Consumers' use of HCAHPS ratings and word-of-mouth in hospital choice.

Health policy advocates argue that supplying consumers with publicly available information about provider quality will induce better, more informed choices. Despite significant investments in collecting, analyzing, and reporting quality data, it remains unclear whether people will use it to choose health care providers. Assessments of quality data utilization by consumers have yielded mixed results. For example, HealthGrades reported that 40 percent of health care consumers considered a hospital's quality rating when choosing among alternative providers (Landro 2004). But other studies indicate that most consumers either remain unaware of publicly available health quality data or fail to fully utilize it (General Accounting Office 1999; Kaiser Family Foundation 2004; Jha and Epstein 2006; Sofaer 2008;). Few consumers use published reports in their decision making (Hibbard et al. 2000; Marshall et al. 2000; RAND Health 2002; Hibbard, Stockard, and Tusler 2005; Dolan 2008;). Why have health care consumers been reluctant to embrace data prepared to assist them in choosing providers, especially since poor choices could pose life-and-death risks? Some researchers have suggested that consumers simply lack information because public health agencies have not made the data accessible, and resistance from providers has discouraged widespread dissemination of comparative quality ratings (Herzlinger 2002; Shaller et al. 2003;). However, rival explanations suggest that consumers may find the information hard to understand and interpret, and the more difficulty people have understanding something, the less they will use it (Hibbard, Slovic, and Jewett 1997; Hibbard and Peters 2003;). Studies of consumer decision making reveal that people often rely on informal, qualitative information from friends, relatives, and acquaintances when making choices among health care providers or health plans (Lupton, Donaldson, and Lloyd 1991; Peters et al. 2007a,b;). Furthermore, recommendations from nonprofessionals often outweigh advice from authoritative sources (Gibbs, Sangl, and Burrus 1996; Crane and Lynch 1998; Fagerlin, Wong, and Ubel 2005;). Similar dynamics have long been observed in markets for goods and services that consumers buy every day. When the work of choosing among competing alternatives increases and the choices involve sorting out complicated data, consumers usually fall back on simple rules of thumb known as heuristics (Tversky and Kahneman 1974). One such heuristic is the “vividness” of how something is described: information presented vividly is more persuasive than information presented in a pallid manner (Rook 1986, 1987), which helps explain why consumers give more weight to anecdotal feedback from friends, relatives, and even casual acquaintances than to quantitative data systematically compiled and analyzed by experts (Schwartz 2004). Vividness is enhanced by presenting information in narratives, which are intrinsically appealing because they represent events the way people experience them in real life (Satterfield, Slovik, and Gregory 2000). For example, in pilot focus groups we conducted before this study, consumers described their decisions among alternative hospitals by telling richly detailed stories of friends' and relatives' experiences involving those hospitals, and how they relied on such anecdotal evidence in making their own choices. Even when quality ratings factor into consumers' hospital choice decisions, people will ask acquaintances for advice, and this anecdotal information may complement or compete with quantitative data. Consumers have become accustomed to seeing quality ratings for many services inside and outside health care, sometimes accompanied by customers' testimonials (Chevalier and Mayzlin 2006). To our knowledge, the relative impact of narrative stories and quantitative ratings of health care providers on hospital choice has not been systematically tested. In an experiment, we examined consumers' reactions to scenarios in which they viewed both quantitative ratings from the CAHPS Hospital Survey (HCAHPS) and anecdotal information about patient satisfaction at a fictional hospital.