The effects of performance evaluations and trust on popular strategies for dealing with uncertainty about the outcome of critical surgery

Dr Neil MunroLecturer in Chinese Politics

“Violence towards healthcare professionals: an assessment of causes, frequency, prevention and solutions”

University of Chicago Center, Beijing September 17-18, 2013.

School of Social and Political Sciences, University of Glasgow, Adam Smith Building, Bute Gardens, Glasgow G12 8RT. Email: Neil.Munro@glasgow.ac.uk

www.gla.ac.uk/petu

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Key Issue

• Why is there violence towards health care professionals?• Understanding reasons for behaviour is often the key to stopping it.• If widespread, it may point to a crisis in the relationship between the

medical profession and the general public.• Outline

– Key concepts– Data– Survey item: strategies to improve outcome of critical surgery– Independent variables: performance evaluations & trust– Effects on choice of strategy– Implications for understanding violence in health care settings

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Key concepts• Agency dilemma: patients are principals, doctors are their agents.

How can patients ensure that the doctor offers as far as possible the same treatment as they would administer to themselves if they were the patient?

• Exit: a strategy for resolving the dilemma by changing the doctor or health care provider for another one, presumed to be more loyal to the patient’s interests

• Voice: a strategy for resolving the dilemma by speaking or acting to influence the behaviour of the doctor or health care provider

• Particularism: a strategy for resolving the dilemma which helps a particular patient but not others in a similar situation.

– VIOLENCE is a particularistic form of voice-in-action.

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Table 1. Three Dimensions of Strategy  Universalistic Particularistic  Voice Exit Voice ExitProactive Make a

formal complaint

Change provider

Pay a bribe,

Ask the provider to change their decision

Use connections to find another provider

Passive Accept the treatment without resolving the dilemma,Don’t know,

Give up treatment

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Source: adapted from Hirschman, A. O. (1970). Exit, Voice and Loyalty: Responses to Decline in Firms, Organizations and States. Cambridge, MA, Harvard University Press.

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Why use violence?• Violence implies a step change in degree of conflict.• Violence is qualitatively different from other forms of voice. It is a

transgression of universal norms of acceptable social behaviour.• Two kinds of logic can be used to explain it (March & Olsen 1989):

– Logic of consequences (egocentric logic): violence will help me get what I want, and consequences for me are acceptable; therefore, I will use it.

– Logic of appropriateness (socio-tropic logic): there are rules of conduct in my subculture under which violence is regarded as an appropriate response in certain circumstances.

• Performance Evaluations, Trust and Utilization of Health Care in China Survey, 2012-13. Funded by the UK Economic and Social Research Council, Grant No. ES/J011487/1.

• nationwide survey in 31 provinces on mainland China • fieldwork carried out 1 November 2012 to 17 January 2013 • target population: mainland citizens age 18 to 70 residing for more

than 30 days in family dwellings• GPS Assisted Area Sampling Method• Sample of 5,424 dwellings: 3,684 valid interviews • Response rate of 67.9 per cent• More information at http://www.gla.ac.uk/petu

Data

Figure 1 Strategies to Improve Chances of Successful Surgery

B22. If your friend needed a life-saving operation but the surgeon in a public hospital told them that he could not guarantee that the operation would be successful, what would you advise the patient to do? (One answer).

(% replies)

7Source: Performance Evaluations, Trust and Utilization of Health Care in China Survey, fieldwork 1 November 2012-17 January 2013, N=3680.

Figure 2a. Perceived Prevalence of Overprescribing

Source: Performance Evaluations, Trust and Utilization of Health Care in China Survey, 2012-13.

C21. Some people say medical ethics is a big problem in this country, but others say such reports are just exaggerated. Judging from your own personal experience, how likely do you think it is that you would encounter the following types of situations in city or county hospitals around here? a) Prescribing medicines not covered by insurance even when effective alternatives covered by insurance are available.

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Figure 2b. Perceived Prevalence of Taking Hongbao

Source: Performance Evaluations, Trust and Utilization of Health Care in China Survey, 2012-13.

b). …Taking bribes (“red envelopes” or hongbao) for treatment which has already formally been paid for.

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Figure 2c. Perceived Prevalence of Unnecessary Testing

Source: Performance Evaluations, Trust and Utilization of Health Care in China Survey, 2012-13.

c). …Requiring comprehensive check-ups from patients even when the diagnosis is perfectly clear.

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So how do people respond to uncertainty?

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• Dependent variable: which strategy does respondent prefer?

• Key independent variables:• Performance evaluations:

• health system as a whole• skills & competence of doctors

• Trust in health care institutions (global trust)• Perceived likelihood of unethical practices (fidelity)• Comparisons between public & private

• Controlling for: demographics, education, urbanization, hukou, self-assessed health, difficulty paying health bills, local government spending per capita

Figure 3a. Impacts of Odds of Using Voice

Source: Generalized linear mixed model for data in Figure 1, N=3,506.

* Impact on logged risk ratio relative to reference category, computed by multiplying multinomial logistic regression coefficients by the mean of the independent variables. Impacts not significant at .05 level are not shown.

Impact*

Overall satisfactionwith healthcare system

Agriculturalhukou

Local gov’t expenditureper capita

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Figure 3b. Impacts on Odds of Using Particularistic Strategies

Source: Generalized linear mixed model for data in Figure 1, N=3,506

Impact*

* Impact on logged risk ratio relative to reference category, computed by multiplying multinomial logistic regression coefficients by the mean of the independent variables. Impacts not significant at .05 level are not shown.

Overall satisfactionwith healthcare system

Unethical practices likely

Education Agriculturalhukou

Strugglesto pay familymedical bills

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Figure 3c. Impact on Odds of Using Exit Strategies

Source: Generalized linear mixed model for data in Figure 1, N=3,506.

Impact*

* Impact on logged risk ratio relative to reference category, computed by multiplying multinomial logistic regression coefficients by the mean of the independent variables. Impacts not significant at .05 level are not shown.

Unethical practiceslikely

Privatetreat-mentbetter

Age in deciles

Educ-ation

Agricul-tural hukou

Struggles to pay family medical bills

Local gov’texpenditureper capita

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Key Findings (System performance) People who are satisfied with performance of the health care system as a whole, are more likely to:

• use voice (ask the doctor to change treatment & make complaints)

• use connections to get a referral.(Medical ethics) People who think unethical medical practices are widespread are more likely to:

• pay hongbao• go to a private hospital.

(Trust) People who trust hospitals are less likely to complain to the hospital administration.(Clinical performance) People who are satisfied with the skills & competence of hospital doctors are more likely to complain.

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A theory about reasons for violence• Unsuccessful surgery can cause people to lose those they love

and on whom they depend. • Patients regard payment, especially informal payment, as

creating an obligation on doctors to resolve a health care problem.

• Failure to fulfil that obligation is a violation of norms of reciprocity.

• Reciprocity is a strong norm in Chinese culture.Violence towards health care professionals is an extreme expression of moral indignation about unfulfilled reciprocal obligations.

Evidence is circumstantial: need detailed case studies

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