characterizations

On Severi varieties as intersections of a minimum number of quadrics

Let \cV be a variety related to the second row of the Freudenthal-Tits Magic square in $N$-dimensional projective space over an arbitrary field. We show that there exist $M\leq N$ quadrics intersecting precisely in \cV if and only if there exists a subspace of projective dimension $N-M$ in the secant variety disjoint from the Severi variety. We present some examples of such subspaces of relatively large dimension. In particular, over the real numbers we show that the Cartan variety (related to the exceptional group $\mathsf{E_6}(\R)$) is the set-theoretic intersection of 15 quadrics

Risk, trust and patients’ strategic choices of healthcare practitioners

Research on patients’ choice of healthcare practitioners has focussed on countries with regulated and controlled healthcare markets. In contrast, low- and middle-income countries have a pluralistic landscape where untrained, unqualified and unlicensed informal healthcare providers (IHPs) provide significant share of services. Using qualitative data from 58 interviews in an Indian village, this paper explores how patients choose between IHPs and qualified practitioners in the public and formal private sectors. The study found that patients’ choices were structurally constrained by accessibility and affordability of care and choosing a practitioner from any sector presented some risk. Negotiation and engagement with risks depended on perceived severity of the health condition and trust in practitioners. Patients had low institutional trust in public and formal private sectors, whereas IHPs operated outside any institutional framework. Consequently, people relied on relational or competence-derived interpersonal trust. Care was sought from formal private practitioners for severe issues due to high-competence-based interpersonal trust in them, whereas for other issues IHPs were preferred due to high relationship-based interpersonal trust. The research shows that patients develop a strategic approach to practitioner choice by using trust to negotiate risks, and crucially, in low- and middle-income countries IHPs bridge a gap by providing accessible and affordable care imbued with relational–interpersonal trust

Comparative Performance Information Plays No Role in the Referral Behaviour of GPs

Comparative performance information (CPI) about the quality of hospital care is information used to identify high-quality hospitals and providers. As the gatekeeper to secondary care, the general practitioner (GP) can use CPI to reflect on the pros and cons of the available options with the patient and choose a provider best fitted to the patient’s needs. We investigated how GPs view their role in using CPI to choose providers and support patients. Method: We used a mixed-method, sequential, exploratory design to conduct explorative interviews with 15 GPs about their referral routines, methods of referral consideration, patient involvement, and the role of CPI. Then we quantified the qualitative results by sending a survey questionnaire to 81 GPs affiliated with a representative national research network. Results: Seventy GPs (86% response rate) filled out the questionnaire. Most GPs did not know where to find CPI (87%) and had never searched for it (94%). The GPs reported that they were not motivated to use CPI due to doubts about its role as support information, uncertainty about the effect of using CPI, lack of faith in better outcomes, and uncertainty about CPI content and validity. Nonetheless, most GPs believed that patients would like to be informed about quality-of- care differences (62%), and about half the GPs discussed quality-of-care differences with their patients (46%), though these discussions were not based on CPI. Conclusion: Decisions about referrals to hospital care are not based on CPI exchanges during GP consultations. As a gatekeeper, the GP is in a good position to guide patients through the enormous amount of quality information that is available. Nevertheless, it is unclear how and whether the GP’s role in using information about quality of care in the referral process can grow, as patients hardly ever initiate a discussion based on CPI, though they seem to be increasingly more critical about differences in quality of care. Future research should address the conditions needed to support GPs’ ability and willingness to use CPI to guide their patients in the referral process

Multilevel modeling and policy development: guidelines and applications to medical travel

Medical travel has expanded rapidly in recent years, resulting in new markets and increased access to medical care. Whereas several studies investigated the motives of individuals seeking healthcare abroad, the conventional analytical approach is limited by substantial caveats. Classical techniques as found in the literature cannot provide sufficient insight due to the nested nature of data generated. The application of adequate analytical techniques, specifically multilevel modeling, is scarce to non-existent in the context of medical travel. This study introduces the guidelines for application of multilevel techniques in public health research by presenting an application of multilevel modeling in analyzing the decision-making patterns of potential medical travelers. Benefits and potential limitations are discussed

What Does It Mean to Be a College Student for Youth with Intellectual Disabilities? : A Survey on Department of Rehabilitation Independence of Korea Nazarene University

<strong>Background:</strong> Governments in several countries are facing problems concerning the accountability of regulators in health care. Questions have been raised about how patients’ complaints should be valued in the regulatory process. However, it is not known what patients who made complaints expect to achieve in the process of health-care quality regulation. <strong>Objective:</strong> To assess expectations and experiences of patients who complained to the regulator. Design Interviews were conducted with 11 people, and a questionnaire was submitted to 343 people who complained to the Dutch Health-care Inspectorate. The Inspectorate handled 92 of those complaints. This decision was based on the idea that the Inspectorate should only deal with complaints that relate to ‘structural and severe’ problems. <strong>Results:</strong> The response rate was 54%. Self-reported severity of physical injury of complaints that were not handled was significantly lower than of complaints that were. Most respondents felt that their complaint indicated a structural and severe problem that the Inspectorate should act upon. The desire for penalties or personal satisfaction played a lesser role. Only a minority felt that their complaint had led to improvements in health-care quality. <strong>Conclusions:</strong> Patients and the regulator share a common goal: improving health-care quality. However, patients’ perceptions of the complaints’ relevance differ from the regulator’s perceptions. Regulators should favour more responsive approaches, going beyond assessing against exclusively clinical standards to identify the range of social problems associated with complaints about health care. Long-term learning commitment through public participation mechanisms can enhance accountability and improve the detection of problems in health care. (aut. ref.