Researchers in England have shown that around one third of women with breast cancer choose not to undergo surgery at their closest hospital, with patient choice often based on the reputation of the hospital or surgeon rather than the quality of care.
Women who were younger, without additional medical conditions, of White ethnic background, or who lived in rural areas were also more likely to travel to more distant hospitals than their counterparts. The investigators believe that the introduction of patient choice policies may be driving inequalities in the health care system without improving patient outcomes.
“Policies allowing patients a choice of where they are treated have been introduced across many high-income countries including the US, UK, and many parts of Europe,” first author Dr Ajay Aggarwal, Professor at the London School of Hygiene & Tropical Medicine in the UK, told Inside Precision Medicine.
He explained: “These policies are meant to make the health system more responsive to patients but also drive quality as those centers losing patients from their local catchment area to other providers are expected to improve their quality to retain patients. In addition, all patients irrespective of their age, ethnicity, socioeconomic status should be able to make choices regarding their care.”
Aggarwal and colleagues investigated factors that influence patient choice and travel among 101,750 patients diagnosed with breast cancer within the English National Health Service (NHS) between 2016 and 2018. The NHS is a publicly funded, single‐payer system in which, in principle, patients can select any hospital providing cancer treatment.
The researchers report in Cancer that 32.7% of 69,153 patients undergoing breast-conserving surgery and 30.5% of 23,536 undergoing mastectomy without reconstruction bypassed their nearest surgical center and had treatment further away from home. For the 9055 patients undergoing mastectomy with immediate reconstruction, the proportion was slightly higher, at 43.2%.
Travel time impacted patient choice, with the likelihood of bypassing the local treatment center decreasing rapidly with additional travel time. Yet the team found that women undergoing BCS were still 1.9 times more likely to be treated at specialist breast reconstruction centers than their nearest hospital despite not undergoing breast reconstruction. Similarly, women undergoing mastectomy without breast reconstruction were 1.5 times were more likely to be treated at specialist breast reconstruction center, while those receiving mastectomy and immediate breast reconstruction were 5.5 times more likely to choose a specialist center.
Hospital quality rating, research activity, breast re‐excision rates, or the status as a multidisciplinary cancer center had no significant impact on the choice to travel further for treatment but women receiving mastectomy and immediate breast reconstruction were a significant 2.4 times more likely to travel to hospitals employing surgeons who had a strong media reputation.
“Information asymmetry is one of the major issues in most healthcare markets,” said Aggarwal.
“Rather than quality and experience driving patient choice, we see that reputation of hospitals or clinicians and the availability of technology are major drivers which are no guarantee for quality.”
He added that although people with always have access to popular media, “more work can be done by government agencies/insurers to provide high quality comparative data on hospital outcomes and patient experience of care to inform choices. At present there is little accredited data available publicly.”
Interestingly, patients were not more likely to choose hospitals with shorter waiting times, which Aggarwal suggests could be because they place greater importance on other aspects of quality, i.e., they are more willing to wait for treatment at centers they perceive to be better and more likely to treat their cancer more effectively.
The of the study co-authors had lived experience of breast cancer. Based on their own experiences and the study findings, they created seven recommendations for supporting patient choices regarding treatment location. “These offer pragmatic solutions to support patients during their cancer journey so that they can get reliable and evidence based information to make important choices about their care,” Aggarwal remarked.
The recommendations include giving all patients access to a named breast clinical nurse specialist to help guide them through their options, providing greater clarity on the types of available breast procedures and the skills and training breast cancer surgeons require to perform these, and providing more transparent information on care quality, including re‐ excision rates for the hospitals and individual surgeons, as well as measures of patient experience.
The authors also say that patients should be supported to make choices that work for them, which may include the provision of accommodation and transport to receive the care they require.
The data show that “choice policies can widen pre-existing inequalities in the health system without necessarily resulting in patients receiving better care,” said Aggarwal. “Policy makers and providers need to ensure patients have access to fair, robust and relevant information on care quality and provide patients with the means (transport and accommodation) to support their choices. This would also create the required incentives to drive improvements in quality which health care markets seek to achieve.”
