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 another
country, this study examines the factors affecting hospital choice deci-
sions of 869 patients in three public and one private hospital policlinics
in 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 in
formulating 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 technological
capabilities 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 of
Health Management, Ankara University, Ankara Turkey.
Dilaver Tengilimoglu is Associate Professor, Educational Faculty of Business and
Tourism, Gazi University, Golbasi Kampusu, Ankara, Turkey.
Amy L. Parsons is Associate Professor, McGowan School of Business, Department
of 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:
akinci@mail.wsu.edu).
Health Marketing Quarterly, Vol. 22(1) 2004
http://www.haworthpress.com/web/HMQ
2004 by The Haworth Press, Inc. All rights reserved.
Digital Object Identifier: 10.1300/J026v22n01_02 3
related to health care facilities and to develop marketing strategies that
may more effectively market their facilities. [Article copies available for a
fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail ad-
dress: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.
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KEYWORDS. Hospitals, consumer choice, hospital selection
INTRODUCTION
Significant changes have been observed in the global health care
field over the past two decades. With increased competition for a given
pool of patients, emphasis on disease prevention and health promotion,
and the availability of more health-related information to consumers in
recent years, patients have become better-informed and more account-
able consumers of health care services. They also have become more
active participants in decisions regarding treatment processes and in
choosing their health care providers. In fact, consumer demand for
greater patient choice has been one of the key driving forces behind the
public backlash against managed care in the United States (Blendon et
al., 1998).
In an increasingly competitive health care market place, especially
on 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 they
truly want to maintain and improve their market shares. Understanding
how patients behave and what patients might want may help managers
to make sure their facilities are offering the services their patients want
and help to determine areas of growth and to identify potential changes
that might need to be made. Such analyses should not be limited to ex-
isting patients, but must include those prospective customers who are
currently healthy and would like to maintain and improve their health
status because they may be patients in the future and it is essential for fa-
cilities to be able to anticipate and adapt to customer needs.
The existing literature suggests that patients use several inputs during
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
the characteristics of the services they offer but also the criteria that con-
sumers use in their purchasing decisions to clearly understand how they
ultimately decide to go to a given institution. A limited number of stud-
ies related to the factors patients consider in hospital choice decisions
have 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 to
test the robustness of findings related to hospital choice in America and
to identify additional factors in the context of the Turkish healthcare
system. Identifying these factors and determining their effect levels play
a key role in helping to concentrate management efforts on these areas
and in formulating effective retention and expansion hospital marketing
strategies.
Since the 1980s, Turkey has experienced increased competition in
the hospital sector and in the 1990s a number of small private hospitals
entered the market. The liberal economic policies of the Turkish gov-
ernment and the prospect of acceptance into the United Nations had a
positive impact on the hospital sector and lead to improvements in the
quality of inpatient care. More recently, the Turkish government passed
legislation allowing direct access to private hospitals for patients who
have government sponsored health insurance coverage. In addition to
instilling more competition into the hospital sector, this development is
expected to improve patient choice even more significantly in the near
future. In the United States, with the retreat from tightly managed care
and the resurgence of providers leverage in the health care marketplace
in recent years, health plans and employer groups are experimenting
with tiered provider network designs as a strategy for containing costs
while maintainingprovider choice (Devers et al., 2003; Mays, Claxton, &
Strunk, 2003). While finding the right balance between provider choice
and costs remains an important challenge for tiered provider networks,
market observers note that since many tiered-network designs allow
consumers to make trade-offs between provider choice and costs, these
designs are likely to prove more attractive to employers than more re-
strictive cost-containment strategies (Mays et al., 2003). Given the fact
that patients continue to enjoy considerable choice in hospital selection
in Turkey it is important to examine patient purchasing decisions to fur-
ther the development of knowledge in the hospital choice literature and
to 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-
Akinci et al. 5
tion explains the data and methodology used in the study. The fourth
section presents findings and discusses the results. The last section
draws conclusions and offers recommendations for managerial and pol-
icy implementation.
BACKGROUND
Choice Criteria
When selecting a hospital, consumers often have a choice between
several 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 on
four factors when they make a hospital choice decision: health services
quality, cleanliness of physical facilities, attitudes and behaviors of hos-
pital personnel, and reputation and image of the hospital. Boscarino and
Steiber (1982, pp. 23-25) expand the criteria for hospital selection and
list 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 or
pleased 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 that
while physicians continue to play an important role in hospital choice
decisions, patients also consider other factors. Wolinsky and Kurz (1984)
further define nine criteria used by patients when selecting a hospital
and summarize themunder four headings: knowledge, cost, quality, and
recommendations. Similarly, Lane and Lindquist (1994) report 14 choice
factors defined by the National Research Corporation (NRC) based on
studies 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 of
services, physicians recommendation, modern equipment, courteous
personnel, good environmental and physical conditions, prior use of
hospital, 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
6 HEALTH MARKETING QUARTERLY
whether the patient needs general, specialized, or emergency care ser-
vices. They identify 12 choice criteria for each type of service. The first
five 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 specialist
physicians, (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) availability and quality
of physical facilities.
Another study by the National Research Corporation (NRC) on the
Consumer Health Care Process Model notes that choice criteria may
also 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 hospitals
overall 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 (Heischmidt
et 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 literature suggests that, in general, the patients themselves make the
final decision on the selection of hospital, except in emergency situations
and under mandatory hospitalization (Wolinsky & Kurz, 1984, pp. 58- 67;
Jackson & Jensen, 1985). According to a study conducted by Lane and
Lundquist (1988), 22 percent of the patients make their own hospital
choice decisions before they become sick (leisure-time decision) and 52
percent of themselect fromalternatives offered by physicians. In another
related 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
Akinci et al. 7
own decisions. A National Research Corporation study conducted in
1986 shows who the hospital choice decision-makers are may change de-
pending on the seriousness of the illness being treated (Lane &Lindquist,
1994, p. 123).
Karafakio lu (1998, p. 84) reports on another U.S. study in which 50
percent of the patients indicated that their doctors had chosen the hospi-
tal for themand 42 percent reported that they changed their doctor in or-
der to go to a hospital they preferred. The fact that the physician plays an
active part in the patients decision may be especially important when
urgent intervention is required, provided that the patients freedom of
choice is not restricted.
Turkish Studies
Limited studies exist in Turkey examining the factors influencing
patient choice of health care organizations and, especially hospital
selection. A study by Be ik (1995, p. 117) examined the factors af-
fecting the selection of gynecologists and concluded that while 57.4
percent of the patients did some research on potential providers, only
12.3 percent conducted detailed research. According to a study by
Kurtulu and Harcar (1993, p. 5-8), 91 percent of prospective health
customers 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 of
the patients made their hospital choice decisions through their doctors,
33 percent by themselves, and 13 percent through their friends (Dalo lu,
1991, p. 20). The same research also indicated that the need to start
treatment in a relatively short period of time and the existence of good
patient-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 and
respect for human dignity were other major influencers on their hospi-
tal choice (Dalo lu, 1991, p. 22).
8 HEALTH MARKETING QUARTERLY
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 questions
about 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 survey
instrument 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 SSKEtlik Training Hospital) and one private
hospital policlinics in Ankara, Turkey. The termpoliclinic 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 the
selection of those patients with private examinations was that they were
considered to make their own decisions on hospital choice independent
of 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 this
figure, 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 used
as a sampling technique to select 869 patients fromthose recorded in ap-
pointment books of the selected hospitals private policlinics. A total of
947 patients were approached and 78 patients refused to participate,
yielding a 92 percent response rate. We pre-tested the survey instrument
with 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. AQuinary Likert scale was
used for the seven questions in the survey to assess the importance level
of choice factors identified by the respondents. Respondents were asked
to rate the importance of factors affecting their hospital choice decisions
using the following five-point scale: (1 = never important, 2 = less impor-
tant, 3 = important, 4 = very important, 5 = certainly important).
Akinci et al. 9
FINDINGS
Socio-demographic characteristics of the study participants are shown
in Table 1. As can be seen fromthe table, most of the patients who 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 were
married (61.4 percent) and had more than a high school education (65.8
percent). In terms of residence, the majority of the patients indicated that
they lived in the city limits of Ankara (70.9 percent). With respect to
health insurance status, while most of the study respondents had access to
government sponsored insurance programs, about 12 percent of themhad
no health insurance coverage at all. When asked, approximately two-
thirds of the participants stated that they had come to the hospital more
than once (61 percent), and average incomes were over 100 million Turk-
ish Liras (60.8 percent) or approximately 255 U.S. dollars.
Table 2 presents the mean and total importance scores for each of the
seven factors that were identified to influence hospital choice decisions.
One-way ANOVA analysis was conducted to examine the differences
across each of the hospitals in the study for each choice factor. Results
of 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 fromthe most important (e.g., highest score)
to least important (e.g., lowest score) and these rankings are reported in
the 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 patients
place of residence (p < 0.05). However, convenience seems to be less of
an important factor in hospital choice for those patients seeking services
in private hospitals as compared to the public ones. The closeness of
hospitals to patient residences or workplaces is even more important for
emergency health services, given that any delay in such services may
potentially cause a loss of human life. In fact, it is found that, especially
in traffic accidents, 10 percent of deaths occur in the first 3-5 minutes
and 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 the
services 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 differential
impact on people with different socio-demographic backgrounds. A
10 HEALTH MARKETING QUARTERLY
Akinci et al. 11
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
study conducted by Diner et al. (1994, pp. 115-121) in Turkey showed
that when the distance from a patients residence to the location of a
health organization increases by 1 unit (km), the risk to an individual of
delaying his/her visit to that institution more than 1 day increases by
1.033 times.
Another important factor in the selection of a hospital is the techno-
logical capabilities of the health care institution (e.g., availability of
modern 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
12 HEALTH MARKETING QUARTERLY
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 3.8
401+ 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
Access to 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 equipment
and 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
Availability of specialty
doctors and services
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.
studied based on the physical conditions of each institution and its cur-
rently available technology (p < 0.10). It appears that this difference is
primarily due to the results from the private hospitals, where hospital
reputation 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 of
the advanced technology and demand reduction in diagnosis errors and
time 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, or
any 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 organizations
perceived image by patients and/or the general public. Corporate image,
expressed as the sum of corporate design, corporate communications, and
corporate behavior, achieves two important functions: creating and main-
taining persuasiveness and reliability for both internal and external target
audiences (Pelteko lu, 1998, p. 279). The corporate image of an organiza-
tion is not created by the organization itself, but rather by public opinion
and the groups and target audiences with whomthat organization maintains
relationships (Ayhan & Karatepe, 1999, p. 113). In our study, the image
factor in the selection of a hospital ranked third for SSKandIbn-i Sina hos-
pitals and second for Gazi hospital and the private hospital. Unfortunately,
the observed differences in patient choice among hospitals with respect to
the image of each institution were not statistically significant.
In the health care field, it is not always easy to prove that hospitals
leave a good impression on patients. In an earlier research conducted by
Esato lu et al. (1998) on 1,028 patients in four public hospitals in Turkey,
only 44.5 percent of the patients rated the image of the hospitals to be
good and very good (Esato lu, Tengilimo lu & Bilgin, 1998, p. 143).
Our findings suggest that the cost of hospital services does not seem
to be an important determinant of hospital choice among the patients
surveyed. The cost factor was ranked fourth in patient hospital choice
decisions and the differences between hospitals were not statistically
significant in this regard. We attribute this finding to the existing man-
dated fixed price systemfor public hospital services (except for special-
ist examinations, procedures, and surgical services) in Turkey.
Akinci et al. 13
Having access to a government sponsored insurance program also
plays an important role in hospital choice. This factor was ranked fifth
by the respondents and the differences between hospitals with respect to
patient insurance status were found to be statistically significant (p < .10).
This was followed by the amount of bureaucratic formalities in the hos-
pital (ranked sixth) and the availability of specialty doctors and services
(ranked seventh). Finally, the capability and reputation of the specialty
physicians were perceived to be important factors on hospital choice,
especially in specialty hospitals (e.g., eye banks, maternity hospitals, re-
habilitation centers, and cardiology institutions) in Turkey.
SUMMARY AND CONCLUSIONS
In this research we captured three types of hospitals that can be found
in the Turkish health care system by using patients from the policlinics
of two university/teaching hospitals, one Social Insurance Organization
hospital, and one private hospital. Any patient in Turkey can obtain in-
patient services from a university hospital. These include patients who
work in the public sector and have a referral; retired patients; self-paid
patients; and patients who have access to private health insurance. So-
cial Insurance Organization hospitals are typically used by patients who
are employed in either the public or the private sector and have access to
employer-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 typically
prefer private hospitals for their inpatient care services. In recent years,
some private hospitals have started to accept patients from the both the
Social Insurance Organization and Ministry of Health hospitals. It is
important to also note that the respondents included in this research
have all obtained private examinations and were willing to pay more
than 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 and the ability to be seen by their preferred faculty physicians
(in university hospitals) were the key reasons for their hospital choice
decisions.
As explained above, the current structure of the Turkish health care
system allows for considerable choice of inpatient service providers. De-
spite the backlash against managed care plans, this is not the case for a
number of U.S. patients who obtain their health care services under restric-
tive managed care plans (e.g., closed panel Health Maintenance Organiza-
14 HEALTH MARKETING QUARTERLY
tionsHMOs). Even under less structured managed care arrangements
(such as Preferred Provider OrganizationsPPOs), U.S. patients continue
to 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 or
HMOdesigns that sort network providers including hospitals into different
tiers 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 intended
to reduce costs without sacrificing the broad choice of providers demanded
by 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 of
several 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 physical
appearance and existing technology, and access to government spon-
sored health insurance programs tend to play major roles in hospital
choice decisions in Turkey. These findings are consistent with findings
in the American hospital choice literature as presented in the back-
ground section of this paper. If hospital managers want to effectively
serve their consumers in their target market area, they must have a clear
understanding of 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 decisions
made. 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 more
active role in the choice process and make decisions either together with
their doctors or choose from those alternatives offered by their doctors.
Yet, they continue to make their own decisions on such elective services
as plastic surgery, breast implants, etc.
Consistent with the findings of the existing international and national
studies 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, especially
in the selection of emergency and general hospital services. Therefore,
Akinci et al. 15
closeness to consumers/patients and availability of transportation ser-
vices should be taken into consideration in the selection of the site of a
hospital in Turkey. For example, many modern hospitals in Ankara
(Hacettepe, Ibn-i Sina, High Specialty Numune, 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 in
traffic 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 which
services are rendered (e.g., examination rooms, patient rooms, recep-
tion rooms in terms of cleanliness and comfort), the availability of mod-
ern machinery and equipment, and the condition of the hospitals
physical facilities (e.g., appearance of building, elevator, car park, etc.).
Therefore, hospital managers have to pay close attention to the physical
appearance of the facilities they currently own and may acquire in the
future, and must strive to offer state of the art medical technology in
their facilities. Recruitment of highly qualified and reputable specialists
is also an important factor in hospital choice, especially for hospitals
that offer specialty 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 appropriate
risk adjustment, sample size and time frame), hospitals in Turkey also
need to document the health outcomes achieved and should be willing
to make outcomes data publicly available to allow prospective patients
to 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 health maintenance organization (HMO) may limit
hospital choice, having access to a government sponsored plan may offer
more alternatives to the patient as indicated by this study. On the other
hand, no choice exists for those people who do not have health insurance
coverage. It is important to note that findings from the HSCs Commu-
nity Tracking Study Household Survey shows that most Americans, es-
pecially lower-income people, are willing to limit their choice of hospitals
and 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
16 HEALTH MARKETING QUARTERLY
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 a
role in hospital choice decisions. It is essential for hospital managers to
create and maintain an environment that assures a good image for both
existing and prospective consumers of the institution. However, that
image should truly reflect what the organization is actually capable of
currently 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 be
given 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 hospital
choice are strong enough to apply to health care systems in other coun-
tries. This study then enhances the growing literature on hospital choice
and provides both U.S. and Turkish managers with additional insights
into the hospital choice decision making process. Regardless of health
care system many key factors influence hospital choice decisions and
the 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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