Referrals and Word of Mouth Trump Online Doctor Ratings

February 18, 2014

Patients increasingly use physician rating Web sites such as Vitals and Healthgrades, but word-of-mouth recommendations and referrals from other physicians nevertheless matter more to Americans when they select a clinician, according to a research letter published online today in the Journal of the American Medical Association (JAMA).

Lead author David Hanauer, MD, and coauthors also write that Americans consider online ratings for cars, movies, books, electronics, and appliances more helpful than those for physicians.

Then again, Web sites that review consumer goods and entertainment have been at it longer, said John Santa, MD, MPH, medical director of Consumer Reports Health, which has gotten into the physician rating business itself.

"The influence of physician ratings will go up," Dr. Santa told Medscape Medical News. "This is a science and endeavour that is in its infancy."

Dr. Hanauer and coauthors gleaned their findings from an online survey conducted in September 2012 that yielded 2137 responses. When it came to selecting a primary care physician, the factor most frequently rated as very important was "accepts my health insurance" (89%) followed at a distance by "convenient office location" (59%). Online ratings ranked last, with 41% flat-out calling them "not important."

Table 1. What Matters Most to Americans in Selecting a Physician

Factor in selecting a primary care physician Very important Somewhat important Not important
Accepts my health insurance 89% 6% 5%
Convenient office location 59% 36% 5%
Physician's years of experience 46% 46% 8%
Part of a trusted group practice 44% 37% 19%
Word of mouth (from family/friends) 38% 47% 15%
Referral from another physician 34% 46% 19%
Physician's rating on Web sites 19% 40% 41%

Source: Public Awareness, Perception, and Use of Online Physician Rating Sites. JAMA. 2014;311:734-735.

 

The results don't surprise Dr. Hanauer, an associate professor of pediatrics at the University of Michigan Medical School.

"Financial issues are so key today," said Dr. Hanauer, referring to health-plan acceptance, the top-ranked factor. "And I think people generally do trust family and friends as a reliable source of information."

Of survey-takers who had never used a physician rating Web site, 43% said they didn't trust the information there. "You don't know who left the comments, and you can't ask questions or have a back-and-forth conversation," Dr. Hanauer explained.

Fear of Physician Reprisal

The relative lack of importance assigned to online physician ratings may reflect how much the public knows about them. Sixty-five percent of respondents said they were aware that such Web sites exist, compared with higher percentages who knew about online ratings for cars (87%), movies or books (82%), and electronics or appliances (81%).

Of Americans who knew about physician rating Web sites, 36% used them at least once in the past year. In contrast, more than half of the respondents who knew about Web sites for movie or books, electronics or appliances, and restaurants were users. Differences between usage rates can be misleading, however, said Dr. Hanauer, because "you might look for a movie every week, but once you find a doctor, you might not go back to the rating site for a long time."

Among all respondents, roughly 23% used a physician rating Web site at least once in the past year. A study by the Kaiser Family Foundation, cited in the research letter, showed that only 6% of Americans used comparative quality data — whether it was online or in print — to choose a physician in 2008.

"Usage is going up," Dr. Hanauer told Medscape Medical News. "It could become second-nature someday."

In terms of usefulness, rating Web sites that specialize in physicians compared favorably with other ones. All of them were graded as very or somewhat useful by more than 90% of respondents.

"Among those who sought online physician ratings in the last year, 35% reported selecting a physician based on good ratings, and 37% had avoided a physician with bad ratings," write Dr. Hanauer and coauthors.

Five percent of survey takers said they had rated a physician or wrote a comment online. Of that group, 54% posted a positive rating, 29% a neutral rating, and 19% a negative one. The study suggests that more Americans might disparage their physicians online if they didn't fear repercussions. Roughly one in 3 worried about their identity being disclosed if they said something negative, and one in 4 worried about the physician retaliating.

Dr. Hanauer noted that some physicians require new patients to promise in writing that they will not post a negative review on a rating Web site.

"The Stakes Are Higher"

Physician rating Web sites have come under fire for being unreliable, partly because they usually derive their scores from a handful of patient responses. In addition, such Web sites focus on qualitative issues such as a physician's bedside manner as opposed to quantitative measures of clinical quality, according to critics.

Dr. Santa at Consumer Reports Health said that his organization is taking physician ratings to the next level by including hard data on adherence to practice guidelines for cancer screenings and pneumonia vaccination, and patients' control of blood pressure and hemoglobin A1c, among other measures. Consumer Reports currently rates physicians in California Massachusetts, Minnesota, and Wisconsin.

Quantitative measures of clinical performance are valuable, said Dr. Hanauer, but they can be just as unreliable as qualitative measures. For example, someone can grade pediatricians on the percentage of their patients who receive childhood vaccines.

"Some practices fire [parents of] patients who don't get vaccinated so they won't have bad numbers," said Dr. Hanauer. "We have to understand how these numbers can be manipulated."

For some physicians, just the mere thought of being rated online as if they were toasters or plumbers is enough to provoke grumbles. Dr. Santa counters that just because physicians are far more complicated than toasters or plumbers doesn't mean they shouldn't be evaluated.

"The public deserves to have more and better information about doctors," he said. "It's more risky choosing a doctor than a plumber."

Dr. Hanauer and his coauthors suggest as much. "The stakes," they write, "are higher."

The authors reported no conflicts of interest. Dr. Santa is an employee of Consumer Reports, which publishes physician ratings online.

JAMA . 2014;311:734-735.

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