How do elderly patients decide where to go for major surgery? Telephon
http://www.100md.com
《英国医生杂志》
1 VA Outcomes Group (111B), VA Medical Center, 215 N Main Street, White River Junction, VT 05009, USA, 2 Department of Surgery, 2101 Taubman Center, 1500 E Medical Center Drive, Ann Arbor, MI 48109-0346, USA
Correspondence to: S Woloshin steven.woloshin@dartmouth.edu
Objective To learn how patients in Medicare, the US medical insurance programme that covers elderly patients, made decisions about where to undergo major surgery and how they would make future decisions.
Design National telephone interview study.
Setting United States.
Participants 510 randomly selected Medicare beneficiaries who had undergone an elective, high risk procedure about 3 years earlier—abdominal aneurysm repair (n = 103), heart valve replacement surgery (n = 96), or resection of the bladder (n = 119), lung (n = 128), or stomach (n = 64) for cancer. Response rates were 48% among eligible survivors and 68% among those able to participate.
Results Although all participants could choose where to have surgery, only 55% said there was an alternative hospital in their area where they could have gone. Overall, only 10% of respondents seriously considered going elsewhere for surgery. Few respondents (11%) looked for information to compare hospitals. Almost all respondents thought their hospital and surgeon had good reputations (94% and 88%, respectively), beliefs mostly determined by what their referring doctors said. When asked how much various factors would influence their advice to a friend about choosing where to go for major surgery, surgeon reputation was the most influential (78% said it would influence their advice "a lot"), followed by the hospital having "nationally recognised" surgeons (63%), and then various performance data (surgeon volume (58%), nurse:patient ratios (49%), number of operations carried out by the hospital (48%), and hospital operative mortality (45%)). Forty per cent said they would act on mortality data, indicating that they would switch from their initial choice of hospital to a different one if its mortality was a percentage point lower (that is, 3% v 4%).
Conclusion Some respondents claimed they would switch hospital for elective surgery on the basis of mortality data. Since most respondents relied on their referring physician's opinion to decide where to have surgery, surgical performance data ought to be accessible to referring physicians.
There is growing interest in providing patients with surgical performance data to help them select the best surgeons and hospitals. New York State, for example, has released hospital mortality data for cardiac surgery to the public since the early 1990s.1 In recent years several US state departments of public health, proprietary health quality rating firms, patient advocacy groups, and purchaser coalitions have launched new public reporting initiatives.2 3 In Britain hospitals,4 surgeon organisations,5 and recently the Guardian newspaper6 have published operational mortality data for individual heart surgeons. These initiatives share the basic assumption that patients will use such data to select higher quality hospitals for their surgery.
However, it is not clear to what extent patients know about and value such information. Several studies have found minimal changes in hospital caseloads after the public reporting of mortality data.7-9 In the only published study to question surgical patients about their decision making, only 12% of patients undergoing coronary artery bypass in Pennsylvania in 1996 were aware of a publicly released report on surgical mortality before their operation.10 Performance data have since become more widely available (particularly with the growth of the internet) and, with increasing media attention on patient safety, more visible to the public. None the less, the usefulness of performance data to patients remains unknown.
To better understand how patients make decisions about where to have surgery, we conducted a national survey of patients in the Medicare programme, the US federal government insurance programme that covers hospital costs for almost all US citizens aged 65 years and older, who had undergone an elective, high risk procedure. In addition to learning how the patients made their original decisions, we assessed whether they thought performance data to be relevant and to what extent such data would be useful in their future decisions.
Methods
Sample selection
Our goal was to learn how patients choose where to go for major surgery and whether performance data are likely to affect this decision. We focused on elective procedures because choice of hospital or surgeon was theoretically possible. We interviewed a random sample of Medicare beneficiaries who had undergone one of five major elective operations (abdominal aneurysm repair, heart valve replacement, or resection of the bladder, lung, or stomach because of cancer). We surveyed Medicare patients because Medicare covers well over half of all patients undergoing these procedures in the United States.11
Our goal was to get 100 interviews for each operation (we chose this number to ensure a confidence interval of at most ±10%). The five procedures differ considerably in procedure frequency and long term survival after surgery, so we sampled some operations more than others. The sampling fractions of patients for each operation were 4.2% for lung resection, 10.8% for gastrectomy, 14.5% for cystectomy, 1.7% abdominal aneurysm repair, and 1.1% for valve replacement.
Figure 1 details the steps of the sampling procedure. Using data provided by the Center for Medicaid and Medicare Services, we selected a random sample of beneficiaries (stratified within each type of surgery) who had a claim for one of the five elective operations in 2000. The centre then provided us with a list of the names and addresses of 2114 beneficiaries (eight of whom subsequently reported they had not had surgery and were considered ineligible). Of these, 1055 were alive in January 2004. To obtain telephone numbers, we sent the sample list of names and addresses to Telematch, an independent company that provides this service. We called Directory Assistance for those cases when Telematch failed to find telephone numbers. We were able to obtain contact information for 828 people (12 had non-US mailing addresses). We attempted to interview 785 patients who were not hospitalised or in a nursing home and who spoke English and were able to hear adequately. A total of 510 individuals without cognitive impairment (such as Alzheimer's disease) completed the telephone interview. We concluded people could not be contacted only after at least six attempts at different times of day and three further attempts two weeks later.
Fig 1 Selection of survey participants
We calculated response rates using the two methods recommended by the American Association of Public Opinion Research.12 With the number of eligible survivors as the denominator, the response rate was 48% (510/1055). With the number of those who were able to participate, the response (or cooperation) rate was 68% (510/751). There was no significant difference in response rates across the five operations.
Interview protocol
Development—To learn what people thought about the decision of where to have surgery, we conducted two focus groups with people who had recently undergone major surgery. We conducted the focus groups and all subsequent survey development in collaboration with the Center for Survey Research, a professional survey research firm affiliated with the University of Massachusetts. We developed a draft survey instrument based on the focus groups' conclusions and on a previously published survey of patients who had undergone coronary bypass surgery in Pennsylvania.10 Experienced interviewers conducted five cognitive interviews with patients who had undergone surgery at Dartmouth Hitchcock Medical Center within the previous three years to ensure that the questions were understood and that the answers were meaningful. After revising the draft instrument, we conducted a pilot test of the telephone survey with 25 patients. These interviews were audiotaped and then coded to identify questions that were difficult for interviewers to read or for respondents to answer. We revised the survey on the basis of these results.
Instrument—The final survey had three sections. The first asked about experiences with major surgery (such as how the respondent decided where to have surgery, what factors influenced this choice, the respondent's perceptions of the hospital and the surgeon). The second section focused on respondents' knowledge and reaction to surgical performance data, specifically information on work volume (number of operations performed by individual surgeons or hospitals), patient mortality, and nurse:patient ratios. The third section asked for respondents' reactions to two scenarios—firstly, what advice they would give to a friend who needed major surgery and, secondly, their reactions to Medicare publishing a list of best hospitals for different operations.
Administration—In December 2003 potentially eligible respondents were sent a notification letter (as required by the Center for Medicaid and Medicare Services) and a second letter two weeks later stating that the Center for Survey Research would be calling. Interviews were conducted by professional interviewers at the Center for Survey Research's telephone facility from January through February 2004. All interviewers received special training on the purposes and procedures of this particular study, all underwent monitoring for quality control and feedback from a supervisor. The interviews took an average of 21 minutes (range 12-46 minutes). Answers to the survey were directly entered into the computer assisted telephone interviewing system by the interviewers.
Statistical analysis
We weighted the results for the five operations to account for the different probabilities of selection into our sample and the slightly different response rates. The weighted results differed by only 1% or 2% from the unweighted results. Because the weighted results assume that non-respondents would answer questions similarly to respondents, we chose to present the unweighted results. We calculated 95% confidence intervals using the binomial Wald function. We performed all analyses using Stata statistical software (version 9, StataCorp, College Station, TX).
Results
Table 1 shows the 510 respondents' characteristics. They had a mean age of 78 years (range 68-93), two thirds were men, and 91% were white. Most reported lower socioeconomic status: 38% reported a total household income less than $25 000, and only 25% had graduated from college or graduate school. Self reported health was low: only 7% rated their health as excellent.
Table 1 Characteristics of 510 Medicare beneficiaries who had undergone elective, high risk surgery about three years earlier. Values are numbers (percentages) of 510 respondents unless stated otherwise
How respondents made their surgery decision
Most respondents had had time to consider where to go for surgery, were aware of other hospitals in their area to choose between, and felt involved in the decision making process. Specifically, 84% said they had at least a week, and 30% had more than a month, between being told they needed surgery and undergoing the surgery. Two thirds said they were involved in selecting the hospital, 41% making the decision equally with their doctor, and 24% deciding mainly on their own or with their family.
Since all respondents were Medicare beneficiaries, all had options with regard to where they had surgery; nonetheless, only 55% said there were other local hospitals where they could have gone. Overall, only 10% seriously considered going elsewhere for surgery (this percentage was the same for those who said there was another local hospital to go to). Few respondents (11%) looked for information to compare hospitals, most commonly turning to friends and family, their primary doctor, or the internet. Most stayed at local hospitals, 73% reporting their travel time to be less than an hour.
Rather than seeking quantitative information, most seemed to rely on hospital or surgeon reputation in deciding where to have surgery. Almost all respondents thought their hospital and surgeon had good reputations (94% and 88% respectively). Thirty one per cent said their hospital was "the best" in the area, 40% said "better than most," 22% said "about the same," and only 1% said it was "worse than most." Eighty per cent and 79% respectively said that surgeon and hospital reputation were "extremely" or "very" important to their decision (fig 2). Other factors influencing patient decisions included having had prior care at the hospital (rated important by 42%) and the recommendations of family and friends (rated important by 28%). When asked why they thought their hospital had a good reputation, 64% of respondents said it was because of what their referring doctor had said, and 31% said so because of what family or friends had said (table 2). These results did not vary importantly across the five surgical procedures.
Fig 2 Importance of different factors in respondents' decisions about where to have major surgery.
Table 2 Responses of 510 Medicare beneficiaries who had undergone elective, high risk surgery about three years earlier to questions about their decision making for their surgery and reactions to surgical performance to data
How respondents would advise others
We asked respondents how much various factors would influence the advice they would give to a friend about where to go for major surgery (fig 3). Of these factors, surgeon reputation was rated the most influential (78% said it would influence their advice "a lot"), followed by the hospital having "nationally recognised" surgeons (63%). When we asked whether performance data could influence decisions, substantial proportions of the respondents said the following items would influence them "a lot"—surgeon's work volume (58%), nurse:patient ratios (49%), hospital work volume (48%), and hospital operative mortality (45%). Moreover, 40% of respondents said they would switch from their chosen hospital if the surgical mortality for another hospital was a percentage point lower (that is, 3% v 4%).
Fig 3 Importance of different factors in respondents' hypothetical advice to a friend due to have major surgery
We also sought to learn what people know about hospital work volume (a measure increasingly used as a proxy for mortality) and found that most people accepted the intuitive notion that "practice makes perfect": 80% of respondents thought that the chance of surviving an operation was better at a high volume hospital than a low volume one. However, only 11% of respondents had heard of volume standards (that is, that there is a minimum number of a certain operation a hospital needs to perform each year to do them well). After we explained this concept, 82% of respondents said they would recommend their friend go to a different hospital if their chosen hospital did not meet the appropriate standard.
To learn if, and how, respondents would like to learn about hospital performance data, we told them to imagine that Medicare planned to create a list of the best hospitals for various surgeries. Most (59%) respondents thought that Medicare would create such a list to help patients receive better quality care, but 23% believed that the list's main purpose would be to help the government save money. Seventy one per cent of respondents said they might consult such a list if it existed (49% said they would be "very likely" to consult such a list). Only 2% said they would like to receive information about the best hospitals directly; 40% wanted such information only from their doctor, and 55% wanted it from their doctor and from other sources as well.
Discussion
Hannan E, H Kilburn J, O'Donnell J, Lukacik G, Shields E. Adult open heart surgery in New York State. An analysis of risk factors and hospital mortality rates. JAMA 1990;264: 2768-74.
Galvin R, Milstein A. Large employers' new strategies in health care. N Engl J Med 2002;347: 939-42.
Milstein A, Galvin R, Delbanco S, Salber P, CR Buck J. Improving the safety of health care: the leapfrog initiative. Eff Clin Pract 2000;3: 313-6.
BBC News. Pressure grows over surgeon data. http://news.bbc.co.uk/1/hi/health/4264435.stm (accessed 15 Apr 2005).
Bridgewater B. Mortality data in adult cardiac surgery for named surgeons: retrospective examination of prospectively collected data on coronary artery surgery and aortic valve replacement. BMJ 2005;330: 506-10.
Carvel J, Boseley S, Evans R, Heslop K, Chevallot I. NHS heart surgery: the data explained 244 doctors and the problem of comparing mortality rates. Guardian 2005 Mar 16; 10.
Mukamel D, Mushlin A. Quality of care information makes a difference: an analysis of market share and price changes after publication of the New York State cardiac surgery mortality reports. Med Care 1998;36: 945-54.
Romano P, Zhou H. Do well-publicized risk-adjusted outcomes reports affect hospital volume? Med Care 2004;42: 367-77.
Schneider E, Epstein A. Influence of cardiac-surgery performance reports on referral practices and access to care. N Engl J Med 1996;335: 251-6.
Schneider E, Epstein A. Use of public performance reports: a survey of patients undergoing cardiac surgery. JAMA 1998;279: 1638-42.
Finlayson E, Birkmeyer J. Operative mortality with elective surgery in older adults. Eff Clin Pract 2001;4: 172-7 Erratum Eff Clin Pract 2001;4: 235.].
American Association of Public Opinion Research. Standards and best practices. Standard definitions: final dispositions of case codes and outcome rates for surveys. www.aapor.org/default.asp?page=survey_methods/standards_and_best_practices/standard_definitions (accessed 7 Feb 2003).
Marshall M, Shekelle P, Leatherman S, Brook R. The public release of performance data: what do we expect to gain? A review of the evidence. JAMA 2000;283: 1866-74.
Hannan EL, Kumar D, Racz M, Siu AL, Chassin MR. New York State's cardiac surgery reporting system: four years later. Ann Thorac Surg 1994;58: 1852-7.
Americans as health care consumers: update on the role of quality information. High-lights of a national survey. Kaiser Family Foundation, Agency for Healthcare Research and Quality, Rockville, MD. www.ahrq.gov/qual/kffhigh00.htm (accessed 20 Jul 2005).
Robinson S, Brodie M. Understanding the quality challenge for health consumers: the Kaiser/AHCPR survey. Jt Comm J Qual Improv 1997;23: 239-44.
Kurz R, Wolinsky F. Who picks the hospital: practitioner or patient? Hosp Health Serv Adm 1985;30: 95-106.
Jewett J, Hibbard J. Comprehension of quality care indicators: differences among privately insured, publicly insured, and uninsured. Health Care Financ Rev 1996;18: 75-94.
Magee H, Davis L-J, Coulter A. Public views on healthcare performance indicators and patient choice. J R Soc Med 2003;96: 338-42.
RAND Health. Consumers and health care quality information: need, availability, utility. Oak-land, CA: California Healthcare Foundation, 2001.
B?rsch-Supan A, Brugiavini A, Jürges H, Mackenbach J, Siegrist J, Weber G, eds. Health, ageing and retirement in Europe—First results from the Survey of Health, Ageing and Retirement in Europe. Mannheim: MEA, 2005. (www.share-project.org)
Levinson W, Kao A, Kuby A, Thisted R. Not all patients want to participate in decision making. A national study of public preferences. J Gen Intern Med 2005;20: 531-5.
Finlayson S, Birkmeyer J, Tosteson A, Nease R. Patient preferences for location of care: implications for regionalization. Med Care 1999;37: 204-9.
Hartz A, Pulido J, Kuhn E. Are best coronary artery bypass surgeons identified by physician surveys? Am J Public Health 1996;87: 1645-8.
Hartz A, Kuhn E, Pulido J. Prestige of training programs and experience of bypass surgeons as factors in adjusted patient mortality rates. Med Care 1999;37: 99-103.
Hannan E, Stone C, Biddle T, DeBuono B. Public release of cardiac surgery outcomes data in New York: What do New York state cardiologists think of it? Am Heart J 1997;134: 1120-8.(Lisa M Schwartz, associate professor of )
Correspondence to: S Woloshin steven.woloshin@dartmouth.edu
Objective To learn how patients in Medicare, the US medical insurance programme that covers elderly patients, made decisions about where to undergo major surgery and how they would make future decisions.
Design National telephone interview study.
Setting United States.
Participants 510 randomly selected Medicare beneficiaries who had undergone an elective, high risk procedure about 3 years earlier—abdominal aneurysm repair (n = 103), heart valve replacement surgery (n = 96), or resection of the bladder (n = 119), lung (n = 128), or stomach (n = 64) for cancer. Response rates were 48% among eligible survivors and 68% among those able to participate.
Results Although all participants could choose where to have surgery, only 55% said there was an alternative hospital in their area where they could have gone. Overall, only 10% of respondents seriously considered going elsewhere for surgery. Few respondents (11%) looked for information to compare hospitals. Almost all respondents thought their hospital and surgeon had good reputations (94% and 88%, respectively), beliefs mostly determined by what their referring doctors said. When asked how much various factors would influence their advice to a friend about choosing where to go for major surgery, surgeon reputation was the most influential (78% said it would influence their advice "a lot"), followed by the hospital having "nationally recognised" surgeons (63%), and then various performance data (surgeon volume (58%), nurse:patient ratios (49%), number of operations carried out by the hospital (48%), and hospital operative mortality (45%)). Forty per cent said they would act on mortality data, indicating that they would switch from their initial choice of hospital to a different one if its mortality was a percentage point lower (that is, 3% v 4%).
Conclusion Some respondents claimed they would switch hospital for elective surgery on the basis of mortality data. Since most respondents relied on their referring physician's opinion to decide where to have surgery, surgical performance data ought to be accessible to referring physicians.
There is growing interest in providing patients with surgical performance data to help them select the best surgeons and hospitals. New York State, for example, has released hospital mortality data for cardiac surgery to the public since the early 1990s.1 In recent years several US state departments of public health, proprietary health quality rating firms, patient advocacy groups, and purchaser coalitions have launched new public reporting initiatives.2 3 In Britain hospitals,4 surgeon organisations,5 and recently the Guardian newspaper6 have published operational mortality data for individual heart surgeons. These initiatives share the basic assumption that patients will use such data to select higher quality hospitals for their surgery.
However, it is not clear to what extent patients know about and value such information. Several studies have found minimal changes in hospital caseloads after the public reporting of mortality data.7-9 In the only published study to question surgical patients about their decision making, only 12% of patients undergoing coronary artery bypass in Pennsylvania in 1996 were aware of a publicly released report on surgical mortality before their operation.10 Performance data have since become more widely available (particularly with the growth of the internet) and, with increasing media attention on patient safety, more visible to the public. None the less, the usefulness of performance data to patients remains unknown.
To better understand how patients make decisions about where to have surgery, we conducted a national survey of patients in the Medicare programme, the US federal government insurance programme that covers hospital costs for almost all US citizens aged 65 years and older, who had undergone an elective, high risk procedure. In addition to learning how the patients made their original decisions, we assessed whether they thought performance data to be relevant and to what extent such data would be useful in their future decisions.
Methods
Sample selection
Our goal was to learn how patients choose where to go for major surgery and whether performance data are likely to affect this decision. We focused on elective procedures because choice of hospital or surgeon was theoretically possible. We interviewed a random sample of Medicare beneficiaries who had undergone one of five major elective operations (abdominal aneurysm repair, heart valve replacement, or resection of the bladder, lung, or stomach because of cancer). We surveyed Medicare patients because Medicare covers well over half of all patients undergoing these procedures in the United States.11
Our goal was to get 100 interviews for each operation (we chose this number to ensure a confidence interval of at most ±10%). The five procedures differ considerably in procedure frequency and long term survival after surgery, so we sampled some operations more than others. The sampling fractions of patients for each operation were 4.2% for lung resection, 10.8% for gastrectomy, 14.5% for cystectomy, 1.7% abdominal aneurysm repair, and 1.1% for valve replacement.
Figure 1 details the steps of the sampling procedure. Using data provided by the Center for Medicaid and Medicare Services, we selected a random sample of beneficiaries (stratified within each type of surgery) who had a claim for one of the five elective operations in 2000. The centre then provided us with a list of the names and addresses of 2114 beneficiaries (eight of whom subsequently reported they had not had surgery and were considered ineligible). Of these, 1055 were alive in January 2004. To obtain telephone numbers, we sent the sample list of names and addresses to Telematch, an independent company that provides this service. We called Directory Assistance for those cases when Telematch failed to find telephone numbers. We were able to obtain contact information for 828 people (12 had non-US mailing addresses). We attempted to interview 785 patients who were not hospitalised or in a nursing home and who spoke English and were able to hear adequately. A total of 510 individuals without cognitive impairment (such as Alzheimer's disease) completed the telephone interview. We concluded people could not be contacted only after at least six attempts at different times of day and three further attempts two weeks later.
Fig 1 Selection of survey participants
We calculated response rates using the two methods recommended by the American Association of Public Opinion Research.12 With the number of eligible survivors as the denominator, the response rate was 48% (510/1055). With the number of those who were able to participate, the response (or cooperation) rate was 68% (510/751). There was no significant difference in response rates across the five operations.
Interview protocol
Development—To learn what people thought about the decision of where to have surgery, we conducted two focus groups with people who had recently undergone major surgery. We conducted the focus groups and all subsequent survey development in collaboration with the Center for Survey Research, a professional survey research firm affiliated with the University of Massachusetts. We developed a draft survey instrument based on the focus groups' conclusions and on a previously published survey of patients who had undergone coronary bypass surgery in Pennsylvania.10 Experienced interviewers conducted five cognitive interviews with patients who had undergone surgery at Dartmouth Hitchcock Medical Center within the previous three years to ensure that the questions were understood and that the answers were meaningful. After revising the draft instrument, we conducted a pilot test of the telephone survey with 25 patients. These interviews were audiotaped and then coded to identify questions that were difficult for interviewers to read or for respondents to answer. We revised the survey on the basis of these results.
Instrument—The final survey had three sections. The first asked about experiences with major surgery (such as how the respondent decided where to have surgery, what factors influenced this choice, the respondent's perceptions of the hospital and the surgeon). The second section focused on respondents' knowledge and reaction to surgical performance data, specifically information on work volume (number of operations performed by individual surgeons or hospitals), patient mortality, and nurse:patient ratios. The third section asked for respondents' reactions to two scenarios—firstly, what advice they would give to a friend who needed major surgery and, secondly, their reactions to Medicare publishing a list of best hospitals for different operations.
Administration—In December 2003 potentially eligible respondents were sent a notification letter (as required by the Center for Medicaid and Medicare Services) and a second letter two weeks later stating that the Center for Survey Research would be calling. Interviews were conducted by professional interviewers at the Center for Survey Research's telephone facility from January through February 2004. All interviewers received special training on the purposes and procedures of this particular study, all underwent monitoring for quality control and feedback from a supervisor. The interviews took an average of 21 minutes (range 12-46 minutes). Answers to the survey were directly entered into the computer assisted telephone interviewing system by the interviewers.
Statistical analysis
We weighted the results for the five operations to account for the different probabilities of selection into our sample and the slightly different response rates. The weighted results differed by only 1% or 2% from the unweighted results. Because the weighted results assume that non-respondents would answer questions similarly to respondents, we chose to present the unweighted results. We calculated 95% confidence intervals using the binomial Wald function. We performed all analyses using Stata statistical software (version 9, StataCorp, College Station, TX).
Results
Table 1 shows the 510 respondents' characteristics. They had a mean age of 78 years (range 68-93), two thirds were men, and 91% were white. Most reported lower socioeconomic status: 38% reported a total household income less than $25 000, and only 25% had graduated from college or graduate school. Self reported health was low: only 7% rated their health as excellent.
Table 1 Characteristics of 510 Medicare beneficiaries who had undergone elective, high risk surgery about three years earlier. Values are numbers (percentages) of 510 respondents unless stated otherwise
How respondents made their surgery decision
Most respondents had had time to consider where to go for surgery, were aware of other hospitals in their area to choose between, and felt involved in the decision making process. Specifically, 84% said they had at least a week, and 30% had more than a month, between being told they needed surgery and undergoing the surgery. Two thirds said they were involved in selecting the hospital, 41% making the decision equally with their doctor, and 24% deciding mainly on their own or with their family.
Since all respondents were Medicare beneficiaries, all had options with regard to where they had surgery; nonetheless, only 55% said there were other local hospitals where they could have gone. Overall, only 10% seriously considered going elsewhere for surgery (this percentage was the same for those who said there was another local hospital to go to). Few respondents (11%) looked for information to compare hospitals, most commonly turning to friends and family, their primary doctor, or the internet. Most stayed at local hospitals, 73% reporting their travel time to be less than an hour.
Rather than seeking quantitative information, most seemed to rely on hospital or surgeon reputation in deciding where to have surgery. Almost all respondents thought their hospital and surgeon had good reputations (94% and 88% respectively). Thirty one per cent said their hospital was "the best" in the area, 40% said "better than most," 22% said "about the same," and only 1% said it was "worse than most." Eighty per cent and 79% respectively said that surgeon and hospital reputation were "extremely" or "very" important to their decision (fig 2). Other factors influencing patient decisions included having had prior care at the hospital (rated important by 42%) and the recommendations of family and friends (rated important by 28%). When asked why they thought their hospital had a good reputation, 64% of respondents said it was because of what their referring doctor had said, and 31% said so because of what family or friends had said (table 2). These results did not vary importantly across the five surgical procedures.
Fig 2 Importance of different factors in respondents' decisions about where to have major surgery.
Table 2 Responses of 510 Medicare beneficiaries who had undergone elective, high risk surgery about three years earlier to questions about their decision making for their surgery and reactions to surgical performance to data
How respondents would advise others
We asked respondents how much various factors would influence the advice they would give to a friend about where to go for major surgery (fig 3). Of these factors, surgeon reputation was rated the most influential (78% said it would influence their advice "a lot"), followed by the hospital having "nationally recognised" surgeons (63%). When we asked whether performance data could influence decisions, substantial proportions of the respondents said the following items would influence them "a lot"—surgeon's work volume (58%), nurse:patient ratios (49%), hospital work volume (48%), and hospital operative mortality (45%). Moreover, 40% of respondents said they would switch from their chosen hospital if the surgical mortality for another hospital was a percentage point lower (that is, 3% v 4%).
Fig 3 Importance of different factors in respondents' hypothetical advice to a friend due to have major surgery
We also sought to learn what people know about hospital work volume (a measure increasingly used as a proxy for mortality) and found that most people accepted the intuitive notion that "practice makes perfect": 80% of respondents thought that the chance of surviving an operation was better at a high volume hospital than a low volume one. However, only 11% of respondents had heard of volume standards (that is, that there is a minimum number of a certain operation a hospital needs to perform each year to do them well). After we explained this concept, 82% of respondents said they would recommend their friend go to a different hospital if their chosen hospital did not meet the appropriate standard.
To learn if, and how, respondents would like to learn about hospital performance data, we told them to imagine that Medicare planned to create a list of the best hospitals for various surgeries. Most (59%) respondents thought that Medicare would create such a list to help patients receive better quality care, but 23% believed that the list's main purpose would be to help the government save money. Seventy one per cent of respondents said they might consult such a list if it existed (49% said they would be "very likely" to consult such a list). Only 2% said they would like to receive information about the best hospitals directly; 40% wanted such information only from their doctor, and 55% wanted it from their doctor and from other sources as well.
Discussion
Hannan E, H Kilburn J, O'Donnell J, Lukacik G, Shields E. Adult open heart surgery in New York State. An analysis of risk factors and hospital mortality rates. JAMA 1990;264: 2768-74.
Galvin R, Milstein A. Large employers' new strategies in health care. N Engl J Med 2002;347: 939-42.
Milstein A, Galvin R, Delbanco S, Salber P, CR Buck J. Improving the safety of health care: the leapfrog initiative. Eff Clin Pract 2000;3: 313-6.
BBC News. Pressure grows over surgeon data. http://news.bbc.co.uk/1/hi/health/4264435.stm (accessed 15 Apr 2005).
Bridgewater B. Mortality data in adult cardiac surgery for named surgeons: retrospective examination of prospectively collected data on coronary artery surgery and aortic valve replacement. BMJ 2005;330: 506-10.
Carvel J, Boseley S, Evans R, Heslop K, Chevallot I. NHS heart surgery: the data explained 244 doctors and the problem of comparing mortality rates. Guardian 2005 Mar 16; 10.
Mukamel D, Mushlin A. Quality of care information makes a difference: an analysis of market share and price changes after publication of the New York State cardiac surgery mortality reports. Med Care 1998;36: 945-54.
Romano P, Zhou H. Do well-publicized risk-adjusted outcomes reports affect hospital volume? Med Care 2004;42: 367-77.
Schneider E, Epstein A. Influence of cardiac-surgery performance reports on referral practices and access to care. N Engl J Med 1996;335: 251-6.
Schneider E, Epstein A. Use of public performance reports: a survey of patients undergoing cardiac surgery. JAMA 1998;279: 1638-42.
Finlayson E, Birkmeyer J. Operative mortality with elective surgery in older adults. Eff Clin Pract 2001;4: 172-7 Erratum Eff Clin Pract 2001;4: 235.].
American Association of Public Opinion Research. Standards and best practices. Standard definitions: final dispositions of case codes and outcome rates for surveys. www.aapor.org/default.asp?page=survey_methods/standards_and_best_practices/standard_definitions (accessed 7 Feb 2003).
Marshall M, Shekelle P, Leatherman S, Brook R. The public release of performance data: what do we expect to gain? A review of the evidence. JAMA 2000;283: 1866-74.
Hannan EL, Kumar D, Racz M, Siu AL, Chassin MR. New York State's cardiac surgery reporting system: four years later. Ann Thorac Surg 1994;58: 1852-7.
Americans as health care consumers: update on the role of quality information. High-lights of a national survey. Kaiser Family Foundation, Agency for Healthcare Research and Quality, Rockville, MD. www.ahrq.gov/qual/kffhigh00.htm (accessed 20 Jul 2005).
Robinson S, Brodie M. Understanding the quality challenge for health consumers: the Kaiser/AHCPR survey. Jt Comm J Qual Improv 1997;23: 239-44.
Kurz R, Wolinsky F. Who picks the hospital: practitioner or patient? Hosp Health Serv Adm 1985;30: 95-106.
Jewett J, Hibbard J. Comprehension of quality care indicators: differences among privately insured, publicly insured, and uninsured. Health Care Financ Rev 1996;18: 75-94.
Magee H, Davis L-J, Coulter A. Public views on healthcare performance indicators and patient choice. J R Soc Med 2003;96: 338-42.
RAND Health. Consumers and health care quality information: need, availability, utility. Oak-land, CA: California Healthcare Foundation, 2001.
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