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Do Informed Consumers in Taiwan Favour Larger Hospitals?

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Do Informed Consumers in Taiwan Favour Larger Hospitals? Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-025202 on 16 May 2019. Downloaded from Do informed consumers in Taiwan favour larger hospitals? A 10-year population-based study on differences in the selection of healthcare providers among medical professionals, their relatives and the general population Raymond N Kuo, 1,2 Wanchi Chen,1 Yuting Lin3 To cite: Kuo RN, Chen W, Lin Y. ABSTRACT Strengths and limitations of this study Do informed consumers in Objectives Exploring whether medical professionals, Taiwan favour larger hospitals? who are considered to be ‘informed consumers’ in the A 10-year population-based ► This is the first study to use matched samples to healthcare system, favour large providers for elective study on differences in the investigate differences among medical profession- selection of healthcare providers treatments. In this study, we compare the inclination of als, their relatives and the general population in the among medical professionals, medical professionals and their relatives undergoing choice of healthcare provider for elective treatment. their relatives and the general treatment for childbirth and cataract surgery at medical ► This study includes medical professionals other than population. BMJ Open centres, against those of the general population. physicians and a broad range of relatives. 2019;9:e025202. doi:10.1136/ Design Retrospective study using a population-based ► Patients who were not medical professionals/rela- bmjopen-2018-025202 matched cohort data. tives may still have had interpersonal connections ► Prepublication history for Participants Patients who underwent childbirth or with individuals working in the healthcare sector. this paper is available online. cataract surgery between 1 January 2004 and 31 ► The spouse of a medical professional who was em- To view these files, please visit December 2013. ployed throughout the entire period of observation the journal online (http:// dx. doi. Primary and secondary outcomes measures We used could be misclassified to the general population. http://bmjopen.bmj.com/ org/ 10. 1136/ bmjopen- 2018- multiple logistic regression to compare the ORs of medical 025202). professionals and their relatives undergoing treatment at Received 3 July 2018 medical centres, against those of the general population. INTRODUCTION Revised 4 March 2019 We also compared the rate of 14-day re-admission In the past, many countries used to enforce Accepted 25 March 2019 (childbirth) and 14-day reoperation (cataract surgery) after strict gatekeeping systems in primary care, discharge between these groups. wherein patients were excluded from the Results Multivariate analysis showed that physicians process of selecting a healthcare provider. As were more likely than patients with no familial connection a result, general practitioners (GPs) played on September 30, 2021 by guest. Protected copyright. © Author(s) (or their to the medical profession to undergo childbirth at medical employer(s)) 2019. Re-use centres (OR 5.26, 95% CI 3.96 to 6.97, p<0.001), followed an important role in selecting healthcare permitted under CC BY-NC. No providers and mediating referrals for specialty by physicians’ relatives (OR 2.68, 95% CI 2.20 to 3.25, 1 commercial re-use. See rights p<0.001). Similarly, physicians (OR 1.63, 95% CI 1.21 to care or hospital admission. Gatekeeping and permissions. Published by was shown to limit unnecessary referrals; BMJ. 2.19, p<0.01) and their relatives (OR 1.43, 95% CI 1.13 to 1.81, p<0.01) were also more likely to undergo cataract however, researchers found that the decision 1Institute of Health Policy and Management, National Taiwan surgery at medical centres. Physicians also tended to of whether to refer a patient to a specialist University, Taipei City, Taiwan select healthcare providers who were at the same level or varied among GPs, resulting in the underuse 2 2Innovation and Policy Centre above the institution at which they worked. We observed and the overuse of referrals. Beginning in for Population Health and no significant difference in 14-day re-admission rates the 1990s, the UK and several western Euro- Sustainable Environment, after childbirth and no significant difference in 14-day pean countries introduced systems in which College of Public Health, reoperation rates after cataract surgery across patient patients were given a choice in healthcare National Taiwan University, groups. Taipei City, Taiwan providers with the aim of improving access, 3 Medical professionals and their relatives 3–5 National Health Insurance Conclusions efficiency and quality of care. Administration, Taipei Division, are more likely than the general population to opt for Previous studies have shown that Taipei City, Taiwan service at medical centres. Understanding the reasons that highly educated patients and those with medical professionals and general populations both have a clearly defined needs for elective treatments Correspondence to preferential bias for larger medical institutions could help are more likely to exercise their choice, rather Dr Raymond N Kuo; improve the efficiency of healthcare delivery. nckuo@ ntu. edu. tw than being treated by local providers.6–8 Kuo RN, et al. BMJ Open 2019;9:e025202. doi:10.1136/bmjopen-2018-025202 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-025202 on 16 May 2019. Downloaded from Moscone et al reported that the absence of informa- elective treatments. We also compared the two groups in tion pertaining to the quality of hospitals often leads to terms of the prevalence of re-admission or reoperation patients selecting hospitals with low quality of care.9 This within a period of 14 days after discharge. This could shed means that allowing provider's choice can improve access light on important issues, such as the influence of health to healthcare and reduce waiting times; however, it also literacy and expert opinions on the utilisation and effi- raises concerns about aggravating inequity in health- ciency of healthcare delivery. Ordinary patients are widely care.4 10 11 blamed for inefficiencies in healthcare utilisation due to Physicians can be considered informed consumers their lack of information pertaining to the care appro- of healthcare services with ready access to healthcare priate to their condition. It should be possible to adopt providers. Literature has shown that individuals working the choices made by medical professionals as a standard in the healthcare sector differ in their consumption to determine whether the criticisms aimed at the general patterns, compared with non-medical professionals. populace are justified. Bunker and Brown found that patients who are physi- cians and their spouses were more likely to undergo oper- ations than were patients in other occupation groups (eg, lawyers or businessmen). Thus, they suggested that the METHODS demand for healthcare increases when patients are well Data and study population informed.12 Domenighetti et al investigated the consump- This study used a combination of data from two cohorts: tion of medical and surgical services by physicians; the National Health Insurance Database of Taiwan 2005 however, they discovered that physicians are far less likely (Longitudinal Health Insurance Database 2005) and than the general population to undergo surgery.13 14 More- 2010 (Longitudinal Health Insurance Database 2010). over, another study based on data from a Swiss Health Each of the cohort data gave us access to all of the orig- Survey found that medical professionals are significantly inal claims data, pertaining to ambulatory and inpa- less likely to visit physicians, compared with those in the tient care for every case between 1 January 2003 and general population.15 Other studies comparing health- 31 December 2013, of 1 000 000 beneficiaries (a random care received by physicians and the general population sample) enrolled in 2005 or 2010. The combination have reported that physicians utilise healthcare less but of data provided a cohort that is representative of the tend to have better outcomes than the general popula- general population including 1 959 927 (7.63%) of the tion.16–19 Physicians are also less likely to undergo breast 25.68 million NHI enrollees. No significant differences cancer screening20 and treatments with deadly adverse were identified between the patients, between the two effects21; however, they are more likely to use hospices and cohorts and the general population in terms of gender, 22 24 intensive care units (ICU) or critical care units (CCU). age or average monthly income. The identities of the http://bmjopen.bmj.com/ A number of studies have explored differences between patients, physicians and hospitals were all encrypted medical professionals and non-medical professionals using the same encryption algorithm to enable the cross- in terms of treatment choice and outcomes; however, linking of data, while ensuring the protection of privacy. very few have examined whether medical professionals The medical personnel registry (PER file) was used to are more likely than the general population to favour determine whether any of the patients was a physician or large hospitals. Many previous studies were also subject medical professional. We also used the National Health to limitations, including a failure to include medical Insurance Enrolment file within the NHID to identify the professionals other than physicians and a broad range of socioeconomic status of patients (ie, level of income). For on
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