Referring physicians' intention to use hospital report cards for hospital referral purposes in the presence or absence of patient-reported outcomes: a randomized trial.

PURPOSE: This study aims to determine the intention to use hospital report cards (HRCs) for hospital referral purposes in the presence or absence of patient-reported outcomes (PROs) as well as to explore the relevance of publicly available hospital performance information from the perspective of referring physicians. METHODS: We identified the most relevant information for hospital referral purposes based on a literature review and qualitative research. Primary survey data were collected (May-June 2021) on a sample of 591 referring orthopedists in Germany and analyzed using structural equation modeling. Participating orthopedists were recruited using a sequential mixed-mode strategy and randomly allocated to work with HRCs in the presence (intervention) or absence (control) of PROs. RESULTS: Overall, 420 orthopedists (mean age 53.48, SD 8.04) were included in the analysis. The presence of PROs on HRCs was not associated with an increased intention to use HRCs (p = 0.316). Performance expectancy was shown to be the most important determinant for using HRCs (path coefficient: 0.387, p < .001). However, referring physicians have doubts as to whether HRCs can help them. We identified "complication rate" and "the number of cases treated" as most important for the hospital referral decision making; PROs were rated slightly less important. CONCLUSIONS: This study underpins the purpose of HRCs, namely to support referring physicians in searching for a hospital. Nevertheless, only a minority would support the use of HRCs for the next hospital search in its current form. We showed that presenting relevant information on HRCs did not increase their use intention.

The elicitation of patient and physician preferences for calculating consumer-based composite measures on hospital report cards: results of two discrete choice experiments.

PURPOSE: The calculation of aggregated composite measures is a widely used strategy to reduce the amount of data on hospital report cards. Therefore, this study aims to elicit and compare preferences of both patients as well as referring physicians regarding publicly available hospital quality information METHODS: Based on systematic literature reviews as well as qualitative analysis, two discrete choice experiments (DCEs) were applied to elicit patients' and referring physicians' preferences. The DCEs were conducted using a fractional factorial design. Statistical data analysis was performed using multinomial logit models RESULTS: Apart from five identical attributes, one specific attribute was identified for each study group, respectively. Overall, 322 patients (mean age 68.99) and 187 referring physicians (mean age 53.60) were included. Our models displayed significant coefficients for all attributes (p < 0.001 each). Among patients, "Postoperative complication rate" (20.6%; level range of 1.164) was rated highest, followed by "Mobility at hospital discharge" (19.9%; level range of 1.127), and ''The number of cases treated" (18.5%; level range of 1.045). In contrast, referring physicians valued most the ''One-year revision surgery rate'' (30.4%; level range of 1.989), followed by "The number of cases treated" (21.0%; level range of 1.372), and "Postoperative complication rate" (17.2%; level range of 1.123) CONCLUSION: We determined considerable differences between both study groups when calculating the relative value of publicly available hospital quality information. This may have an impact when calculating aggregated composite measures based on consumer-based weighting.

The use intention of hospital report cards among patients in the presence or absence of patient-reported outcomes.

BACKGROUND: So far, the adoption of hospital report cards (HRCs) falls short of expectations. One promising strategy is to modify the content of HRCs by presenting patient-reported outcomes (PROs). OBJECTIVE: To identify the key determinants influencing patients to use HRCs for hospital decision making and determine the effect of presenting PROs on HRCs on their use intention. METHODS: Primary survey data were collected (5/6-2021) on a sample of 2000 randomly selected insurees from a German statutory health insurance who have undergone elective hip arthroplasty surgery. RESULTS: Overall, 447 participants (mean age 66.56) completed the survey and were included in the analysis. Respondents rated "PROs" as most important for the hospital choice followed by "Mobility at hospital discharge" and "Confirmed diagnosis rate". Patients generally perceive HRCs to be a good idea that makes searching for a hospital more interesting. We identified attitude and social influence as the most important determinants for using HRCs (p<.001 each). The presence of PROs on HRCs was not associated with an increased intention to use HRCs neither in our descriptive analysis (p=.593), nor in our research model (p=.763). CONCLUSIONS: Patients value PROs to be an important information for choosing a hospital. Nevertheless, health policy makers should note that presenting PROs on HRCs as a single approach is not likely to increase the use of HRCs.

[Satisfaction of Rehabilitation Patients on Social Media Websites and Online Rating Portals]. / Rehabilitandenzufriedenheit in den sozialen Medien und auf Online-Bewertungsportalen.

PURPOSE: Patients increasingly express themselves about their medical rehabilitation stay, evaluate health service providers with star ratings, and write reviews on the internet. So far, no results are available regarding online patient satisfaction for inpatient medical rehabilitation in Germany. For the first time, this study conducted a systematic analysis of rehabilitation patient satisfaction on social media websites and hospital rating portals. METHODS: We collected reviews of medical rehabilitation on the portal Klinikbewertungen.de and the social network Facebook for 8 indication groups (orthopedics, psychosomatics/psychotherapy, oncology, cardiology, neurology, internal medicine, pulmonology/dermatology, gastroenterology) with a full data extraction over 3 survey years (October 2014-September 2017) and for rehabilitation clinics with main bed occupancy of retirement insurance (N=497). The star ratings, aggregated according to indication groups, were evaluated to determine patient satisfaction (Pearson's chi-square test, Fisher's exact test, Phi coefficient). RESULTS: A total of 97.2% of the rehabilitation clinics were represented, with 24,806 ratings on Klinikbewertungen.de. The most frequently evaluated indication groups were orthopedics (38.5%) and psychosomatics/psychotherapy (27.1%). Facebook ratings (N=4,127) were collected for rehabilitation clinics with one department (38.6%) in order to ensure an indication group assignment. Almost the same number of ratings were determined on official (48.7%) and unofficial Facebook pages (51.3%), with no significant correlation between website management and overall satisfaction (p>0.05). On the Facebook pages of the rehabilitation clinics, 49.1% of the ratings were written by women (38.5% by men; 12.4% not assignable). Sociodemographic information on Klinikbewertungen.de was based solely on the status of the insured (89.1% of those with statutory insurance). Overall, 95.4% of the reviews were written by patients and 4.0% by relatives, with 77.5% of patients recommending the clinic to other users (relatives: 37.2%). Most patient ratings were positive. However, there were differences in overall satisfaction between the indication groups. Patients in oncology (77.9%) were more satisfied than those in neurology (59.0%). CONCLUSIONS: Online ratings of inpatient medical rehabilitation were collected to a considerable extent. These were mostly positive. The results are comparable to standardized surveys. Despite restrictions in the use of social media data, the results indicated that the publicly available real-time online feedback from patients can provide useful information for the quality management of clinics as well as for patients in exercising their right to choose a rehabilitation clinic.

[User Satisfaction in Social Media: How do Patients Rate their Hospital Stay Online?] / Nutzerzufriedenheit in den sozialen Medien. Wie beurteilen Patienten ihren Krankenhausaufenthalt online?

BACKGROUND: Patients are increasingly using social media and review sites to get information on hospitals, to rate them or to write a review about their own experiences during hospital stay. Hospitals have the opportunity to use these patient reviews for internal quality assurance as well as online reputation marketing. OBJECTIVE: The objective is to analyze the satisfaction ratings of previous hospitals stays by social media users on platforms such as "Google", as well as reviews from the German site "Klinikbewertungen.de", and to compare them. METHODS: User reviews (n=16,691) for all hospitals (n=180) in the federal state of Lower Saxony (complete survey) for 2013-2018 were extracted from the platforms Google and the German Klinikbewertungen.de. Subsequently, a descriptive and inductive analysis (Chi²-test) of the user reviews and a comparison specific for the platforms were completed. RESULTS: Most users are satisfied with their hospital stay, whereby users of the platform Google ratd their hospital stay worse (n=6,181; 57.6% satisfied) than users of the platform Klinikbewertungen.de (n=10,509; 65.4% satisfied). Features of the hospital (number of beds, specialist departments) and features of the users (author, type of insurance) were significantly associated with the rating for the hospital stay (star review). (Google: number of beds p<0.001; Klinikbewertungen.de: number of beds p<0.001, author p<0.001, specialist departments p<0.001, type of insurance p<0.001). CONCLUSION: The online review of a hospital stay is associated with the number of beds, the specialist departments of hospitals, whether the author is the patient or a relative, and the type of health insurance they have, namely private or statutory. Online reviews and ratings for hospitals may be used for internal quality assurance or improvements of company online reputation.

[Positive association between successful rehabilitation and patient hospital ratings: Experience reports of patients in rehabilitation on a hospital rating and review site]. / Klinik-Weiterempfehlung bei Reha-Erfolg: Erfahrungsberichte von Rehabilitanden auf einer Klinik-Bewertungsplattform.

INTRODUCTION: Feedback from patients about aspects of rehabilitation services is increasingly provided online, for example, on specialized hospital comparison websites. Therefore, we examined which kind of online statements from rehabilitation patients published on the leading hospital comparison website "Klinikbewertungen.de" (KB) is associated with a positive recommendation of a rehabilitation clinic and which negative aspects are associated with a non-recommendation. METHODS: For eight indication groups stratified online statements of rehabilitants at KB were evaluated qualitatively using content analysis. The relationship between positive (negative) statements and the (non-) recommendation was examined. RESULTS: Content analysis of 911 experience reports revealed 20 categories. Most often, it was the "rehabilitation success" perceived by rehabilitation patients that was significantly associated with a recommendation or a non-recommendation of a hospital, and in five quality assurance (QA) comparison groups the category "catering" was associated with a positive or negative recommendation. In all QS comparison groups, there was an association with at least one of the following process-oriented rehabilitation categories: "rehabilitation measures", "rehabilitation plan and rehabilitation goals" and / or "diagnosis to discharge". DISCUSSION AND CONCLUSION: Patient experiences with the perceived "rehabilitation success" and with the central processes of rehabilitation are particularly important for the recommendation or non-recommendation of a hospital for patients in all eight indication groups. On the basis of these results, rehabilitation hospitals can specifically identify the aspects of care that are important when patients recommend a hospital for rehabilitation. Online narratives of patients provide additional insights into the reasons for patients' satisfaction or dissatisfaction with their rehabilitation. These narratives are available to potential rehabilitation patients as a low-threshold source of information and decision-making aid.

[Are Facebook Ratings Associated with Hospital Quality and Patient Satisfaction? A Cross-Sectional Analysis of Obstetrics Care in German Hospitals]. / Spiegeln Facebook-Bewertungen die Versorgungsqualität und Patientenzufriedenheit von Krankenhäusern wider? Eine Querschnittstudie am Beispiel der Geburtshilfe in Deutschland.

OBJECTIVE: Social media websites, such as Facebook, have been gaining popularity. Little is known about the usefulness of such online ratings when searching for a hospital. We therefore assessed the association between online Facebook ratings and clinical quality of care measures as well as patient satisfaction for German hospitals in obstetrics care. METHODS: (1) We identified all German hospitals providing services in obstetrics care based on the German external quality assurance system (2015) and gathered relevant data. (2) Based on a structured dialogue, we determined quality of care results for all hospitals and (3) assigned them to 3 different performance groups. (4) We collected Facebook online ratings as well as (5) patient satisfaction (Patients' Experience Questionnaire, PEQ) results for all included hospitals. (6) We applied the Spearman rank coefficient of correlation. RESULTS: We could find a Facebook page for almost all of the included hospitals (728/752; 96.8%). Facebook hospital ratings in general were mostly positive, especially in obstetrics care. There was no association between Facebook hospital ratings (ρ=0.007; p=0.860) or those for obstetrics care (ρ=0.008; p=0.856) and clinical quality of care measures. In contrast, we could detect an association between Facebook ratings and patient satisfaction scores. The association was stronger for overall hospital ratings (ρ=0.383-0.543; p<0.001) than those for obstetrics care (ρ=0.111-0.250; p<0.05) in particular. CONCLUSION: So far, Facebook online ratings are of limited usefulness in guiding patients towards high-performing hospitals from a clinical point of view. However, our findings suggest that Facebook ratings may serve as an indicator of patient satisfaction when searching for hospitals.

Characteristics and decision making of hospital report card consumers: Lessons from an onsite-based cross-sectional study.

BACKGROUND: Hospitals report cards (HRCs) have had little impact on the hospital choice of patients. Thus, health policy makers should learn more about HRC consumers to better understand how to present and target hospital-related quality information. OBJECTIVE: We sought to learn more about consumers of HRCs and determine the impact of the complexity and tailoring of HRCs on the hospital choice. METHODS: We used primary data drawn from an onsite-based survey, conducted in 2017 at Germany's premier portal, Weisse Liste (N = 635). We performed hierarchical multivariate logistic regression models to identify main predictors associated with hospital choices. RESULTS: HRC consumers differ from the national online population and the national population in general. Eighty percent of those patients or family members, who have used a HRC before, confirmed an impact on the hospital choice. The quality of hospital choices decreased with an increasing level of complexity (p < .001); the latter was identified as a significant predictor for making good choices. However, tailoring HRCs did not have an impact on the quality of the hospital choice (p > .05). CONCLUSIONS: HRCs have a significant impact on the hospital choice among report card consumers. Health policy makers might focus on decreasing the level of complexity; this, more than tailoring report cards, may help consumers make good hospital choices.

Do German public reporting websites provide information that office-based physicians consider before referring patients to hospital? A four-step analysis.

BACKGROUND: In recent years, many different performance frameworks and quality assurance systems have been developed to measure health care quality. In Germany, an external quality assurance system for hospitals was introduced in 2005. The data of these systems are often reported by public reporting websites (PRWs) to inform patients and other stakeholders interested in health care systems about health care providers' quality. However, publication is obligatory (at least in Germany) for most of the existing quality assurance measures; some may be reported voluntarily. An important target group for this information is the group of all office-based physicians as they are crucial for patients' hospital choice. However, public reporting initiatives in Germany and other countries have not increased the use of quality reports for hospital choice. OBJECTIVES: (1) To summarize the criteria that office-based physicians consider to be of high, medium, and low importance for hospital selection when referring patients and (2) to examine whether German public reporting websites (PRWs) provide these hospital-related criteria. METHODS: The analysis comprised four steps: 1) Five databases were systematically searched for peer-reviewed English- and German-language literature. 2) The selection of articles was based on compliance with inclusion criteria, and all the criteria relevant to the referral of patients to hospital were extracted. 3) The criteria were then divided into five main categories: structural quality, process quality, outcome quality, patient experience, and referring physicians' experience. In addition, the criteria were classified into three importance categories (high-, medium-, and low-priority criteria) according to their relevance to the referral decision. 4) We investigated whether German PRWs publicly report high-priority criteria. RESULTS: A total of N=11 articles published in peer-reviewed journals met our inclusion criteria. The studies were published in Germany (n=4), the Netherlands (n=3), Denmark, France, Norway, and the USA (n=1 each). In total, N=86 criteria were identified, most of them relating to structural quality (n=43) and process quality (n=26). We found just n=3 outcome quality criteria, only one of which fell in the high-priority category (breast cancer indicators with clinically relevant differences). In total, n=25 low-, n=40 medium-, and n=34 high-priority criteria could be established, which is due to the fact that some criteria had been investigated in several studies evaluating the importance of some criteria differently. Most of the high-priority criteria were related to process quality. All the high-priority structural quality criteria and high-priority outcome quality criteria were available on German PRWs, whereas just 38.5 % of those relating to process quality could be identified on these portals. We also identified 66.7 % of the high-priority criteria regarding patient experience and 50.0 % concerning the referring physicians' experience. Overall, a larger amount of low- and medium-priority criteria are available on German PRWs than high-priority criteria. DISCUSSION: A substantial amount of hospital information regarding structural quality and outcome quality is available on German PRWs. However, the development of further process quality criteria (which are currently underrepresented) should be considered, for example whether hospital physicians continue the medication initiated by office-based doctors. Also, hospital quality reports should be tailored for specific user groups, for instance for referring gynecologists or referring general practitioners (GPs).

[Do laymen understand information about hospital quality? An empirical verification using risk-adjusted mortality rates as an example]. / Verstehen Laien Informationen über die Krankenhausqualität? Eine empirische Überprüfung am Beispiel der risikoadjustierten Mortalität.

INTRODUCTION: The effect of public reporting to improve quality in healthcare is reduced by the limited intelligibility of information about the quality of healthcare providers. This may result in worse health-related choices especially for older people and those with lower levels of education. There is, as yet, little information as to whether laymen understand the concepts behind quality comparisons and if this comprehension is correlated with hospital choices. METHODS: An instrument with 20 items was developed to analyze the intelligibility of five technical terms which were used in German hospital report cards to explain risk-adjusted death rates. Two online presentations of risk-adjusted death rates for five hospitals in the style of hospital report cards were developed. An online survey of 353 volunteers tested the comprehension of the risk-adjusted mortality rates and included an experimental hospital choice. RESULTS: The intelligibility of five technical terms was tested: risk-adjusted, actual and expected death rate, reference range and national average. The percentages of correct answers for the five technical terms were in the range of 75.0-60.2%. Between 23.8% and 5.1% of the respondents were not able to answer the question about the technical term itself. The least comprehensible technical terms were "risk-adjusted death rate" and "reference range". The intelligibility of the 20 items that were used to test the comprehension of the risk-adjusted mortality was between 89.5% and 14.2%. The two items that proved to be least comprehensible were related to the technical terms "risk-adjusted death rate" and "reference range". For all five technical terms it was found that a better comprehension correlated significantly with better hospital choices. DISCUSSION: We found a better than average intelligibility for the technical terms "actual and expected death rate" and for "national average". The least understandable were "risk-adjusted death rate" and "reference range". Since the self-explanatory technical terms "actual and expected death rate" and "national average" are easy to understand and the comprehension is correlated with hospitals choices, we recommend using them for the presentation of measures which contain risk-adjusted mortality. The technical terms "risk-adjusted death rate" and "reference range" should stay in the background, since comprehension problems can be expected and explanations would have to be provided.

Do Physicians Respond to Web-Based Patient Ratings? An Analysis of Physicians' Responses to More Than One Million Web-Based Ratings Over a Six-Year Period.

BACKGROUND: Physician-rating websites (PRWs) may lead to quality improvements in case they enable and establish a peer-to-peer communication between patients and physicians. Yet, we know little about whether and how physicians respond on the Web to patient ratings. OBJECTIVE: The objective of this study was to describe trends in physicians' Web-based responses to patient ratings over time, to identify what physician characteristics influence Web-based responses, and to examine the topics physicians are likely to respond to. METHODS: We analyzed physician responses to more than 1 million patient ratings displayed on the German PRW, jameda, from 2010 to 2015. Quantitative analysis contained chi-square analyses and the Mann-Whitney U test. Quantitative content techniques were applied to determine the topics physicians respond to based on a randomly selected sample of 600 Web-based ratings and corresponding physician responses. RESULTS: Overall, physicians responded to 1.58% (16,640/1,052,347) of all Web-based ratings, with an increasing trend over time from 0.70% (157/22,355) in 2010 to 1.88% (6377/339,919) in 2015. Web-based ratings that were responded to had significantly worse rating results than ratings that were not responded to (2.15 vs 1.74, P<.001). Physicians who respond on the Web to patient ratings differ significantly from nonresponders regarding several characteristics such as gender and patient recommendation results (P<.001 each). Regarding scaled-survey rating elements, physicians were most likely to respond to the waiting time within the practice (19.4%, 99/509) and the time spent with the patient (18.3%, 110/600). Almost one-third of topics in narrative comments were answered by the physicians (30.66%, 382/1246). CONCLUSIONS: So far, only a minority of physicians have taken the chance to respond on the Web to patient ratings. This is likely because of (1) the low awareness of PRWs among physicians, (2) the fact that only a few PRWs enable physicians to respond on the Web to patient ratings, and (3) the lack of an active moderator to establish peer-to-peer communication. PRW providers should foster more frequent communication between the patient and the physician and encourage physicians to respond on the Web to patient ratings. Further research is needed to learn more about the motivation of physicians to respond or not respond to Web-based patient ratings.

Public reporting of hospital quality shows inconsistent ranking results.

BACKGROUND: Evidence from the US has demonstrated that hospital report cards might generate confusion for consumers who are searching for a hospital. So far, little is known regarding hospital ranking agreement on German report cards as well as underlying factors creating disagreement. OBJECTIVE: This study examined the consistency of hospital recommendations on German hospital report cards and discussed underlying reasons for differences. METHODS: We compared hospital recommendations for three procedures on four German hospital report cards. The agreement between two report cards was determined by Cohen's-Kappa. Fleiss' kappa was applied to evaluate the overlap across all four report cards. RESULTS: Overall, 43.40% of all hospitals were labeled equally as low, middle, or top performers on two report cards (hip replacement: 43.2%; knee replacement: 42.8%; percutaneous coronary intervention: 44.3%). In contrast, 8.5% of all hospitals were rated a top performer on one report card and a low performer on another report card. The inter-report card agreement was slight at best between two report cards (κmax=0.148) and poor between all four report cards (κmax=0.111). CONCLUSIONS: To increase the benefit of public reporting, increasing the transparency about the concept of - medical - "quality" that is represented on each report card seems to be important. This would help patients and other consumers use the report cards that most represent one's individual preferences.

Do Health Care Providers Use Online Patient Ratings to Improve the Quality of Care? Results From an Online-Based Cross-Sectional Study.

BACKGROUND: Physician-rating websites have become a popular tool to create more transparency about the quality of health care providers. So far, it remains unknown whether online-based rating websites have the potential to contribute to a better standard of care. OBJECTIVE: Our goal was to examine which health care providers use online rating websites and for what purposes, and whether health care providers use online patient ratings to improve patient care. METHODS: We conducted an online-based cross-sectional study by surveying 2360 physicians and other health care providers (September 2015). In addition to descriptive statistics, we performed multilevel logistic regression models to ascertain the effects of providers' demographics as well as report card-related variables on the likelihood that providers implement measures to improve patient care. RESULTS: Overall, more than half of the responding providers surveyed (54.66%, 1290/2360) used online ratings to derive measures to improve patient care (implemented measures: mean 3.06, SD 2.29). Ophthalmologists (68%, 40/59) and gynecologists (65.4%, 123/188) were most likely to implement any measures. The most widely implemented quality measures were related to communication with patients (28.77%, 679/2360), the appointment scheduling process (23.60%, 557/2360), and office workflow (21.23%, 501/2360). Scaled-survey results had a greater impact on deriving measures than narrative comments. Multilevel logistic regression models revealed medical specialty, the frequency of report card use, and the appraisal of the trustworthiness of scaled-survey ratings to be significantly associated predictors for implementing measures to improve patient care because of online ratings. CONCLUSIONS: Our results suggest that online ratings displayed on physician-rating websites have an impact on patient care. Despite the limitations of our study and unintended consequences of physician-rating websites, they still may have the potential to improve patient care.

A cross-sectional study assessing the association between online ratings and structural and quality of care measures: results from two German physician rating websites.

BACKGROUND: Even though physician rating websites (PRWs) have been gaining in importance in both practice and research, little evidence is available on the association of patients' online ratings with the quality of care of physicians. It thus remains unclear whether patients should rely on these ratings when selecting a physician. The objective of this study was to measure the association between online ratings and structural and quality of care measures for 65 physician practices from the German Integrated Health Care Network "Quality and Efficiency" (QuE). METHODS: Online reviews from two German PRWs were included which covered a three-year period (2011 to 2013) and included 1179 and 991 ratings, respectively. Information for 65 QuE practices was obtained for the year 2012 and included 21 measures related to structural information (N = 6), process quality (N = 10), intermediate outcomes (N = 2), patient satisfaction (N = 1), and costs (N = 2). The Spearman rank coefficient of correlation was applied to measure the association between ratings and practice-related information. RESULTS: Patient satisfaction results from offline surveys and the patients per doctor ratio in a practice were shown to be significantly associated with online ratings on both PRWs. For one PRW, additional significant associations could be shown between online ratings and cost-related measures for medication, preventative examinations, and one diabetes type 2-related intermediate outcome measure. There again, results from the second PRW showed significant associations with the age of the physicians and the number of patients per practice, four process-related quality measures for diabetes type 2 and asthma, and one cost-related measure for medication. CONCLUSIONS: Several significant associations were found which varied between the PRWs. Patients interested in the satisfaction of other patients with a physician might select a physician on the basis of online ratings. Even though our results indicate associations with some diabetes and asthma measures, but not with coronary heart disease measures, there is still insufficient evidence to draw strong conclusions. The limited number of practices in our study may have weakened our findings.

Information presentation features and comprehensibility of hospital report cards: design analysis and online survey among users.

BACKGROUND: Improving the transparency of information about the quality of health care providers is one way to improve health care quality. It is assumed that Internet information steers patients toward better-performing health care providers and will motivate providers to improve quality. However, the effect of public reporting on hospital quality is still small. One of the reasons is that users find it difficult to understand the formats in which information is presented. OBJECTIVE: We analyzed the presentation of risk-adjusted mortality rate (RAMR) for coronary angiography in the 10 most commonly used German public report cards to analyze the impact of information presentation features on their comprehensibility. We wanted to determine which information presentation features were utilized, were preferred by users, led to better comprehension, and had similar effects to those reported in evidence-based recommendations described in the literature. METHODS: The study consisted of 5 steps: (1) identification of best-practice evidence about the presentation of information on hospital report cards; (2) selection of a single risk-adjusted quality indicator; (3) selection of a sample of designs adopted by German public report cards; (4) identification of the information presentation elements used in public reporting initiatives in Germany; and (5) an online panel completed an online questionnaire that was conducted to determine if respondents were able to identify the hospital with the lowest RAMR and if respondents' hospital choices were associated with particular information design elements. RESULTS: Evidence-based recommendations were made relating to the following information presentation features relevant to report cards: evaluative table with symbols, tables without symbols, bar charts, bar charts without symbols, bar charts with symbols, symbols, evaluative word labels, highlighting, order of providers, high values to indicate good performance, explicit statements of whether high or low values indicate good performance, and incomplete data ("N/A" as a value). When investigating the RAMR in a sample of 10 hospitals' report cards, 7 of these information presentation features were identified. Of these, 5 information presentation features improved comprehensibility in a manner reported previously in literature. CONCLUSIONS: To our knowledge, this is the first study to systematically analyze the most commonly used public reporting card designs used in Germany. Best-practice evidence identified in international literature was in agreement with 5 findings about German report card designs: (1) avoid tables without symbols, (2) include bar charts with symbols, (3) state explicitly whether high or low values indicate good performance or provide a "good quality" range, (4) avoid incomplete data (N/A given as a value), and (5) rank hospitals by performance. However, these findings are preliminary and should be subject of further evaluation. The implementation of 4 of these recommendations should not present insurmountable obstacles. However, ranking hospitals by performance may present substantial difficulties.

Do German hospital report cards have the potential to improve the quality of care?

BACKGROUND: Hospitals report cards have been put in place within the past few years to increase the amount of publicly reported quality information in Germany. OBJECTIVE: The aim of this study was to assess the potential of German hospital report cards to improve quality of care. METHODS: First, a systematic Internet search aimed at identifying available report cards was conducted. Second, cross-sectional data (August/September 2013) were analyzed with respect to awareness, comprehension, and impact of report cards by using descriptive analysis and binary multivariate logistic regression models. RESULTS: Hospital report cards (N=62) have become broadly available. However, awareness remains low, about one third (35.6%) of all respondents (N=2027) were aware of German hospital report card. Regarding comprehensibility, in 60.7% of all experiments (N=6081), respondents selected the hospital with the lowest risk-adjusted mortality; significant differences could be determined between the report cards (p<.001) with scores ranging from 27.5% to 77.2%. Binary multivariate logistic regression analysis revealed different significant respondent-related predictors on each report card. Finally, an impact on hospital choice making was determined. CONCLUSIONS: To increase the potential of hospital report cards, health policy makers should promote the availability of report cards. In addition, the comprehensibility of German hospital report cards cannot be regarded as satisfying and should be enhanced in the future.

What do patients say about their physicians? an analysis of 3000 narrative comments posted on a German physician rating website.

BACKGROUND: Physician rating websites (PRWs) could be shown to have an impact on physician choice making. However, little research has been carried out to assess the content and nature of narrative comments. OBJECTIVE: The aim of this study was to explore the concerns of patients who commented on physician care and to address and enhance patient satisfaction. METHODS: Content analysis of 3000 randomly selected narrative comments from the German PRW, jameda, from 2012. We therefore developed a theoretical categorization framework addressing physician, staff, and practice related patient concerns. FINDINGS: In total, 50 sub-categories addressing the physician (N=20), the office staff (N=13), and the practice (N=17) were derived from the content of all comments. The most frequently mentioned concerns were assessing the professional competence of the physician (63%, N=1874) and friendliness of the physician (38%, N=1148). Thereby, 80% of all comments (mean length 45.3 words ± 42.8) were classified as positive, 4% as neutral and 16% as negative. CONCLUSION: Users of the German PRW, jameda, are mostly satisfied with their physicians. However, physicians should focus on the time spent with the patients, waiting time, as well as on taking the patients more seriously.

Physician choice making and characteristics associated with using physician-rating websites: cross-sectional study.

BACKGROUND: Over the past decade, physician-rating websites have been gaining attention in scientific literature and in the media. However, little knowledge is available about the awareness and the impact of using such sites on health care professionals. It also remains unclear what key predictors are associated with the knowledge and the use of physician-rating websites. OBJECTIVE: To estimate the current level of awareness and use of physician-rating websites in Germany and to determine their impact on physician choice making and the key predictors which are associated with the knowledge and the use of physician-rating websites. METHODS: This study was designed as a cross-sectional survey. An online panel was consulted in January 2013. A questionnaire was developed containing 28 questions; a pretest was carried out to assess the comprehension of the questionnaire. Several sociodemographic (eg, age, gender, health insurance status, Internet use) and 2 health-related independent variables (ie, health status and health care utilization) were included. Data were analyzed using descriptive statistics, chi-square tests, and t tests. Binary multivariate logistic regression models were performed for elaborating the characteristics of physician-rating website users. Results from the logistic regression are presented for both the observed and weighted sample. RESULTS: In total, 1505 respondents (mean age 43.73 years, SD 14.39; 857/1505, 57.25% female) completed our survey. Of all respondents, 32.09% (483/1505) heard of physician-rating websites and 25.32% (381/1505) already had used a website when searching for a physician. Furthermore, 11.03% (166/1505) had already posted a rating on a physician-rating website. Approximately 65.35% (249/381) consulted a particular physician based on the ratings shown on the websites; in contrast, 52.23% (199/381) had not consulted a particular physician because of the publicly reported ratings. Significantly higher likelihoods for being aware of the websites could be demonstrated for female participants (P<.001), those who were widowed (P=.01), covered by statutory health insurance (P=.02), and with higher health care utilization (P<.001). Health care utilization was significantly associated with all dependent variables in our multivariate logistic regression models (P<.001). Furthermore, significantly higher scores could be shown for health insurance status in the unweighted and Internet use in the weighted models. CONCLUSIONS: Neither health policy makers nor physicians should underestimate the influence of physician-rating websites. They already play an important role in providing information to help patients decide on an appropriate physician. Assuming there will be a rising level of public awareness, the influence of their use will increase well into the future. Future studies should assess the impact of physician-rating websites under experimental conditions and investigate whether physician-rating websites have the potential to reflect the quality of care offered by health care providers.

Eight questions about physician-rating websites: a systematic review.

BACKGROUND: Physician-rating websites (PRWs) are currently gaining in popularity because they increase transparency in the health care system. However, research on the characteristics and content of these portals remains limited. OBJECTIVE: To identify and synthesize published evidence in peer-reviewed journals regarding frequently discussed issues about PRWs. METHODS: Peer-reviewed English and German language literature was searched in seven databases (Medline (via PubMed), the Cochrane Library, Business Source Complete, ABI/Inform Complete, PsycInfo, Scopus, and ISI web of knowledge) without any time constraints. Additionally, reference lists of included studies were screened to assure completeness. The following eight previously defined questions were addressed: 1) What percentage of physicians has been rated? 2) What is the average number of ratings on PRWs? 3) Are there any differences among rated physicians related to socioeconomic status? 4) Are ratings more likely to be positive or negative? 5) What significance do patient narratives have? 6) How should physicians deal with PRWs? 7) What major shortcomings do PRWs have? 8) What recommendations can be made for further improvement of PRWs? RESULTS: Twenty-four articles published in peer-reviewed journals met our inclusion criteria. Most studies were published by US (n=13) and German (n=8) researchers; however, the focus differed considerably. The current usage of PRWs is still low but is increasing. International data show that 1 out of 6 physicians has been rated, and approximately 90% of all ratings on PRWs were positive. Although often a concern, we could not find any evidence of "doctor-bashing". Physicians should not ignore these websites, but rather, monitor the information available and use it for internal and ex-ternal purpose. Several shortcomings limit the significance of the results published on PRWs; some recommendations to address these limitations are presented. CONCLUSIONS: Although the number of publications is still low, PRWs are gaining more attention in research. But the current condition of PRWs is lacking. This is the case both in the United States and in Germany. Further research is necessary to increase the quality of the websites, especially from the patients' perspective.

Evaluation of two CD-ROMs from a series on cell biology.

Two CD-ROMs from a series dealing with various major aspects of cell biology are evaluated in this paper using quantitative and qualitative approaches. The findings delimit similarities and differences of the two CD-ROMs and shed light on how the programs could be used in the learning process and how they should not be. The overall impression, as well as the graphical and technical features, received a predominantly good rating. The defined target groups were reached (e.g., students in secondary schools), different learning approaches were supported (e.g., discovery and autonomous learning), the CD-ROMs' usability was assessed as being easy and intuitive, and the majority of the evaluators were satisfied with the level of interactivity. Navigational problems encountered in CD-ROM 1 were overcome by a successful implementation of new navigational functions in CD-ROM 2. Most students found the CD-ROM to be a suitable complement to, or an extension of, their lessons. We conclude that many, but not all of the requirements for the various stages of the learning process could be satisfied with the existing CD-ROMs. The requirements not met are discussed to obtain insights that could help to improve the production of multimedia learning material. The use of quantitative and qualitative approaches in the evaluation of learning modules is discussed, as the study began by collecting and analyzing anecdotal reviews and was then extended to include a qualitative evaluation.