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Hospital Choice Factors:A Case Study in Turkey

Fevzi Akinci, PhD

A. Ezel Esato lu, PhD

Dilaver Tengilimoglu, PhD

Amy Parsons, PhD

ABSTRACT. In an attempt to test the robustness of the numerous

American findings related to hospital choice in the context of anothercountry, this study examines the factors affecting hospital choice deci-

sions of 869 patients in three public and one private hospital policlinicsin Ankara, Turkey and attempts to determine their importance levels.

Identification of these factors and determining their effect levels is im-portant in concentrating management efforts on these key areas and informulating effective marketing strategies to retain and expand hospital

patient bases in the future. Our findings highlight the importance of ac-cessibility of hospital services to consumers in hospital choice as well as

the role of hospitals image, its physical appearance, and technologicalcapabilities in informing such choices. American health care managers

can use these findings to further understand how patients make choices

Fevzi Akinci is Assistant Professor, Department of Health Policy and Administration,Washington State University, Spokane, WA.

A. Ezel Esato lu is Assistant Professor, Faculty of Health Education, Department ofHealth Management, Ankara University, Ankara Turkey.

Dilaver Tengilimoglu is Associate Professor, Educational Faculty of Business andTourism, Gazi University, Golbasi Kampusu, Ankara, Turkey.

AmyL. Parsons is AssociateProfessor, McGowan School of Business, Departmentof Business and Management, Kings College, Wilkes-Barre, PA.

Address correspondence to: Fevzi Akinci, Department of Health Policy and Adminis-tration, Washington State University, P.O.Box 1495, Spokane, WA 99219-1495 (E-mail:[email protected]).

Health Marketing Quarterly, Vol. 22(1) 2004http://www.haworthpress.com/web/HMQ 2004 by The Haworth Press, Inc. All rights reserved.

Digital Object Identifier: 10.1300/J026v22n01_02 3
http://www.haworthpress.com/web/HMQhttp://www.haworthpress.com/web/HMQ


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related to health care facilities and to develop marketing strategies that

may more effectively market their facilities. [Article copies available for afee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail ad-dress: Website: 2004 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Hospitals, consumer choice, hospital selection

INTRODUCTION

Significant changes have been observed in the global health carefield over the past two decades. With increased competition for a givenpool of patients, emphasis on disease prevention and health promotion,and the availability of more health-related information to consumers inrecent years, patients have become better-informed and more account-able consumers of health care services. They also have become moreactive participants in decisions regarding treatment processes and inchoosing their health care providers. In fact, consumer demand forgreater patient choice has been one of the key driving forces behind thepublic backlash against managed care in the United States (Blendon etal., 1998).

In an increasingly competitive health care market place, especiallyon the inpatient side, it is crucial for health care managers to analyze the

purchase behaviors of their patients, to identify who the decision mak-ers in hospital choice are, to identify who plays a major role in such de-cisions, and to study the factors influencing consumer choices, if theytruly want to maintain and improve their market shares. Understandinghow patients behave and what patients might want may help managersto make sure their facilities are offering the services their patients wantand help to determine areas of growth and to identify potential changesthat might need to be made. Such analyses should not be limited to ex-isting patients, but must include those prospective customers who arecurrently healthy and would like to maintain and improve their healthstatus because theymay be patients in the future and it is essential for fa-cilities to be able to anticipate and adapt to customer needs.

Theexisting literature suggests that patients useseveral inputsduring

the hospital-choice decision-making process. Such inputs vary depend-ing on the urgency of the situation and the type of services needed.Therefore, health services marketing managers need to know not only

4 HEALTH MARKETING QUARTERLY
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thecharacteristicsof theservices they offer butalso thecriteria that con-sumers use in their purchasing decisions to clearly understand how theyultimately decide to go to a given institution. A limited number of stud-ies related to the factors patients consider in hospital choice decisionshave been conducted in Turkey. The purpose of this study was to exam-ine the factors affecting the hospital choice decisions of patients in Tur-key and to determine what factors were most important in an attempt totest the robustness of findings related to hospital choice in America andto identify additional factors in the context of the Turkish healthcaresystem. Identifying these factors anddetermining their effect levelsplaya key role in helping to concentrate management efforts on these areasand in formulating effective retentionandexpansionhospitalmarketing

strategies.Since the 1980s, Turkey has experienced increased competition inthe hospital sector and in the 1990s a number of small private hospitalsentered the market. The liberal economic policies of the Turkish gov-ernment and the prospect of acceptance into the United Nations had apositive impact on the hospital sector and lead to improvements in thequality of inpatient care. More recently, the Turkish government passedlegislation allowing direct access to private hospitals for patients whohave government sponsored health insurance coverage. In addition toinstilling more competition into the hospital sector, this development isexpected to improve patient choice even more significantly in the nearfuture. In the United States, with the retreat from tightly managed careand the resurgence of providers leverage in thehealthcare marketplace

in recent years, health plans and employer groups are experimentingwith tiered provider network designs as a strategy for containing costswhile maintaining providerchoice(Devers et al., 2003; Mays, Claxton, &Strunk, 2003). While finding the right balance between provider choiceand costs remains an important challenge for tiered provider networks,market observers note that since many tiered-network designs allowconsumers to make trade-offs between provider choice and costs, thesedesigns are likely to prove more attractive to employers than more re-strictive cost-containment strategies (Mays et al., 2003). Given the factthat patients continue to enjoy considerable choice in hospital selectionin Turkey it is important to examine patient purchasing decisions to fur-ther the development of knowledge in the hospital choice literature andto be able to share the findings with researchers and managers in Turkey

and in other developed nations.This paper is organized as follows. The second section provides a

brief overview of the relevant hospital choice literature. The third sec-

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tion explains the data and methodology used in the study. The fourthsection presents findings and discusses the results. The last sectiondraws conclusions and offers recommendations for managerial and pol-icy implementation.

BACKGROUND

Choice Criteria

When selecting a hospital, consumers often have a choice betweenseveral health organizations. Given todays competitive environment it

is important to understand how consumers make choices and what fac-tors they consider when making these choices. There is extensive litera-ture identifying the factors affecting patients hospital choice decisions.According to Berkowitz and Flexner (1981, p. 25), consumers focus onfour factors when they make a hospital choice decision: health servicesquality, cleanliness of physical facilities, attitudes and behaviors of hos-pital personnel, and reputation and image of the hospital. Boscarino andSteiber (1982, pp. 23-25) expand the criteria for hospital selection andlist them, in rank order, as follows: closeness to residence, recommen-dation by the doctor, availability of technology and good equipment,availability of specialist doctors, quality of facilities, being familiar orpleased with hospital personnel, prior experience with the hospital per-sonnel, prices (charges), hospital size, and religious affiliation.

Based on these results, Boscarino and Steiber (1982) conclude thatwhile physicians continue to play an important role in hospital choicedecisions, patientsalso consider other factors. Wolinsky and Kurz (1984)further define nine criteria used by patients when selecting a hospitalandsummarize them under four headings: knowledge, cost, quality, andrecommendations. Similarly, Lane and Lindquist (1994) report 14 choicefactors defined by the National Research Corporation (NRC) based onstudies covering three thousand people for three years, between 1984-1986, as follows: quality of the medical personnel, quality of emer-gency services, quality of nursing care, availability of a complete set ofservices, physicians recommendation, modern equipment, courteouspersonnel, good environmental and physical conditions, prior use ofhospital, cost of care, family recommendations, closeness to residence,

availability of private rooms, and friends recommendation.Boscarino and Steiber (1982) state that the type of service offered by

the hospital is also important and choice criteria may vary depending on



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whether the patient needs general, specialized, or emergency care ser-vices. They identify 12 choice criteria for each type of service. The firstfive criteria used for each type of service are summarized as follows.

General care services:(1) closeness to residence/convenience, (2) phy-sicians use/recommendation, (3) past hospital experience, (4) being fa-miliar with hospital personnel, (5) quality of physical facilities.

Specialized care services: (1) availability of qualified specialistphysicians, (2) physicians recommendation, (3) past hospital expe-rience, (4) availability of best equipment and technology, (5) close-ness to residence.

Emergency care services:(1) closeness to residence, (2) past hos-

pital experience, (3) physicians recommendation, (4) being famil-iar and pleased with hospital personnel, (5) availabilityand qualityof physical facilities.

Another study by the National Research Corporation (NRC) on theConsumer Health Care Process Model notes that choice criteria mayalso change depending on the type of treatment (e.g., disease, accident,and surgery) involved (Lane & Lindquist, 1994, pp. 106-107).

Hospital choice factors identified by recent studies include hospitalsoverall reputation (Heischmidt & Heischmidt, 1991; Heischmidt et al.,1993), patients previous experiences and perceptions (Gooding, 1995;Heischmidt et al., 1993), and overall cost of hospital services (Heischmidtet al., 1993; Sloane et al., 1999).

Identifying the Decision Maker

An important element in the marketing efforts of a hospital is to iden-tify who the final decision maker is in a hospital choice situation. The ex-isting literaturesuggests that, in general, thepatients themselves make thefinal decision on the selection of hospital, except in emergency situationsand under mandatory hospitalization (Wolinsky & Kurz, 1984, pp. 58- 67;Jackson & Jensen, 1985). According to a study conducted by Lane andLundquist (1988), 22 percent of the patients make their own hospitalchoice decisions before they become sick (leisure-time decision) and 52percent of them select from alternatives offered by physicians. In anotherrelated study, Smith and Clark (1994, p. 390) report that, generally physi-

cians make decisions related to hospital choice on behalf of their patients(62.5 percent), while 32.7 percent of the patients make their decisions to-gether with their physicians and only 21.1 percent of them make their

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own decisions. A National Research Corporation study conducted in1986 shows who the hospital choice decision-makers are may changede-pending on theseriousness of the illness being treated (Lane & Lindquist,1994, p. 123).

Karafakio lu (1998, p. 84) reports on another U.S. study in which 50percent of the patients indicated that their doctors had chosen the hospi-tal for them and 42 percent reported that they changed their doctor in or-der togo to a hospital they preferred. The fact that the physician plays anactive part in the patients decision may be especially important whenurgent intervention is required, provided that the patients freedom ofchoice is not restricted.

Turkish Studies

Limited studies exist in Turkey examining the factors influencingpatient choice of health care organizations and, especially hospitalselection. A study by Be ik (1995, p. 117) examined the factors af-fecting the selection of gynecologists and concluded that while 57.4percent of the patients did some research on potential providers, only12.3 percent conducted detailed research. According to a study byKurtulu and Harcar (1993, p. 5-8), 91 percent of prospective healthcustomers think that consulting only one physician is not sufficient.When people experience any significant health problems, these re-searchers recommended that they should consult two or more physi-

cians.Survey research conducted by Dalo lu covering 200 hospitalized

patients in two private hospitals in Turkey showed that 54 percent ofthe patients made their hospital choicedecisions through their doctors,33 percent by themselves, and 13 percent throughtheir friends (Dalo lu,1991, p. 20). The same research also indicated that the need to starttreatment in a relatively short period of time and the existence of goodpatient-doctor relations were the two most important factors influenc-ing the selection of a private hospital by patients. Other important fac-tors included high quality nursing services, good personnel behaviors,good food, hygiene, existing accommodations for personal caregivers,and long-enough visit times. Finally, in addition to all of the above

factors, patients noted that availability of a doctor when needed andrespect for human dignity were other major influencers on their hospi-tal choice (Dalo lu, 1991, p. 22).



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DATA AND METHODOLOGY

Data for this study were gathered from face to face interviews con-ducted with patients using a survey instrument developed by the au-thors. Based on the existing literature, patients were asked 40 questionsabout the factors which may have an impact on their hospital choice de-cisions. The importance levels of each factor to the patients were mea-sured by using Likert scale items. The reliability level of the surveyinstrument was high, with a Cronbachs alpha of 74 percent.

The study population consisted of patients who had private examina-tions in three public (Ankara University Ibn-i Sina Hospital, Gazi Uni-versity Gazi Hospital, and SSK Etlik Training Hospital) and oneprivate

hospital policlinics in Ankara, Turkey. The term policlinic is used to re-fer to hospital-based clinics only. The policlinic a patient goes to influ-ences which hospital a patient may be admitted to. The reason for theselection of those patients with private examinations was that they wereconsidered to make their own decisions on hospital choice independentof the existing patient referral system (e.g., without being mandatory).

Since the number of total annual visits to the selected hospital pol-iclinics was quite large (45,345) the number of total private examina-tions in the first three months of 1999 was calculated and, based on thisfigure, the number of average monthly private examinations was esti-mated. Given the large number of patients (8,690) involved and re-source limitations, 10 percent of this number was taken as our target

sample. Systematic sampling, a probability sampling method, was usedas a sampling techniqueto select869patients from those recorded in ap-pointment books of the selected hospitals private policlinics. A total of947 patients were approached and 78 patients refused to participate,yielding a 92 percent response rate. We pre-tested the survey instrumentwith 50 other patients to ensure clarity and understanding. Actual inter-views and data collection took place from May 3-7, 1999, during nor-mal business hours.

Research data were analyzed using one-way analysis of variance(ANOVA) using the SPSS statistics program. A QuinaryLikert scale wasused for the seven questions in the survey to assess the importance levelof choice factors identified by the respondents. Respondents were asked

to rate the importance of factors affecting their hospital choice decisionsusing the following five-point scale: (1 = never important, 2 = less impor-tant, 3 = important, 4 = very important, 5 = certainly important).

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FINDINGS

Socio-demographic characteristics of the study participants are showninTable 1. As can beseen from the table,mostof the patientswho partici-pated in the study were women (55 percent) and were in the 26-55 age-group (64 percent). Approximately two-thirds of the respondents weremarried (61.4 percent) and had more than a high school education (65.8percent). In terms of residence, the majority of the patients indicated thatthey lived in the city limits of Ankara (70.9 percent). With respect tohealth insurance status,while most of the study respondents had access togovernment sponsored insuranceprograms, about12 percentof them hadno health insurance coverage at all. When asked, approximately two-

thirds of the participants stated that they had come to the hospital morethan once (61percent), and average incomes were over 100million Turk-ish Liras (60.8 percent) or approximately 255 U.S. dollars.

Table 2 presents the mean and total importance scores for each of theseven factors that were identified to influence hospital choice decisions.One-way ANOVA analysis was conducted to examine the differencesacross each of the hospitals in the study for each choice factor. Resultsof the ANOVA analysis, overall F-statistic values (with SD) and p-val-ues (indicating the statistically significant differences across hospitals)are reported in Table 2. In addition, for each hospital, mean factor im-portance scores are ranked from the most important (e.g., highest score)to least important (e.g., lowest score) and these rankings are reported inthe table.

The results presented in Table 2 suggest that the most important fac-tor in hospital choice is the closeness of the hospital to the patientsplace of residence (p < 0.05). However, convenience seems to be less ofan important factor in hospital choice for those patients seeking servicesin private hospitals as compared to the public ones. The closeness ofhospitals to patient residences or workplaces is even more important foremergency health services, given that any delay in such services maypotentially cause a loss of human life. In fact, it is found that, especiallyin traffic accidents, 10 percent of deaths occur in the first 3-5 minutesand 54 percent occur within the first half-hour (Ege, 1981, p. 16).

Convenient access to health care providers not only facilitates the se-lection of a given provider but also helps improve the efficiency of theservices provided in such institutions. Research findings by Gesler and

Meade (1989, p. 67) suggest that the distance factor is an important de-terminant in health services access and use and may have a differentialimpact on people with different socio-demographic backgrounds. A



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TABLE 1. Distribution of Hospitals and Demographic Characteristics of the

Study Participants (N = 869)

Characteristics N Percentage (%)

Hospitals

Ibn-i Sina 282 32.5

Gazi 188 21.6

SSK 298 34.3

Private 101 11.6

Total 869 100

Sex

Male 391 45.0

Female 478 55.0

Age Groups

< 25 208 23.9

26-35 215 24.7

36-45 215 24.7

46-55 127 14.6

56-65 71 8.1

66+ 33 3.7

Marital Status

Married 534 61.4

Single 262 30.1

Widowed 73 8.4

Education

Illiterate 26 3.0

Elementary school 140 16.1

Middle school 131 15.1

High school 330 38.0

College 242 27.8

Residential Status

In the city (Ankara) 616 70.9

Outside the city (Ankara) 107 12.3

Other cities 146 16.8

Type of Insurance

None 102 11.7

Government org. coverage 60 6.9

Other Type of government org. coverage 295 33.9

Social Insurance Organization 311 35.8

Bag-kur 90 10.4

Green card 11 1.3

Occupation

Private 122 14.0

Housewife 191 22.0

Student 123 14.2

Official 243 28.0

Worker 93 10.7


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study conducted by Diner et al. (1994, pp. 115-121) in Turkey showedthat when the distance from a patients residence to the location of ahealth organization increases by 1 unit (km), the risk to an individual ofdelaying his/her visit to that institution more than 1 day increases by1.033 times.

Another important factor in the selection of a hospital is the techno-logical capabilities of the health care institution (e.g., availability ofmodern technology and equipment) as well as the physical condition

and appearance of its facilities (e.g., building structure, cleanliness, ele-vator access, and surroundings). Our findings suggest that there is a sta-tistically significant difference in patient choice among the hospitals


TABLE 1 (continued)

Characteristics N Percentage (%)

Retired 71 8.2

Other 26 3.0

Experience with Hospital Visit

First time 339 39.1

Second time 102 11.7

Third time 87 10.0

Many times 341 39.2

Income (in Million TL)

< 100 341 39.2

101-200 335 38.6

201-300 130 14.9

301-400 33 3.8401+ 30 3.5

TABLE 2. Hospital Choice Factors

Factors BN-I SINA GAZI SSK PRIVATE TOTAL F 3,868 P

M SD R M SD R M SD R M SD R M SD R

Cost 3.06 1.35 4 3.07 1.37 4 3.14 1.40 3 3.04 1.27 3 3.09 1.36 4 0.2673 0.899

Closeness to home/Accessibility

3.63 1.16 1 3.40 1.22 1 3.44 1.16 1 3.23 1.20 1 3.47 1.86 1 2.9056 0.021

Hospital image 3.07 1.18 3 3.27 1.20 2 3.23 1.27 3 3.09 1.23 2 3.17 1.23 3 1.3945 0.234

Accessto gov.spon-sored health insurance

2.84 1.28 5 2.51 1.32 5 2.69 1.33 5 2.76 1.34 5 2.71 1.31 5 2.2121 0.066

Modern equipmentand facilities

3.25 1.15 2 3.16 1.24 3 3.33 1.28 2 2.98 1.16 4 3.23 1.22 2 2.2312 0.064

Bureaucracy 2.59 1.22 6 2.34 1.32 7 2.49 1.3 6 2.61 1.32 6 2.51 1.30 6 1.5974 0.173

Availabilityof specialtydoctors andservices

2.32 1.26 7 2.51 1.33 6 2.42 1.37 7 2.43 1.33 7 2.41 1.32 7 0.7896 0.532

M: Mean, SD: Std. Deviation, R: Rank.


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studied based on the physical conditions of each institution and its cur-rently available technology (p < 0.10). It appears that this difference isprimarily due to the results from the private hospitals, where hospitalreputation and image ranks second in patients hospital choice deci-sions. In recent years, there have been rapid technological develop-ments in the medical field. Naturally, patients want to take advantage ofthe advanced technology and demand reduction in diagnosis errors andtime losses in treatment. There are indications in recent years that lapor-oscopic surgical applications and laser therapy have shortened treat-ment time in certain diseases.

Image and reputation of the hospital also play a role in hospital choice.The image, described as the sumof views on anybody, any organization,orany situation in the most general way, has an important effect on consum-ers purchase decisions. Modern equipment and facilities, employee atti-tudes and behaviors, and communication style influence an organizationsperceived image by patients and/or the general public. Corporate image,expressed as the sum of corporate design, corporate communications, andcorporate behavior, achieves two important functions: creating and main-taining persuasiveness and reliability for both internal and external targetaudiences (Pelteko lu, 1998, p. 279). The corporate image of an organiza-tion is not created by the organization itself, but rather by public opinionand the groupsandtarget audiences withwhom thatorganizationmaintainsrelationships (Ayhan & Karatepe, 1999, p. 113). In our study, the imagefactor in the selection of a hospital ranked third for SSK andIbn-i Sina hos-

pitals and second for Gazi hospital and the private hospital. Unfortunately,the observed differences in patient choice among hospitals with respect tothe image of each institution were not statistically significant.

In the health care field, it is not always easy to prove that hospitalsleave a good impression on patients. In an earlier research conducted byEsato lu et al. (1998) on 1,028 patients in four public hospitals inTurkey,only 44.5 percent of the patients rated the image of the hospitals to begood and very good (Esato lu, Tengilimo lu & Bilgin, 1998, p. 143).

Our findings suggest that the cost of hospital services does not seemto be an important determinant of hospital choice among the patientssurveyed. The cost factor was ranked fourth in patient hospital choicedecisions and the differences between hospitals were not statistically

significant in this regard. We attribute this finding to the existing man-dated fixed price system for public hospital services (except for special-ist examinations, procedures, and surgical services) in Turkey.

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Having access to a government sponsored insurance program alsoplays an important role in hospital choice. This factor was ranked fifthby therespondents andthedifferences between hospitals with respect topatient insurance status were foundto be statistically significant (p < .10).This was followed by the amount of bureaucratic formalities in the hos-pital (ranked sixth) and the availabilityof specialtydoctors andservices(ranked seventh). Finally, the capability and reputation of the specialtyphysicians were perceived to be important factors on hospital choice,especially in specialtyhospitals (e.g., eyebanks,maternityhospitals, re-habilitation centers, and cardiology institutions) in Turkey.

SUMMARY AND CONCLUSIONS

In this research we captured three types of hospitals that can be foundin the Turkish health care system by using patients from the policlinicsof two university/teaching hospitals, one Social Insurance Organizationhospital, and one private hospital. Any patient in Turkey can obtain in-patient services from a university hospital. These include patients whowork in the public sector and have a referral; retired patients; self-paidpatients; and patients who have access to private health insurance. So-cial Insurance Organizationhospitals are typicallyused by patients whoare employed in either the public or the private sector and have access toemployer-sponsored health insurance coverage. Patients who can af-ford 100 percent of health care costs from their own pockets (e.g.,

self-paid) and those with private health insurance coverage typicallyprefer private hospitals for their inpatient care services. In recent years,some private hospitals have started to accept patients from the both theSocial Insurance Organization and Ministry of Health hospitals. It isimportant to also note that the respondents included in this researchhave all obtained private examinations and were willing to pay morethan 90 percent of the clinic visit fee (about ten times higher than a nor-mal visit fee) from their own pockets. Shorter waiting times for an ap-pointment andtheability to be seen by their preferred faculty physicians(in university hospitals) were the key reasons for their hospital choicedecisions.

As explained above, the current structure of the Turkish health caresystem allows for considerable choice of inpatient service providers. De-

spite the backlash against managed care plans, this is not the case for anumber of U.S. patients who obtain their health care services under restric-tive managed care plans (e.g., closed panel Health Maintenance Organiza-



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tionsHMOs). Even under less structured managed care arrangements(such as Preferred Provider OrganizationsPPOs), U.S. patients continueto face significant cost sharing requirements (e.g., 20 percent coinsurance)if they seek care outside of the plans selected network of providers. As al-ready explained, health plans are recently experimenting with new PPO orHMOdesigns that sort network providers includinghospitals into differenttiers with varying cost-sharing requirements and developing consumer-driven plans, or high-deductible plans with personal spending accounts(Green, 2003; Lesser& Ginsburg,2003).While these features are intendedto reducecosts without sacrificing thebroad choiceof providers demandedby consumers, critics argue that consumers do not have enough informa-tion to make meaningful choices among the options provided (Lesser &

Ginsburg, 2003).In this paper, we have examined the role and importance levels ofseveral factors affecting the hospital choice decisions of Turkish pa-tients. Even though the degree of importance of each choice factor var-ies across the four hospitals, proximity to the hospital, its physicalappearance and existing technology, and access to government spon-sored health insurance programs tend to play major roles in hospitalchoice decisions in Turkey. These findings are consistent with findingsin the American hospital choice literature as presented in the back-ground section of this paper. If hospital managers want to effectivelyserve their consumers in their target market area, they must have a clearunderstandingof the factors influencing their patients/consumers hos-pital choice decisions. Conducting focus groups of current patients may

provide invaluable information to managers in this regard. In addition,they have to identify the parties involved in the decision-making pro-cess and assess the relative influence of each on the ultimate decisionsmade. However, it should be emphasized that in Turkey patients them-selves currently constitute the most important decision-makers on hos-pital choice. In recent years, with the growing emphasis on population-based medicine and health promotion, patients have been taking a moreactive role in thechoiceprocess andmake decisionseither together withtheir doctors or choose from those alternatives offered by their doctors.Yet, they continue to make their own decisions on such elective servicesas plastic surgery, breast implants, etc.

Consistent with the findings of the existing international and nationalstudies on hospital choice, our study highlights the importance of acces-

sibility of hospital services to consumers in selecting a hospital. Prox-imity to a hospital remains the single most important factor, especiallyin the selection of emergency and general hospital services. Therefore,

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closeness to consumers/patients and availability of transportation ser-vices should be taken into consideration in the selection of the site of ahospital in Turkey. For example, many modern hospitals in Ankara(Hacettepe, Ibn-i Sina, HighSpecialtyNumune, and Rehabilitation Cen-ters at S hh ye) are located at the center of the city; however, this situa-tion presents some significant problems such as extreme density intraffic and inadequate parking space for personal vehicles of the pa-tients and their visitors.

Another factor influencing patients/consumers hospital choice de-cisions and their hospital service experiences is the environment in whichservices are rendered (e.g., examination rooms, patient rooms, recep-tion rooms in terms of cleanliness andcomfort), theavailabilityof mod-

ern machinery and equipment, and the condition of the hospitalsphysical facilities (e.g., appearance of building, elevator, car park, etc.).Therefore, hospital managers have to pay close attention to the physicalappearance of the facilities they currently own and may acquire in thefuture, and must strive to offer state of the art medical technology intheir facilities. Recruitment of highlyqualifiedandreputable specialistsis also an important factor in hospital choice, especially for hospitalsthatofferspecialty services (e.g., cardio-vascular surgery centers, cardi-ology, cerebral surgery units, etc.). While there are a number of method-ological issues with hospital-specific outcomes data (such as appropriaterisk adjustment, sample size and time frame), hospitals in Turkey alsoneed to document the health outcomes achieved and should be willing

to make outcomes data publicly available to allow prospective patientsto make informed decisions about their hospital choice.The type of health insurance coverage a patient has may also affect

hospital choice decisions. For example, while being a member of a tradi-tional, very structured healthmaintenance organization(HMO)may limithospital choice, having access to a government sponsored plan may offermore alternatives to the patient as indicated by this study. On the otherhand, no choice exists for those people who do not have health insurancecoverage. It is important to note that findings from the HSCs Commu-nity Tracking Study Household Survey shows that most Americans, es-pecially lower-incomepeople, arewilling to limit their choiceof hospitalsand physicians in return for lower out-of-pocket costs (Center for Study-ing Health System Change, 2002). Trude (2003) argues that as patient

cost sharing increases, more individuals, particularly low-income em-ployees and those with serious health conditions, might embrace an op-portunity to make this cost-choice trade-off in the future. It is important



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therefore to consider the impact of health insurance status and health in-surance plan design when examining patient hospital choice decisions.

Finally, the image and reputation of the hospital continue to play arole in hospital choice decisions. It is essential for hospital managers tocreate and maintain an environment that assures a good image for bothexisting and prospective consumers of the institution. However, thatimage should truly reflect what the organization is actually capable ofcurrently doing given its institutional mission and the resources avail-able to it. It should be kept in mind that patients now gather more infor-mation than ever before when selecting a hospital and they should begiven factual and accurate information about the institution to better in-form their hospital choice decision making.

Overall, these findings suggest that U.S. findings related to hospitalchoice are strong enough to apply to health care systems in other coun-tries. This study then enhances the growing literature on hospital choiceand provides both U.S. and Turkish managers with additional insightsinto the hospital choice decision making process. Regardless of healthcare system many key factors influence hospital choice decisions andthe results may help managers in both the U.S. and Turkey to more ef-fectively market their services to their local populations.

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