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The American Journal of Managed Care May 2013
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Can Cancer Patients Seeking a Second Opinion Get Better Care?

Hui-Ru Chang, PhD; Ming-Chin Yang, DrPH; and Kuo-Piao Chung, PhD
Colorectal resection patients in Taiwan with heavy hospital shopping behaviors got better surgical care than those who did not shop or hospitals.
Objectives: To investigate whether cancer patients who sought a second opinion received better medical care.

Study Design: A total of 1358 newly diagnosed colorectal cancer patients undergoing resection were identified from Taiwan’s National Health Insurance Research Database between 2004 and 2008. The frequency of doctor shopping and hospital shopping in the 6 months before resection was used to define “seeking a second opinion.”

Methods: A generalized hierarchical linear model was used to determine the influence of doctor shopping and hospital shopping on in-hospital complications and prolonged hospitalization after colorectal resection.

Results: The risk of in-hospital complications for heavy doctor shoppers was significantly higher than that for patients who were not doctor shoppers (odds ratio [OR] = 1.675, P = .037). However, the risk was significantly lower for heavy hospital shoppers compared with those who were not hospital shoppers (OR = 0.272, P = .007). The frequency of doctor shopping and hospital shopping was not significantly associated with prolonged hospitalization.

Conclusions: For colorectal resection patients, the selection of a proper hospital for surgery resulted in better surgical care. The quality of surgical care was worse with heavy doctor shopping. We suggest that healthcare authorities disclose data about the quality of a hospital’s cancer treatment to increase patient access to such information. This may help patients find quality healthcare providers more quickly and reduce the waste of medical resources resulting from the long process of seeking medical care.

Am J Manag Care. 2013;19(5):380-387
Seeking second opinions increases the cost of medical care. However, seeking second opinions might be recommended for cancer patients due to the variety of cancer treatments.

  • Among colorectal resection patients in Taiwan, those who were heavy hospital shoppers had a lower risk of in-hospital complications, whereas those who were heavy doctorshoppers had a higher risk of in-hospital complications.

  • Prolonged hospitalization was not significantly affected by frequencies of hospital shopping and doctor shopping.

  • Information on quality of cancer care should be disclosed to help patients shorten their process of seeking medical care.
The development of public insurance and the availability of media for medical information have reduced the obstacles that hinder patients from seeking medical care and raised patients’ consumer awareness.1 With the ability to choose a preferred treatment, patients can seek a second opinion for the same illness to receive better quality of medical care.2 Unlike the 1-way medical care of the past, patients can now not only spontaneously seek the medical care that they need, but also change their healthcare provider if they are dissatisfied with their first provider.3 However, in view of increasing medical expenses, many researchers have examined hospital shopping or doctor shopping to test the hypothesis that seeking a second opinion could cause a financial burden on the medical care system.4-6

Seeking a second opinion is defined as seeking medical care from more than 1 physician for the same condition. Compared with the judgment made by only 1 physician, a diagnosis made by multiple doctors is considered less likely to be inaccurate and can reduce a patient’s anxiety. 4,7,8 Most previous studies have evaluated the seeking of a second opinion by patients with specific conditions such as upper respiratory diseases, pulmonary tuberculosis, cancers, neurologic disorders, or polypharmacy. 5,9-11 A patient’s targets for comparison include both physicians and hospitals. Factors influencing a patient’s choice of a hospital include reputation, service volume, location, cost, and the patient’s own previous experiences.12-14 Factors important in the choice of a physician include the physician’s attitude, treatment recommendations, and patient satisfaction with  that physician’s care.15-17 Patients select a preferred care provider after a thorough comparison of all these factors.

There are 3 broad areas in the research on seeking a second opinion. One area of research has been to study the  characteristics of patients who are on the receiving end of poor communication.2,18,19 A second area involves investigation into the motives for seeking a second opinion.18,20 A few studies have evaluated the results after seeking a second opinion.18,21-23 Some earlier studies found that improperly seeking a second opinion could waste medical resources and should be avoided.18 In addition, patients tended to feel even more lost if the second physician made the same diagnosis. Conversely, some researchers suggested that when there are diagnostic differences between the first and second opinions,the second opinion could be helpful for providing proper medical care and avoiding excessive or insufficient treatment.21,22

Due to the nature of their disease and the potential harm from toxic treatment modalities, cancer patients are more likely to seek a second opinion. According to studies, nearly 60% of cancer patients have sought a second opinion.24,25 A diagnosis of cancer is a great shock to a patient, and cancer patients often have many questions about their diagnosis and treatment. If they do not obtain satisfactory answers from the first physician, patients go to other doctors for reassurance about their disease.10,18 In some instances, seeking a second opinion is beneficial for cancer patients. Reassurance from another physician could increase a patient’s confidence in the treatment. Furthermore, there may be differences in testing methods, medications, therapeutic techniques, and medical teams in different hospitals. During the process of seeking a second opinion, patients can choose a medical technology that is newer, more effective, or more suitable for them.10 Because of patient psychological factors and the development of therapeutic technologies, perhaps second opinions should be advised for cancer patients.

Although seeking a second opinion is increasingly common for cancer patients, little is known about the relationship between seeking a second opinion and the outcomes of medical care. Therefore, we investigated whether cancer patients who sought second opinions received better medical care. Through the process of hospital or surgeon selection, we assumed that patients had more chances to choose a better medical team with better therapeutic skills. Therefore, we inferred that seeking a second opinion could be helpful in getting better care. Using colorectal resection patients as an example, the aim of this study was to determine the relationship between seeking a second opinion and therapeutic outcome.


Study data came from Taiwan’s National Health Insurance Research Database (NHIRD), which was provided by the Bureau of National Health Insurance in Taiwan for research purposes. The National Health Insurance program in Taiwan contains data on  more than 99% of the entire population of 23.74 million people. The NHIRD is a national and representative database that contains comprehensive claim records of outpatient, inpatient, and emergency care. These data were cross-checked and validated to ensure accuracy.26,27 We used the database for a sampled cohort of 1 million people from 2004 to 2008. We also used admission files from the population-based inpatient expenditures database from 2004 to 2005.

From the hospitalization claims data of 1 million randomly chosen patients in NHIRD from July 2004 to November 2008, we identified patients who were newly diagnosed with colorectal cancer as a primary or secondary diagnosis 6 months before surgery (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 153.XX or 154.XX). We excluded patients with anal tumors (ICD-9-CM code 154.2) because surgical resection is not usually considered first-line treatment for this disease. For patients who underwent multiple surgical resections, data from only the first operation were analyzed.

We used doctor shopping and hospital shopping in the 6 months before surgery as second opinion–seeking behaviors. The number of physicians or hospitals that patients consulted about their colorectal cancer was calculated after the operating physician or hospital was excluded. Patients who shopped for 0, 1, and 2 or more physicians were classified as non–doctor shoppers, light doctor shoppers, and heavy doctor shoppers, respectively. Hospital shoppers were classified using the same criteria. Sex, age, Charlson Comorbidity Index (CCI) score, urbanization level, site of the tumor, use of preoperative screening colonoscopy, and use of preoperative chemotherapy were controlled for in the analyses. The urbanization level, which was developed by the Taiwan National Health Research Institute, was stratified into 7 classifications ( I, II, III, IV, and >V)and ranged from greater to lower degrees of urbanization in the analyses.28 Hospital characteristics obtained from the population-based inpatient expenditures database included in the analysis were accreditation level (academic medical center, regional, district), ownership (public, private), and average annual hospital volume for colorectal cancer surgery in 2004 and 2005.

Based on the study objective and the limitations of secondary data, we used in-hospital complications and prolonged  hospitalization as the indicators of surgical outcome. Mortality has been used to measure the quality of operations, and many studies have used mortality as a quality indicator following colorectal resection.29-33 The low number of deaths during a short surgical period, however, may result in a poor level of statistical confidence. Zheng and colleagues34 suggested overcoming this problem by improving the selection of indicators, extending the study period, or enlarging the sample size. Therefore, we used in-hospital complications and prolonged hospitalization, which are intermediate clinical indicators, as the outcome measures. In-hospital complications were defined as infections and cardiovascular, respiratory, gastrointestinal, urologic, or other complications.35-37 Patients who developed any of these conditions were classified as having in-hospital complications. To avoid overestimating the incidence of complications, patients presenting with comorbidities 1 month before surgery were excluded. Not all complications are the result of bad care or lower technical skills, and the correlation between comorbidities and complications has been observed in colorectal cancer patients.38 Therefore, prognostic factors, including patient characteristics and comorbid conditions, were controlled for in our analysis to reduce estimation bias. Furthermore, prolonged hospitalization was defined as a length of stay of more than 14 days.

The x2 test (or Fisher exact test, as appropriate) was used to explore the relationship between seeking a second opinion and outcomes of surgical care. In addition, data in the present study had a hierarchical structure, with patients nested within physicians and physicians nested within hospitals because the clustering effect and the dependence of observations within groups made the traditional regression model unsuitable. Considering the same size and that the dependent variables were binary outcomes, the 2-level hierarchical generalized linear model was applied (level 1 was the patient level; level 2 was the hospital level). The analyses were performed using the SPSS 17.0 (SPSS Inc, Chicago, Illinois) and HLM 6.02 (Scientific  Software International, Inc, Skokie, IL) software packages. Significance was defined as a 2-sided P value of <.05.

Along with the hierarchical linear model, a null model with no predictor variables at any level was first used to verify suitability. A null model can measure the magnitude of variation in an outcome measure across the different levels. The proportion of the variance across different levels can be expressed as an inter-class correlation coefficient (ICC). For the 2-level dichotomous  outcome model, the ICC between level 2 and the total variation was represented as σ2/(σ2 + π2/3).39After confirming the existence of significant variances among groups, further mean-as-outcomes models were applied to predict the intercept in level 1.


The study subjects included 1358 patients from 77 hospitals.Patient characteristics and surgical outcomes are shown in Table 1. There were 767 (56.5%), 434 (32.0%), and 157 (11.6%) non–doctor shoppers, light doctor shoppers, and heavy doctor shoppers, respectively. The non–hospital shoppers, light hospital shoppers, and heavy hospital shoppers totalled 978 (72.0%), 334 (24.6%), and 46 (3.4%), respectively. There were 77 hospitals where patients underwent surgery. Among hospitals, 24.7%, 61.0%, and 14.3% were academic medical centers, regional hospitals, and district hospitals, respectively. There were 22 (28.6%) public hospitals and 55 (71.4%) private hospitals. The mean annual hospital volume for colorectal surgery was 99.3 (±128.8) patients. Complications during hospitalization occurred in 255 (18.8%) of patients, and prolonged hospitalization occurred in 631 (47.3%) of the 1333 patients who survived at least 14 days after resection.

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