Why do not all hip- and knee patients facing long waiting times accept re-referral to hospitals with short waiting time?: Questionnaire study
Introduction
A large majority of Danish and English healthy citizens report that they would be willing to travel to distant hospitals for treatment with short waiting time [1], [2], [3]: waiting time being viewed as a performance indicator for hospitals [4], and short waiting time being viewed as an indisputable and important good in patients’ choice of hospital. Meanwhile, a growing number of studies of patients’ choice performed in various countries and in different health care systems demonstrate inverse or negative relationships between distance to health care and its utilisation [5], [6], [7]. This study concerns a natural experiment, where elective patients were offered a trade-off between short waiting time and short distance to hospital.
Due to long waiting times (6 months) for artificial hip or knee replacement a Danish county offered patients on a waiting list a choice between remaining on the local hospital's waiting list with the long waiting time or re-referral to a hospital outside the county with a shorter waiting time, assuming that almost all patients would accept re-referral to reduce their waiting time. However, fewer patients (59%) than expected took advantage of the offer of re-referral to cut waiting time. Other Danish counties have carried out similar initiatives, but we have not found any scientific studies of these projects. Two English studies presented different patient groups with a simple trade-off between a long waiting time and a long distance to hospital and found very different results: roughly half of patients waiting for surgery chose re-referral to a distant hospital [8], while 95% of parents of clinically relevant children with recurrent tonsillitis chose a distant hospital [9]. New legislation allows Danish patients to choose among a larger number of public and private hospitals, and hospitals’ financial incentives to receive patients have been strengthened, making it more difficult to perform a prospective study of a simple trade-off between short distance and short waiting time. Therefore, we have investigated why patients accepted or declined the offer of earlier treatment at a distant hospital (“accepters” and “decliners”), testing the following hypothesis:
On average accepters were younger than decliners.
Men were more likely to accept re-referral than women.
Hip- and knee patients were equally likely to accept re-referral.
Decliners were more likely to regret their decision than accepters.
Short distance was the most important factor behind decliners’ choice.
Short transport time was more important to decliners than short distance.
Section snippets
Setting
In Denmark, examination and treatment by the general practitioner (GP) and at public hospitals is tax-financed and provided free of charge by the patients’ home county. Each Dane chooses a local GP, who is responsible for basic examinations and treatments. The GPs are self-employed and responsible for their own facilities and never carry out their work in a hospital but may refer their patients to admittance or out-patient services at any public hospital for specialised services. The private
Results
The source group consisted of 184 patients. Forty patients (22%) did not respond to the invitation or asked to be deleted from the waiting list. The 86 accepters and 58 decliners made up the study group and received a questionnaire (n = 144). One hundred and twenty-five (87%) filled in and returned the questionnaire. Univariate and multivariate analysis of the whole study group showed that choice of local hospital (decliners) versus choice of distant hospital (accepters) was not associated with
Discussion
Our study was performed in a country, where much emphasis has been put on providing patients with a choice of hospital and achieving short waiting times to surgery, and where conventional wisdom states that patients are willing to travel long distances in order to receive treatment with short waiting time elsewhere in the country. However, patients’ choice of hospital is also influenced by the distance to hospital, the hospitals’ quality and reputation and the patients’ social network.
Conclusion
We found that accepters were slightly older than decliners within the study population's narrow age range, female patients were slightly more likely to accept re-referral than male patients, knee patients were slightly more likely to accept re-referral than hip patients, and accepters were slightly more likely to regret their choice than decliners, but all of these results were insignificant. Short distance to hospital was the most important reason behind decliners’ choice, and short distance
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