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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
The complexity of measuring patient priorities
Would the UK NHS patients really considering paying for performance?
Expectations of patients.
Why patients attend private clinics? willing to pay for!
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Carolyn C Tarrant, Leicester, UK Department of Health Sciences, University of Leicester
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Understanding patients’ priorities is essential in designing services to meet patient needs and desires, and the discrete choice method is clearly a useful and powerful tool for measuring priorities (1). However, if information about patients’ priorities is to be used to inform service design and provision, we need to be aware that measuring attribute importance is a complex issue with many unresolved questions. Cheraghi-Sohi et al (1) acknowledge in their paper that discrete choice methods can be criticised for not reflecting patients’ choices and priorities in ‘real life’. The discrete choice method rests on assumptions of rational choice; the authors’ tests of this assumption showed that while most respondents made consistent choices, a substantial proportion were unwilling to trade between attributes. In reality people’s decisions are often based on habit and heuristics (cognitive ‘shortcuts’), rather than a weighing up of alternatives. In addition, patients’ priorities in reality may depend on their expectations or experiences of the services available. For example, technical quality of care emerges as a pivotal attribute from the discrete choice study, but if in ‘real life’ patients assume there is little variation in technical quality, they may instead place more weight on other attributes which vary more between different service providers. If service delivery is designed solely around the priorities identified through experimental studies such as discrete choice studies, then this may not acknowledge and reflect the priorities that people actually have in accessing and evaluating services. The discrete choice method is one of many methods of identifying patients’ priorities, others include open-ended questions and rating of attributes. There is evidence that the type of method used can influence the order of ranking of priorities (2), and different methods may tap into different dimensions of importance. There are at least three different dimensions of attribute importance: salience (how immediately an attribute comes to mind), relevance (how well the attribute fits with an individual’s values and desires), and determinance (an attribute’s contribution to choice) (3), with discrete choice analysis argued to measure determinance. It may be that different methods of measuring the importance of service attributes are appropriate in different contexts, for example, in measuring patients’ priorities when they make consulting decisions, as compared to when they evaluate the quality of their care. These complexities highlight the need for a clearer understanding of how patients actually formulate their priorities in real life, and how their priorities impact on their consulting decisions and their evaluation of care. This would provide a valuable context within which to interpret the findings of empirical studies. 1. Cheraghi-Sohi S, Risa Hole A, Mead N, McDonald R, Whalley D, Bower P, Roland M (2008). What patients want from primary care consultations: A discrete choice experiment to identify patients’ priorities. Ann Fam Med; 6:107-115. 2. Phillips KA, Johnson FR, Maddala T (2002). Measuring what people value: A comparison of "attitude" and "preference" surveys. Health Services Research;37(6):1659–1679. 3. Myers JH, Alpert MI (1977). Semantic confusion in attitude research: salience vs. importance vs. determinance. Adv Consum Res;4:106–110. Competing interests: None declared |
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Edoardo Cervoni, Southport GPwSI (ENT) - Central lancashire PCT NHS
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Sir, The paper from Sudeh Cheraghi-Sohi and Colleagues is both original and informative. Yet, it fails to tell the reader about the characteristics of the non-responder group, which accounts for more than 40% of patients interviewed. Also, the paper moves from the assumption that patients would be honestly consider paying cash for the performance. This is debeatable as it is unrealistic that the UK NHS patient would be ready to pay for Primary Care Medical Services. In fact, practical business experience tell us that this is not the case troughout the UK, with the exception, maybe, of London City. Overall, I feel to subscribe the caveat from Dr Gurinderpal Singh. Finally, I would welcome a study on how patients would assess technical care. I would be not surprised to be told that good techinical care impression is the result of having received a physical examination, with no relationship to the semeiotic skills of the examiner (ergo, physical contact), and good bed-side manners. Competing interests: None declared |
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Gurinderpal Singh Khaira, Nevada, USA Clinical Assistant
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I would like to discuss my personal views regarding this topic. Well I am graduate from south asia where I worked in county hospital for two years before moving to United states and had opportunity to work as assistant in family pratice clinic as well as simultaneously I am pursuing my carrer goals. I was able to observe the difference in methodoly of practicing Medicine in this country. I strognly believe that to reaching a diagnosis and working it out in primary care practice is certainly a major factor in satisfaction of patients, but I would like to add that the time physician spends with patient explaining things in clear as well as simple manner, also has great contribution to overall expectations satisfaction of patient. It goes in long run to contribute better compliance and hence a better health. I have witnessed instances where the patient health lagged not becuase of lack of expertise and professionalism ,but simply due to commuication gap as well as the time factor spent with each individual. Competing interests: None declared |
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Khalil R H Al-Yousifi, Kuwait, Kuwait Private sector Family Practitioner
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My comment is not based on a study, but based on my experience, being a practicing doctor for more than 24 years and having a private medical center. The title of my comment seems to be different than the topic but it is 100% related because our Health System in Kuwait is different than the Health System in the U.K. I will list the reasons (in order of importance) why patients in Kuwait attend private clinics and centers despite Health Services provided for free to citizens, and the topic "What Patients Want from Primary Care Consultations" applies to primary care and to specialized clinics alike: 1-Technical Quality of care, patients go to a doctor that is well known for his clinical expertise or technical (surgery), so it is the quality of care which is most important. 2-The ability to get early appointments in private clinic and according to patients' own agenda (convenience) rather than waiting for a long time to see the doctor or even bothering to get a referral and then getting appointment and so on, and this applies to laboratories, surgery (operations), endoscopies and so on. 3-For accessory Health Services such as Plastic surgery, Lasik sight correction, laser, Botox and so on, which explains why most of private sector at tenders are FEMALE. 4-Lack of trust on the quality of care provided by governmental health services, and this applies sometimes to the drugs prescribed (generic brands). So patient expects excellent technical quality of care because they are not attending primary care clinics to make friends with doctors or to chit chat, they want to solve their health issues, then there is no problem and should (doctors) establish a good and solid patient doctor relationship, because without this relationship and trust doctors will not be able to attain a good medical history which is very important in quality of care (to reach the correct diagnosis and management plan). Even this relationship will impact your patient compliance with your management plan. Of course all of us want to get our jobs done as soon as possible which include solving our Health problems to alleviate the anxiety of waiting to know what is wrong. Bottom line, it is the technical quality of care that is important, that is what patients hold most precious about you as a doctor, praise, talked about in front of their family and friends, not your lovely smile, neck tie and the young generation doctors HAIR GEL (which I have to admit they are important but as a second line). Competing interests: None declared |
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