Background
Health care reform is widespread among Western countries in search of more efficient health care provision. While countries with private payers like the Netherlands introduced a form of managed competition, other countries with a public payer system like the United Kingdom (UK) introduced elements of provider competition. Regardless of health care system, recent health care reforms stimulate providers to compete for the benefit of the patients. To achieve this goal provider quality needs to be transparent. Public reporting of provider quality can enable quality improvement at the provider and system level. Providers may use the information to improve processes and results. Patients, payers, and referring professionals such as general practitioners (GPs) may use the information to select providers, and thus shifting capacity towards the high quality providers.
Much is expected from GPs, who know their patients' conditions and circumstances, are able to evaluate quality information and know their patients place great trust in their advice. Consequently, policy makers in different countries are strengthening the position of GPs to allow them to guide the patient to the appropriate hospital. For instance, within proposed NHS reform the GP consortia will commission the majority of care for their patients. Also in the US initiatives such as 'Medical Homes' are introduced, where primary care physicians are expected to take on the responsibility for coordination of care, which includes referring people to the right provider. In the Netherlands, quality information about hospitals became public, to allow patients and GPs to choose hospitals based on objective indicators.
Previous studies show that patients may experience difficulties interpreting quality information on report cards. This may be one of the factors that providers that perform well on report card metrics do not attract more patients even if they outperform other providers on public metrics for consecutive years. GPs know which outcomes are important for patients and what processes may lead to these outcomes. Consequently, they are well equipped for judging the meaning and relevance of quality information. In addition, research shows that in the Dutch context GPs have significant influence in directing patients: 68% of patients who searched for information to select a hospital, state that they determined their choice for a hospital based on the advice of their GP. This percentage is likely to be higher for patients that do not seek information. This puts GPs in the driving seat, and the success or failure of competition on quality depends largely upon the extent to which GPs use quality information to refer patients.
In this study we investigate to what extent GPs are influenced in their hospital choice by using report cards with quality indicators on medical effectiveness and patient experiences for the conditions: breast cancer, cataract surgery, hip and knee replacement when referring patients to hospitals.