Physicians Often Choose Surgical Facility for Patients

BY DIANA MAHONEY

Many patients who undergo major surgery do not decide where their operations will take place, a study has shown.

Nearly one-third of 510 randomly selected Medicare patients who had undergone elective high-risk surgery said that their physician was the main decision maker, reported Dr. Chad T. Wilson of the Veterans Affairs Medical Center, White River Junction, Vt., and colleagues (Arch. Surg. 2007 March;142:242-6).

In light of recent efforts by government agencies and patient advocacy groups to distribute hospital performance data directly to consumers to help them choose a facility, the degree to which patients assume an active role is especially relevant, the authors wrote. The investigators analyzed national data collected as part of a larger 2004 telephone survey in which patients were asked how they chose a hospital, what their perceptions were of the hospital and surgeon, and what factors influenced their choice.

SINCE THE PHYSICIAN OFTEN DECIDES FOR MANY PATIENTS, THE QUESTION IS WHETHER PATIENTS ARE AS INVOLVED AS THEY WOULD LIKE TO BE.

The authors wrote that the survey focused on patients who had undergone elective procedures because such patients could theoretically choose a hospital. The Medicare population was targeted because more than half of all patients undergoing major elective surgery in the United States are covered by Medicare.

All of the surveyed patients had undergone surgery within 3 years of the study. The mean patient age was 78 years; 68% of the population were men. Of the 510 patients, 103 underwent abdominal aneurysm repair; 96 had heart valve replacement surgery; and 119, 128, and 64 had resections for bladder, lung, or stomach cancer, respectively.

According to the survey results, 31% of the patients said their physician decided where their surgery would be performed, 42% said their input was equal to that of their physician, 22% reported being the primary decision maker, and 5% said the decision was made by a family member.

The patients who reported that their physician was the primary decision maker were more likely to be men, to be in overall poorer health, and to be more acutely ill than those who took a more active role in selecting a hospital--findings that are consistent with other work exploring general decision-making styles, the authors wrote.

A review of the selection process by surgery type showed that the physician drove the choice of hospital for 39% of patients who underwent cardiovascular surgery, and for 26% of patients who had cancer surgery.

Hospital location and consumer behavior also were factors in the decision. Patients who were less than an hour's drive from the hospital were more likely than patients who lived more than an hour away to report the physician as the main decision maker, as were patients who expressed little interest in taking an active consumer role and those who sought no comparative information on hospitals, the authors noted.

The findings have important implications for policy makers interested in helping patients make informed choices about surgeons and hospitals.

"First, the fact that two-thirds of our respondents said they were involved in deciding where to have surgery helps validate a key assumption underlying the public dissemination of performance data, namely, that patients will adopt an active decision-making role," the authors wrote.

And the finding that the physician is the main decision maker for a substantial proportion of patients raises the question of whether patients are as involved in choosing a hospital as they would like to be, according to the authors.

They concluded that, while some patients might not want an active role, "it is also possible that these patients may have wanted a greater role in the decision-making process but were unable to participate more," either because the choice was imposed on them or because they lacked the information they needed to participate.

Dr. Wilson is now at Massachusetts General Hospital, Boston.