Around one third of breast cancer patients in the UK choose to bypass the nearest hospital offering cancer surgery to receive care at a more distant one, according to a new national study in the journal Cancer.
Patients’ choices are often driven by surgeons’ media reputation, availability of specialised services that they don’t need or use, sociodemographic factors. Younger, healthier, and patients of a White ethnic background are more likely to travel to hospitals farther away. Quality of care did not stand out as a determinant of treatment location.
The result is “an ineffective market that does not improve the standard of care or achieve equitable outcomes”, said principal investigator Ajay Aggarwal, MD, of the London School of Hygiene and Tropical Medicine in an interview with Medscape News UK.
Study Background
The picture painted by the new study is decidedly different from what was envisioned by the 2008 shift in NHS policy to give patients their choice of provider. The goal was to achieve more efficient, quality-driven, and equitable healthcare.
The study was undertaken because “little was known about decisions where breast cancer patients obtain care and why they decide to receive care there”, said Aggarwal. The finding that one third bypass their nearest hospital is far higher than the expected rate of 5%-10%, he observed.
The study was of all 102,000 breast cancer patients across the UK who underwent breast conserving surgery or mastectomy (with or without immediate reconstruction) from 2016 to 2018. Nearly 57% had stage I cancer. The study used geographic information system software known as ArcGIS to trace the extent to which patients bypassed their nearest hospital to access surgical care. It also examined patient characteristics and hospital quality in relation to patient mobility. “Patient mobility was an indicator of patient choice,” said Aggarwal.
Among the indicators of a hospital’s quality were its perceived prestige and media reputation (according to Daily Mail rankings of breast cancer surgeons), whether the hospital specialised in breast reconstruction, the hospital’s overall performance ratings by the UK Care Quality Commission (from inadequate to outstanding), and the hospital’s breast conserving surgery re-excision rate.
Media Reputation as a Deciding Factor
Women receiving breast conserving surgery were almost twice more likely to choose care at specialty breast reconstruction centres even though they don’t need breast reconstruction. Similarly, women receiving a mastectomy without immediate reconstruction were 1.5 times more likely to receive care at such a specialty centre.
Patients were not more likely to opt for hospitals with lower breast re-excision rates, a strong indicator of quality, or to opt for hospitals with more active research programs, or with better overall performance ratings. For example, more than 50% of all patients chose hospitals whose overall performance was ranked as “requiring improvement”, whereas only 5%-10% chose hospitals ranked as “outstanding”. Patients with the most complex care (ie, mastectomy with immediate reconstruction) were more likely to choose hospitals employing a surgeon with a strong media reputation.
These findings collectively suggest that “patient hospital choice primarily seems to be driven by other factors than ‘true’ quality differences”, said Marco Varkevisser, professor of market regulation in healthcare at the Erasmus School of Health Policy & Management in the Netherlands, speaking to Medscape News UK. Varkevisser was not involved in the study.
Transparent Information on Quality Needed
The study provided a list of seven recommendations to improve the exercise of patient choice. The recommendations were made by three study co-authors, themselves breast cancer patients.
The foremost recommendations are to provide “more transparent information about quality of care in a meaningful format for patients to understand”, said Aggarwal, and to provide transportation to quality care and accommodation (ie, more time off work) for patients who are elderly, less healthy, less affluent, or from non-White backgrounds.
The recommendations, observed Varkevisser, “clearly illustrate that patient choice policies require publication of standardised information on treatment options, clinical outcomes, and patient experiences; and support for vulnerable groups”.
Richard Sullivan of King’s College London and Guy’s Comprehensive Cancer Centre, also not involved in the study, remarked that, “The recommendations at the end of the paper are to be commended and … help policymakers understand that real evidence is needed on patient journeys/pathways in order to design the right services and the right intelligence to guide rational decision making.”
The study was supported by the National Institute for Health and Care Research. Aggarwal reported grants/contracts from the National Cancer Institute outside the submitted work. Co-author Joanne Taylor reported honoraria and/or support for travel to attend meetings for patient and public involvement activities from Novartis, Gilead, Veracyte, and Greater Manchester Breast Pathway Board outside the submitted work. The remaining authors declared no conflicts of interest.
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