Agency in health care. Examining patients' preferences for attributes of the doctor–patient relationship
Introduction
In analysing the agency relationship in health care, health economists have tended to ignore the `black box' of the doctor–patient relationship. Recently, attempts have been made to re-examine the nature of this relationship (Mooney and Ryan, 1993; Ryan, 1994) and there has been some suggestions as to what patients might want from the doctor–patient relationship in terms of involvement in decision making and in addressing asymmetry of information in the doctor–patient relationship (Williams, 1988; Evans, 1984). Furthermore, economic theory has placed great weight on informed consumers making their own decisions about the goods and services they purchase. However, there have been suggestions that consumers of health care services may experience disutility from being involved in decision making about the treatment of their health problems (Shackley and Ryan, 1994).
Although there has been no empirical work by economists on these issues, there is a diverse non-economics literature examining the nature of the doctor–patient relationship in general practice. Amongst a variety of attributes that have been shown to be important in the general practice consultation, are the extent to which patients are involved in decision making and the amount of information that is transferred from doctor to patient (and vice a versa) (Williams and Calnan, 1991). Attributes of the doctor–patient relationship have been shown (a) to have a greater influence on overall patient satisfaction with general practitioners (GPs) than attributes related to the organisation of general practice care, e.g. opening hours, convenience etc. (Haigh Smith and Armstrong, 1989; Williams and Calnan, 1991; Calnan et al., 1994; Rees Lewis, 1994); and (b) to influence compliance and the health outcomes of consultations (Kaplan et al., 1989; Wartman et al., 1983).
The analysis of the doctor–patient relationship is also relevant in the context of current health policy where fixed budgets have been given to doctors in primary care (for example, the introduction of GP fundholding in the UK and Health Maintenance Organisations in the USA). Although fixed budgets have the aim of encouraging doctors to behave more efficiently, they have arguably compromised the nature of the relationship that doctors have with individual patients. Many doctors in primary care now act as `double agents' for the patient and for society (although doctors have always implicitly rationed due to the time constraints of the typical consultation) (Blomqvist, 1991).
Given that the role of an agent is to maximise the utility of the principal (within available resources), then it is important for the doctor to have information about the nature of the patient's utility function. In the context of the doctor–patient consultation, the limited resources available in the consultation (i.e., the doctor's time), and the need to maximise patients' utility, it is therefore important to examine patients' preferences for the various attributes of the consultation.
The aim of this paper is to present the findings of an empirical study of aspects of the doctor–patient relationship in primary care. After identifying the relevant hypotheses to be tested, Section 2presents the method used to test the hypotheses. The results are then presented in Section 4, followed by the discussion and conclusions in Section 5.
Three main hypotheses were identified from the health economics and non-economics literature. These are all concerned about the value patients attach to information and being involved in decision making in the doctor–patient relationship.
Hypothesis 1: patients prefer to give the doctor information about their health problem, relative to not giving this information.
Hypothesis 2: patients prefer more information to less about the effects of different treatments on their health status and about their health problem.
Hypothesis 3: patients prefer to be involved in decision making, rather than the doctor choosing on their behalf.
These factors may also interact with one another, suggesting a further three hypotheses.
Hypothesis 4: respondents value having a choice more highly if they also have some information on which to base their choice.
Hypothesis 5: choice is valued more highly if the information is understood.
Hypothesis 6: a little information that is explained well is valued more highly than lots of information that is difficult to understand.
Section snippets
Method
This study was conducted in a general practice in Aberdeen. A questionnaire was distributed by receptionists to 160 consecutive attendees between the ages of 16 and 70 yr old. Parents or guardians attending with children were also asked to complete the questionnaire. A prepaid envelope was provided for respondents who wished to complete the questionnaire later.
In the questionnaires, conjoint analysis was used to present individuals with hypothetical scenarios that differed with respect to the
Econometric model
The dependent variable was whether the respondents chose visit A (0) or visit B (1) in each discrete choice. The values of independent variables (Table 3) were the differences in the levels of each attribute between visit A (constant throughout) and visit B. For example, a move from `a lot of information' (coded as 1) to `a little information' (coded as 0) means that the value of the independent variable for this attribute is −1.
A random effects probit model was used to analyse the data, where
Results
Of the 160 questionnaires handed out, 101 were returned (63%). The mean time taken to complete the questionnaire was just over 10 min. This was not influenced by age, sex, or education. Close to eighty percent of respondents found the questionnaire `OK', `quite easy' and `very easy' to complete (distribution of 43%, 19%, and 15% respectively). Nineteen percent found it `quite difficult' and two per cent `very difficult'. For those questions where there was one obviously dominant option, between
Discussion
Although economists have began to analyse the agency relationship in health care, there has been no empirical work using economic techniques. The aim of this study was to examine the value that patients attach to various attributes of the general practice consultation. The first hypothesis, that patients prefer to give the doctor information about the contents of their utility function, relative to not giving this information, is supported. Above all else, patients preferred the GP to listen to
Acknowledgements
The authors would like to thank Dr. John Duncan, of the Westburn Medical Group, for permission to pilot the questionnaire. Useful comments were also provided by Mandy Ryan, John Cairns, Cam Donaldson, Warren Greenberg, Jane Hall and two referees. HERU is supported by the Chief Scientist Office of the Scottish Office Department of Health (SODH). The views expressed in this paper are those of the authors and not SODH.
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