Elsevier

Health Policy

Volume 77, Issue 3, August 2006, Pages 318-325
Health Policy

Why do not all hip- and knee patients facing long waiting times accept re-referral to hospitals with short waiting time?: Questionnaire study

https://doi.org/10.1016/j.healthpol.2005.08.002Get rights and content

Abstract

Patients’ preferences are often assumed to be homogeneous and to favour hospitals with a short waiting time and high quality. Due to long waiting times (6 months) for artificial hip or knee implantation a Danish county in 1999–2000 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. Fewer patients than expected took advantage of the offer of re-referral (“accepters”): 89 of 149 patients (60%). In 2003, we asked patients about the reasons for their choice: 87% of patients responded. Respondents and non-respondents were similar by decision, choice of hospital, diagnosis and age; men were significantly more likely to respond than women. Accepters and decliners were similar by age, sex, diagnosis and the presence of a car in the household. Short distance, short transport time and previous experience with the nearby hospital were the most important reasons for choosing that hospital. Some patients appeared to be willing to accept a long waiting time, if they were told exactly when they would undergo surgery. The results of this study question the validity of the conventional wisdom, that patients are willing to travel long distances in order to receive treatment with short waiting time.

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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