The Commercialization of Patient-Related Decision Making in Hospitals

eMethods

Supplementary information about the methods

• 1. Study data

  • Development of study concept: 2013

    Commencement of pilot study: late 2013

    Public discussion of preliminary results: 2014/2015

    Beginning of guided interviews: summer 2014

    Conclusion of interview phase: fall 2016

    Publication of study results: fall 2017/early 2018

    Financed through authors’ own resources—decision to forgo third-party funding

• 2. Material and phases of research

  • Concept of qualitative social research based on the grounded theory of Glaser and Strauss (17)

  • Analysis of empirical data based on the method of Mayring (25) and Flick (26)

• 2.1 Phase 1: Exploration and pilot phase

  • Interviews with five open questions (see eSupplement-Interview [in German]) about the changes in hospitals and in medicine in the previous few years

  • The term “commercialization” was not used in the pilot phase.

  • Selection of 10 chief executive officers following a personal approach by the economist. Selection of 12 doctors in the same way by the doctor.

  • Selection criteria:

    • Several years’ experience

    • Variously funded hospitals (public/communal, independent/non-profit-making, private)

    • Hospitals of various categories: basic care, full range of care, university hospitals

    • Hospitals from several different federal states

    • Doctors from various medical disciplines and of varying seniority (department heads, senior physicians, juniors)

    • Men and women

  • Conduct of the exploratory interviews by the authors themselves, bearing in mind the risk of the probands being influenced by the research hypotheses. The latter were not mentioned. The word “commercialization” was avoided.

  • Initial training in methods (oriented on a German Research Foundation training course on passive euthanasia attended by one of the authors)

  • Recording of the participants’ contributions, written documentation of interview and description of environment

  • Duration of interview: 60 to 120 min

  • Joint discussion of every protocol, definition of categories, classification of phenomena according to how often they were mentioned

  • Compilation of several preliminary reports

• 2.2 Phase 2: Design of guided interview

  • On the basis of the 22 interviews in the exploration and pilot phase, a guided interview with open and closed questions was designed and tested (see eSupplement-Interview)

• 2.3 Phase 3: Conduct of guided interview

  • Selection of interview partners so as to achieve a group of chief executive officers and doctors that was as varied as possible. The following criteria were observed:

    • Public, independent/non-profit-making, and private hospitals (exclusion of psychiatric facilities and hospitals run by employers’ liability insurance associations)

    • Various federal states

    • Hospitals of various categories: basic care, focal care, full range of care, university hospitals

    • Doctors: department heads, qualified specialists, senior physicians, junior doctors

    • Doctors: various specialties

    • Men and women

  • Potential probands approached in writing or in person, appointment made

  • With one exception, all doctors approached were prepared to participate.

  • Of the 68 chief executive officers approached, 21 agreed to an interview. “Lack of time” was stated as the reason for not taking part.

  • Interviews conducted in privacy. Documentation as in step 2.1—supplementation of verbal interviews with a questionnaire (see eSupplement-Interview) and description of environment. Reference to the possibility of a second meeting or telephone call.

  • Duration of interviews: 60 to 140 min

• 2.4 Phase 4: Focus groups

  • At three hospitals focus groups were convened, with a total of 22 participants. Those who took part were doctors, nurses, controllers, hospital chaplains, works council members, and managers. Individual reports from the interviews were presented as case vignettes and discussed openly. The discussions were recorded, transcribed, and evaluated in the context of a master’s degree project at the University of Bremen. The focus group meetings essentially yielded no new findings but broadly confirmed the statements of both interview groups.

• 2.5 Supplementary information
• Several doctors contacted the interviewer at a later date. The contents of the conversations were noted and included in the analysis.
• 2.6.1 Written follow-up questionnaire and workshop
• Evaluation of the guided interviews showed differences, some of them pronounced, between the statements of the chief executive officers and the doctors. Therefore, 10 members of each group were asked how they thought these differences could be explained. The written responses were included in the analysis. The 20 participants were also invited to a 4-h workshop in Berlin. Five doctors and seven chief executive officers attended. The written record of the meeting was also included in the analysis.
• 2.6.2 Field research notes
• Simultaneously with but independent of the research project, staff at several hospitals were asked about reporting of problems. Some of the notes made during these conversations were included in the analysis.
• 3. Analysis

  • All interviews were read word for word, interpreted, and discussed jointly.

  • The phenomena documented were categorized and the respective text segments classified into the categories.

  • All available responses to the questions in the guided interview were classified in tabular form.

  • The results of the guided interviews were classified quantitatively and by text separately for the doctors and the chief executive officers, enabling comparison of the content of the responses in tabular form.

  • The summarized results were discussed intensively and jointly committed to writing.