Capturing the Patient Perspective: The Missing Voice in the World of Hospital Expansion

The composition of US hospital systems is dramatically shifting: mergers, acquisitions, consolidations, and strategic alliances are now pervasive, which has created unique challenges in regional health care delivery.¹ Hospital system formation has been economically driven, rather than with direct intent to improve patient care quality. Health system leaders are secondarily forced to either adapt old, or develop new, regional care delivery models.² “Hub-and-spoke” health systems, the subject of the accompanying article by Broman and colleagues³ have increasingly emerged, particularly within cancer care. Cancer centers with rural catchment areas represent a key strategic opportunity to improve high-quality cancer care delivery for rural patients with historically poor access.

In “Patient preferences for cancer care within hub and spoke networks: A discrete choice experiment,” Broman and colleagues³ capture an often-missing voice in the world of hospital expansion: the patient. Through a discrete choice experiment, they quantify patient preferences for cancer care delivery by forcing respondents to choose between two alternatives, thereby identifying their relative importance. From these findings, they generated preference phenotypes for both surgical and non-surgical care. While this represents the perspective of the patients within this one health system, broad generalizable concepts emerged that could benefit all regional cancer delivery systems.

Not all patients, and not all care, are the same

This study elegantly identifies that regional cancer networks cannot be designed around a one-size-fits-all philosophy. Patients clearly weigh each element of care delivery – proximity to home, physician expertise, in-person visits – differently, depending on their own personal values, community support, and financial means. Prior work has demonstrated this variation in patient’s willingness to travel for expertise, with willingness often increasing with disease severity or complexity.^4–6 The authors expand upon this work by investigating preferences in both surgical and non-surgical care, with marked differences between these 2 scenarios. For surgical care, most patients prioritized specialty expertise with a minority prioritizing limited travel. In contrast, patients were nearly evenly split with respect to desiring specialty expertise and limiting travel for non-surgical care. Regional cancer care delivery systems should allow flexibility for patients who prioritize specialty expertise and face-to-face interactions differently across the cancer continuum, particularly for non-surgical care. This flexibility would increase the need for robust navigation to ensure no patients are lost in the cracks of a complex system.

The power of the “virtual” network

On the other hand, a health system will not be able to offer all services at all locations: there are practical limitations to what a system can support physically and financially. Virtual and asynchronous care are 2 strategies to ameliorate constraints while ensuring region-wide access to specialty care. For instance, virtual visits and indirect case review via tumor boards may enable expert review and recommendations for patients who are the most sensitive to travel limitations. Prior research has demonstrated patients’ acceptance of virtual visits for surgical consultation, and as virtual platforms grow increasingly common in the post-COVID era, it is likely that patient comfort with these platforms will similarly increase.^7,8 As the authors note, however, there is inconsistent and inequitable insurance coverage for virtual and asynchronous clinical activities; attention must be paid to the impact of clinical pathway design on differently insured patient populations.

Additionally, the authors extend their findings to identify opportunities to leverage technology for cultural, social, and educational integration across a regional network. They suggest that health leaders should “be intentional about creating forums for hub-and-spoke providers to interact such as network-wide case conferences, journal clubs, and continuing medical education activities.” Cultural unity is a key facet of developing an integrated healthcare network, as it encourages a system-wide identity, engenders trust across providers, and facilitates regional cooperation. Health leaders must thus conceptualize their health system as not only a physical network of integrated providers, but also as a virtual community.

A warning against exacerbating disparities

Importantly, this study leveraged demographic and socioeconomic factors in their analysis of patient preferences, offering a rich understanding of the patient phenotypes. Specific attention should be paid to the finding that preferences tend to run in parallel to socioeconomic patterns. For example, the phenotype most willing to travel for a surgical specialist, while the largest group, were predominantly White, privately insured, and college educated. Conversely, the phenotype least willing to travel were predominantly Black or persons of color, publicly insured, and without college education. Health systems must be careful that building patient preference sensitive pathways does not unintentionally exacerbate systemic quality gaps, as current evidence suggests that care at affiliated spokes may be inferior to that at academic hub hopsitals.^9,10 Future work should explore the underpinnings of these preference patterns – e.g. resource scarcity, cultural beliefs, mistrust of institutions – and ensure care delivery is sensitive to patient-centered factors.

Similarly, redesigning regional health systems will require a careful balance of revenue streams and allocation of financial resources. While the authors mention the potential for shifting revenue to hubs and away from rural hospitals and surgeons, this point begs amplification. Much has been written about the closure of rural hospitals and consequent care access problems for certain populations.¹¹ Depending on the nature of the partnership with rural affiliates, cancer centers must be careful not to siphon care and expertise away from the peripheral sites and exacerbate this issue. Relying on the strategies identified by these authors may mitigate this issue by shifting aspects of care back to the community, if enacted thoughtfully.

Moving forward

As the healthcare landscape evolves, health system leaders must think creatively to maximize efficiency of regional care delivery, while ensuring access and quality within the context of patients’ clinical needs, socioeconomic limitations, and personal preferences. By understanding patient phenotypes, we might design interventions that cater to the needs of a wide patient catchment area, while still allowing for realistic adjustments in service offerings. Employing virtual and asynchronous care will be key to enabling integration, particularly if reimbursement models align with network demands. Importantly, health system leaders must be mindful that their interventions are sustainable and do not unintentionally exacerbate existing care inequities.