|Year : 2020 | Volume
| Issue : 6 | Page : 260-265
Patient preference for a particular hospital: A prospective questionnaire-based investigation from India
Srinivas Bojanapu1, Mayank Mathur2, Jini Jacob2, Anju Sharma2, Samiran Nundy2
1 Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi; Department of Surgical Gastroenterology and Liver Transplantation, Kauvery Hospital, Bengaluru, Karnataka, India
2 Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India
|Date of Submission||11-Nov-2020|
|Date of Decision||12-Nov-2020|
|Date of Acceptance||17-Nov-2020|
|Date of Web Publication||24-Dec-2020|
Dr. Srinivas Bojanapu
No. 1469, 4th Floor CB Block, Sir Ganga Ram Hospital, New Delhi - 110060
Source of Support: None, Conflict of Interest: None
Background: The ubiquitous access to media, the Internet, and suggestions from friends relatives have empowered patients not only choose but also make informed decisions about their health needs and how and where to be addressed. Although there are many guides and studies on the main factors which infl choice, particularly in the USA. There are very few from India and also hospitals from the large private sector constantly advertise their strengths.
Aim: We studied the factors which influenced a patient's decision to seek medical attention at a not-for-profit tertiary care centre in India.
Materials and Methods: Four hundred consecutive patients or their relatives were provided with a printed sheet that contained a total of 15 questions, which included the unit's and hospital's trustworthiness, reputation, infrastructure, affordability and accessibility, among others. SPSS (version 24) was used, and reliability and validity tests were done. Principal component analysis with Varimax rotation method was done.
Results: There were four constructs from 15 observed variables with a cumulative variance of 55%. Construct 1 had a variance of 31%, and it included variables such as trust in hospital and doctor, infrastructure, diagnostic facilities and ancillary programmes. Construct 2, with a variance of 8.9%, had accreditation, academics and research. Construct 3, with a variance of 7%, had information seeking through the Internet and easy accessibility. Construct 4 had a variance of 7% with health insurance and a suggestion from a neighbour/family or from a friend. Nearly 64% of the patients in the study group travelled more than 100 km.
Conclusion: The most influential factors for choosing a hospital are trust in hospital and doctor, along with infrastructure and ancillary services, followed by certified standards of care and academics and research. Surprisingly, the distance was not a deciding factor in the majority, nor was empanelment with insurance companies.
Keywords: Accreditation, choosing hospital, India, Joint Commission International, National Accreditation Board for Hospitals and Healthcare Providers, patient's choice
|How to cite this article:|
Bojanapu S, Mathur M, Jacob J, Sharma A, Nundy S. Patient preference for a particular hospital: A prospective questionnaire-based investigation from India. Curr Med Res Pract 2020;10:260-5
|How to cite this URL:|
Bojanapu S, Mathur M, Jacob J, Sharma A, Nundy S. Patient preference for a particular hospital: A prospective questionnaire-based investigation from India. Curr Med Res Pract [serial online] 2020 [cited 2021 Jan 19];10:260-5. Available from: http://www.cmrp.org/text.asp?2020/10/6/260/304826
| Introduction|| |
A patient's choice of a private healthcare provider occurs after he or she actively seeks information about its quality and compares its possible costs to the benefits it might yield. Consumerism permeating into healthcare and economics playing a more significant role in the private healthcare sector, patients now seek information such as returns on investment in the quality of care provided by different providers and make a conscious decision based on that information.
Healthcare delivery in India is an amalgam of high-tech, multi-storeyed structures catering to international tourists seeking medical care on one end of the spectrum, and, the another end, we see deficient basic healthcare facilities in the remote corners of rural India. This enormous diversity in India is the result of the prevailing literacy, affordability, geography and accessibility. These are the pillars on which healthcare delivery occurs.
In the USA, hospitals are ranked based on credible data-driven specialty rankings that are available in the public domain with various parameters including teaching status, affiliation to medical school, bed strength, and available technology. These, in previous studies, have helped patients choose particular healthcare centres for their treatment., There is a lack of such data and reliable rankings in India, and, in the absence of a similar investigation here, we decided to find out which factors influenced a patient to choose a particular healthcare provider to consult.
We studied the factors which influenced a patient's decision to seek medical attention in our not-for-profit tertiary care centre in India.
| Materials and Methods|| |
Using a prospective, questionnaire-based, cross-sectional investigation, all consecutive patients or their caretakers who attended the outpatient department as well as those who were admitted to the Department of Surgical Gastroenterology and Liver Transplantation (Unit I), Sir Ganga Ram Hospital, New Delhi, India, between January 2019 and August 2019, were provided with the questionnaire by non-doctor colleagues, and the information was collected. There was no restriction on demographics. The questionnaire had two categories. The first category sought a survey of the patient demographics such as their age, gender, place of residence, and level of education. The second category was divided into four sections, with each having multiple items. The sections were reputation, infrastructure, cost, and others, comprising a total of 16 items. Each item sought the respondent's response on a Likert scale from 1 to 5, with one depicting having no influence at all on decision-making and 5 being hugely influential. The sample size was calculated based on Comrey and Lee sampling guidelines wherein for conducting an exploratory factor analysis with various sample sizes, a sample size of 300 was considered good, 500 as very good and ≥1000 as excellent. In this study, a total of 400 responses were collected, which is good. SPSS version 24 (IBM, New York, United States) software was used for statistical analysis.
| Data Analysis and Results|| |
The study questionnaire was administered amongst a total of 400 consecutive respondents, and all completed it voluntarily. The collected data of the 400 patients were entered in a spreadsheet, and their responses were coded for further analysis. The demographic characteristics are presented in [Table 1]. A reliability test was conducted before applying factor analysis using Cronbach's alpha test. [Table 2] shows the Cronbach's alpha for the 15 different items, which was found to be 0.797, characterising the reliability of data for analysis.
Before applying the factor analysis, the Kaiser–Meyer–Olkin measure of sampling adequacy was computed, and it was found to be 0.85, more than the recommended value of 0.6 to perform factor analysis. Bartlett's test of sphericity was performed, and the correlation matrix was found to be statistically significant (P < 0.001) [Table 2]. Principal component analysis with Varimax rotation method was used to reduce the variables to the representative constructs. The factor analysis started with 15 observed variables, and, after the analysis, four constructs were found. The four constructs accounted for 55.2% variance in the data and had an Eigen value of more than 1, as shown in [Figure 1] and [Table 3]. The constructs with % of variance and loading values are shown in [Table 4].
| Discussion|| |
Growing health awareness due to improvement in literacy, growth in purchasing power and also the massive amounts of information on the Internet and social media has resulted in a flood of information available to patients. This purportedly makes it easier to make the right decision. However, much of this information may be incorrect and misleading.
However, now, most patients do search for supportive information before seeking specialist/hospital services for their illness. From the era of no choice to the present where patients as 'consumers' can choose healthcare services, in the large private healthcare sector in India, to which 80% of the population goes, there is still limited access to reliable information. This country has a different societal structure from that of the West, and we live in tightly knit communities and tend to seek many opinions before deciding on buying any commodity. We were interested in investigating which sources of information influenced our patients most in their choice of a healthcare provider and hence this study.
Age/gender/place of residence/qualification
In a study conducted in a metropolitan city by Ghosh, 66% of the patients were aged between 26 and 55 years, and, in this study, 55% of the patients belonged to that age group. Chauhan et al., in their study in northern India, found that 44% of the patients were in the age group of 31–50 years. However, in this study, it was 35%. In this study, patients aged between 51 and 60 years formed 23% of the whole group. That can be explained by the geography of the study and also, the ailments for which patients go to the hospital and hence is divergent. In addition, because this study included inpatients, and generally an elderly group, we found patients to be of later age. We found that the mean age of patients seeking healthcare services within this study was 48 years, similar to a study by Manning et al., which was done in Chicago for finding a foot and ankle surgeon.
In the present study, we found that the gender ratio was 1.4:1 (M:F, 234:166), and the discrepancy was higher in a survey by Ghosh at 2.6:1 (M:F, 164:61), which was also done in a metropolitan city of India. In other Indian studies,,, gender was not specified.
Indian studies show that distance from the residence had a low impact on patients choosing a hospital. Musunuru, in his study, showed that only 17% of the patient location of the hospital had an influence. However, Ghosh and Chauhan et al. found 11% and 9% variance in their studies, respectively, and the variance in the present study was 6.9%, re-iterating that distance from residence does not bear a significant influence when choosing a hospital. This is a stark contrast to the Western studies as shown by Tai et al. wherein 60% of the patients opted a hospital nearby to their residence. Moreover, in a study by Birk and Henriksen, patients were willing to wait longer for surgery than get a re-referral for the hospital which is far away and have a shorter waiting list. An important finding in this study was the distance travelled by the respondents, with a third of the patients coming upwards of 500 km to seek treatment in this hospital.
Regarding educational qualifications, 20% of the patients had only schooling, 45% had done their graduation and 35% were postgraduates. In contrast, in a study done by Ghosh in a metropolitan city, 53% of the patients were graduates and 23% had done only schooling.
Construct 1 – Infrastructure
Infrastructure including cleanliness; diagnostic facilities such as computed tomography, magnetic resonance imaging and other advanced medical equipment; therapeutic equipment for radiotherapy; and vehicle parking have a vital impact, which has been proven in various studies done in India,, and elsewhere. As a patient seeks a hospital only if the needed facilities are present, infrastructure, especially medical equipment, becomes a major influencing factor in choosing a hospital.
In a study by Dubey and Sharma, 156 completed responses were evaluated and it was found that the most influential factors in choosing a hospital were punctual staff, publicity, hospital location near home, 24-h service, good-condition equipment, good approach of doctor to patient, confidential treatment and quality specialist. Similar factors were found influential in deciding on a hospital in the present study.
In another study by Chahal and Kumari conducted at a public hospital in northern India with 400 inpatients across general speciality departments, it was found that service quality, trust, price effectiveness, diagnostic facilities and physical environment were influential in choosing a hospital. However, as the study was conducted in a public hospital, it would not account for the choices of an economically well-to-do patient who would seek treatment from a speciality hospital at a different geographical place – for instance, diabetic patients seeking treatment from an endocrinologist. Furthermore, patients seeking treatment at a public healthcare facility may not have subscribed to health insurance or are unable to afford an expensive treatment at a private hospital. Hence, the study may not be representative of a large section of affordable patients seeking healthcare facilities, wherein patients pay and request services from a hospital. In that dimension, the present study is more representative.
Chauhan et al. in their study comprising 258 patients from government and private hospitals re-iterated the importance of infrastructure, cleanliness, the reputation of hospital, lab facilities and cost of treatment, among others, but also substantial were the availability of banking facilities, food joints and mode of payment, which had influenced a patient to choose a particular hospital, which was not studied in the previous studies. However, this study was conducted on outpatients, and medical insurance may not be a deciding factor in such a scenario because inpatient treatment costs are invariably higher when compared to that of outpatient services. It more so happens that patients pay from their pocket to seek an opinion from a trusted doctor and then opt for an inpatient service at a hospital where insurance is covered, for instance, knee replacement or cholecystectomy. In this study, we have included both inpatient and outpatients and hence this brings a more accurate sample and results.
In this study, we found that ancillary services, such as post-discharge services including wound care, stoma care, physical rehabilitation and intravenous medication, which are provided at a patient's residence, would decrease frequent travelling to the hospital after discharge for these services and are among the essential factors which influence a patient's choice for a hospital. There have been no studies done in India with these factors included, and this study adds to the present literature.
Doctor, expertise, trust in the hospital and ethical practice
The doctor–patient relationship has evolved from the priest–seeker relationship from the Egyptian practices to the 18th-century practices, where the supremacy of doctors was established, and the paternalistic nature of relationship existed, to the present times where there is mutual participation of both the patient and the doctor in addressing various health issues. Although this is a subjective factor and cannot be equated with other studies, it has a significant influence on decision-making. In a study by Ansell et al., 57.8% of the respondents cited the high quality of care provided for choosing the hospital. In the present study, trust in the hospital's ethical practices and belief in a particular healthcare provider were found to be the major influencing factors in 79% of the patients choosing a hospital.
Result of prior experience
Loyalty to the hospital is a significant factor influencing a patient's decision, especially more so when they are getting treated in the same hospital for some other ailment. In the present study, 58% of the patients' decision was due to this, indicating that they have had some sort of treatment from same the hospital before the visit. In a similar study done in India by Musunuru, 40% of the patients chose a hospital based on their clinical experience. These were similar to the findings in the research done in the USA by Ansell et al. and Jung et al.,
Construct 2 – Standards and recommendations
Objective standards are deficient in the Indian healthcare set-up and to certify a certain standard-of-care delivery, accreditation is provided by the National Accreditation Board for Hospitals and Healthcare Providers (NABH) and Joint Commission International (JCI) after a thorough inspection of various parameters of the hospital. In addition, we found that accreditation bodies such as NABH and JCI and academic research has some influence on choosing a hospital with 8.9% of the variance and is a new factor that has not been studied so far in other studies. These would be the factors on which patients are going to choose a hospital in the absence of hospital-wise rankings available to the patients, as in the West.
Academics and research
A Spanish study showed that institutes that conduct research, either basic or clinical, have a positive effect on hospital efficiency, and, with more knowledge of scientific publications, hospitals will be better at diagnosis and treatment. In the present study, accreditation for standards and academics with research had influenced the patient's selection of hospital. This factor was not studied in any of the Indian studies. However, in the West objective, rankings and hospital statistics are widely available which help a patient to choose a particular hospital. Also, this applies to private institutions and not public healthcare due to a vast shortage of them, and hence many patients do not have a choice for public healthcare setups.
Construct 3 – Information on the Internet and advertisements
Still, hospital search on the world wide web is not an influential factor in choosing a hospital, which is in contrast to consumer behaviour for other commodities or services. This may be due to ethics prohibiting advertisements by doctors, and hence not much direct information is available on the world wide web for choosing a doctor.
Surprisingly, in contrast to other studies where travel time and distance were important factors that influenced a patient to chose a hospital, we in this study found that distance or travel time was having the least influence in selecting a hospital.
Construct 4 – Insurance and suggestions by known people
Having empanelment for health insurance is an important factor that influences a patient's decision to choose a hospital. This was found in studies done by Chauhan et al. However, in this study, insurance availability did not have a high % variance, with 61% of the patients having no health insurance in the studied patient cohort and were paying from their pockets.
| Conclusion|| |
We conclude that traditionally well studied factors such as trust in doctor and hospital, good infrastructure, availability of expertise and affordability are still the most important factors based on which patients choose a particular hospital. However, the availability of insurance and distance from residence do not bear a strong influence on deciding a hospital. A new finding in this study is that factors such as accreditation status, research and ancillary services, also influence a patient in choosing a particular hospital.
There are some limitations to the study in that the questionnaire was provided to patients of only a particular unit of the department. This study involves only a section of patients who could afford treatment in a private hospital. Patients who had come for a revisit or on regular follow-up were not identified. Patients admitted as an emergency were not included.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]