The role of information in choosing the right hospital

In the case of choosing a hospital, simply having all the information available is no guarantee that patients will make an informed decision.

When it comes to information, quality is more important than quantity.

The King's Fund Director of Policy, Anna Dixon, and senior fellow Tammy Boyce, together with Barbara Fasolo of the London School of Economics and Elena Reutskaja of IESE, examined the ways that organizations can help patients make better use of information about clinical quality when deciding which hospital to go to.

Based on a year-long study using focus groups and a series of online experiments, the report makes several useful recommendations for information providers.

In the case of hospital choice, people do not have firm or stable preferences about what is important to them. There is a tendency to choose convenience over clinical quality. Yet, as the research shows, it is possible to guide people toward making a choice that puts quality considerations first.

The researchers designed an interactive website in which people were presented with information about different hospitals and had to choose which hospital they would go to for elective routine surgery. The authors studied the effect of several different decision aids, or "nudges," which could help people to pay more attention to information about the clinical quality of services, and use this information to choose a hospital.

Presentation makes a difference

In the online scorecard designed by the researchers, the quality measures were listed first. These ended up being viewed most frequently, indicating that the order in which information is presented makes a difference.

For example, the researchers thought that by sorting the options in order of quality, patients might be more inclined to choose the highest quality hospital.

However, it actually resulted in people making worse choices. In fact, those who had the options presented by distance did better.

Sorting can have perverse effects, and needs to be carefully tested. Policy makers should also be cautious about patients' ability to make complex decisions based on ratings, unless they receive some form of guidance.

Use of decision aids

The researchers were interested in whether different nudges can improve the choices people make, how satisfied people are with the choice they made, and whether nudges can help people make more informed choices in future. No nudge performed well on all these criteria.

The researchers focused on three nudges:

• a pre-select nudge, where the highest quality hospital was pre-selected.
• a preference nudge, where participants were asked to rank the indicators before they were presented with the scorecard.
• a feedback nudge, where participants were asked to reconsider their choice if they had not chosen the highest quality hospital.

The pre-select nudge performed worse in terms of choosing the highest quality hospital, but people who had this scorecard did best in terms of making a choice when presented with a similar task a few weeks later, when nudges were not used. The participants who had the pre-select nudge were also quite dissatisfied with their choice, compared with those who had a very simple scorecard, sorted by distance or quality.

Giving people feedback on their selection and asking them to reconsider can increase the proportion that will choose a high-quality hospital, but it does not necessarily help people to make better choices in future, without nudges present.

Making people think about what was important to them in a hospital, and that the quality of hospitals varied, meant that fewer were very satisfied with their choice, and these people did worst when presented with a similar task a few weeks later.

The results also show that nudges have different impacts on different people. The feedback nudge made it more likely that elderly participants would choose the highest quality hospital, but in general, younger participants, particularly those with higher education, appear to have been helped more by the nudges. It appears from the findings that younger participants benefited from information about differences in quality of care and from being made to think about what was important to them before making the choice.

Nudges require the information provider to decide on what they are seeking to nudge people toward, and therefore, a normative decision is inherent.

Reducing anxiety

Exposing people to differences in quality between hospitals and forcing them to consider these difficult trade-offs may actually increase the dissatisfaction they feel with their choice.

Take an extreme example: You are told that you are more likely to die if you are treated at one hospital rather than another. If you are unfamiliar with making hospital choices, the stakes are so high that the decision would generate high levels of stress and anxiety.

Most patients would find it easier to base their choice on other factors such as convenience and waiting times. Therefore, patients could benefit from official information reassuring them that all the hospitals concerned are adequate, even if not top ranked.

If people feel that the differences they have to consider are between "good" and "excellent," they will be less anxious than if they think a wrong decision could put their life at risk.

Practice makes perfect

The research suggests that repeating the task — even just a few weeks later — increased the chances of people choosing a better quality hospital. This applied regardless of age and education. It is likely that younger people are less familiar with health care, so giving them the opportunity to practice making a choice like this increases their awareness of the factors involved.

This builds on the idea of giving people the right information before asking them to make a choice, something that appears to help young people the most. Older people may be more familiar with hospitals, but are perhaps less familiar with the task ? that is, using the Internet to compare products or services. So giving them the opportunity to practice online would also help them to make better choices.

Policy makers and information providers should understand that just making information available on its own will not result in people making informed choices. If choice and competition between hospitals is to raise standards, information providers must present the information in ways that are understandable and useful.

Making people more aware that quality differs, and giving them opportunities to practice making a choice, would appear to help people to make better decisions.