Choice of health care provider has been introduced in several health care systems with the objective of improving quality of care and efficiency. Microeconomic theory presupposes that allowing patients to freely choose their health care service provider will stimulate competition and send signals to providers to improve quality and responsiveness. As money follows patients’ choices, this is expected to economically benefit providers with better quality over providers with lower quality. Poorly performing providers will thus eventually be forced to exit the market (1, 2).
An important assumption behind introducing choice policies in health care is that patients will choose those health care providers offering the best service and medical quality. This requires patients to not only choose a provider based on their personal preferences and values (for instance, the geographically closest provider), but a provider which performs well in terms of clinical quality and safety (3). To promote high quality-providers, patients need to make informed choices, basing their decisions on information that enables them to judge the clinical quality and responsiveness of the services offered. Uninformed choices may lead to providers shirking on quality and under-performing providers may not be outcompeted (1, 4).
Previous studies have not explicitly discussed what kind of information patients should seek in order to make well-informed decisions regarding their choice of healthcare provider. The broader field of decision theory states that in order for individuals to make good decisions, they need to use information that helps them understand the potential consequences of choosing one alternative over another. This involves using both relevant and reliable information (5, 6). The use of relevant information requires that individuals seek a breadth of information that covers as many aspects as possible of the different alternatives available as possible (7–9). In the context of health care, we argue that this includes seeking multiple types of information from several information sources. Patients may thus gain a multi-faceted understanding of provider quality regarding areas including for instance competence, accessibility, and clinical results. The use of reliable information requires that individuals turn to trustworthy information sources to avoid biased and potentially incorrect information (5). With respect to the choice of provider, we argue that this entails the use of professional and independent sources, such as data disclosed by public authorities, which facilitate comparisons of different health care providers and ensure a certain quality and objectivity of the information.
Previous research shows that patients consider several aspects of quality to be important when asked to hypothetically choose a health care provider. These include for instance expected treatment outcomes, complication risks, the staff’s competence and responsiveness, care facilities, accessibility and other patients’ recommendations (10–12). However, studies reporting whether patients seek information about the quality of services in hypothetical choice situations show that less than 40% would actually do so (13, 14). In a study by authors x (15) which investigated if patients in active choice situations (i.e. patients who had previously switched or considered switching health care provider) searched for information prior to their choice, not even 20% reported that they had done so.
In studies investigating information seeking behaviour among patients who did seek some sort of information prior to their choice of provider, results demonstrated that most patients relied on dependent information sources such as recommendations from family and friends, information from the referring doctor, or from the chosen provider (16–18). Significantly fewer had searched for “advanced” information from independent and professional information sources, such as comparative information about differences in quality of services disclosed by official authorities (19–21).
Despite the vast number of studies which have investigated if and how patients use information when choosing health care provider, research has paid limited attention to what specific types of information patients seek and the number of different information sources patients turn to when actively choosing a health care provider. Although studies about patients’ information preferences in hypothetical choice situations may contribute with interesting insights, those results give a limited understanding regarding patients’ information seeking behaviour in real choice situations. By more thoroughly analysing the specific types of information and the number of information sources patients turn to in active choice situations, this study contributes with a more in-depth understanding of how patients use information, and hence to what extent they are engaged in making well-informed choices according to theoretical premises underlying patient choice.
Furthermore, it has not been investigated whether patients who actively seek some sort of information prior to their choice of health care provider are also more inclined to seek more “advanced” information in line with the theoretical premises behind patient choice, i.e. seeking a breadth of relevant information types and from multiple reliable sources. This is important knowledge, since this group of patients may potentially have better qualifications to perform well- informed choices and thus stimulate competition among providers. Also, if the results show that more active information seekers do not act in a way that underpins informed choices it is not reasonable to expect that other patient groups will do so either.
To bridge the knowledge gap outlined above this study aims to investigate the following two questions:
1) What types of information and information sources do patients turn to when actively choosing a health care provider?
2) Are active information seekers also more motivated to seek a more advanced information, i.e., relevant and reliable information when choosing a health care provider?
An informed choice has been described in literature as a patient being properly informed to judge the quality and responsiveness of services offered by different health care providers (4). Yet, the concept of being ‘properly informed’ is not well developed. Several studies emphasise the importance of patients being provided with physically and cognitively accessible information, as well as accurate, timely and relevant information. Furthermore, patients need to base their choice on the accessible information. This entails processing, correctly interpreting, and identifying relevant factors in the information to integrate into the decision. It also includes weighing and making trade-offs between those factors (22, 23).
We argue, however, that essential components of an informed choice are left out by previous literature. First, patients cannot use information as a basis for their choice of provider before they have actively searched for accessible information. Second, the information patients seek must also be of such a quality that it allows them to independently determine the best provider in terms of both personal preferences and clinical performance.
In normative decision theory the process of supporting a choice or a decision through a thorough analysis of information has been termed “decision quality” or “information processing performance” (5, 6). A good decision in a choice situation requires that the individual systematically process information so that arguments for and against an alternative are carefully examined and related to earlier experience. This further implies that the information sought out must be of such quality that it fulfils the requirements of relevance and reliability (5, 24, 25).
Relevant information is defined as all the important information that the individual already has, wants, or needs to acquire to understand the outcomes of a decision (5). Gathering relevant information requires that the individual has a sufficient “search breadth”, i.e., that the individual searches for information that covers as many arguments for or against a certain choice as possible. Apart from seeking many different types of information, it also entails seeking information from several information sources. Using varied types and sources of information facilitates comparisons of different alternatives, and allows patients to judge the quality and value of information from each source (7–9, 26).
Reliable information implies information that is trustworthy and supplied by professional and independent sources. In seeking reliable information, the individual needs to avoid using dependent sources, information based on incorrect data, or information “cherry picked” to support biased opinions and assumptions (5).
We argue that both the breadth of relevant information and the reliability of the information patients seek are crucial to making sound judgments about providers’ quality of services, and consequently their ability to make informed choices. In this specific context, i.e., primary healthcare, it includes seeking various types of information that may capture the complexity of the notion of quality of health care services: providers’ structural quality (e.g., quality of professionals and medical facilities), process quality (e.g., waiting times, staff courtesy) and outcome quality (e.g., improvement in health) (27). Additionally, it includes seeking information from a number of professional and independent sources that describe the quality of health care providers’ services in a correct and unbiased manner (e.g., information from clinical registries or patient surveys supplied by public authorities).