Panel Size Tied to Online Ratings, Study Suggests

Marcia Frellick

March 21, 2018

Online patient ratings were lower for California urologists who had higher-volume practices, according to a research letter published online today in JAMA Surgery.

Gregory P. Murphy, MD, assistant professor of surgery at Washington University in St. Louis, Missouri, and colleagues found that for every 100 Medicare patients seen, ratings were lowered by 0.04 (P = .001) in a multivariable analysis.

The accuracy and usefulness of online rating systems are already hotly debated in medicine, and the authors acknowledge that more studies are needed to better determine what makes for more satisfied patients.

An expert not involved in the current study agrees that these data are only one step toward understanding the "sweet spot" of satisfaction levels and the busyness of a practice.

"There's always a challenge in knowing what the patients are actually reviewing us on," Kurt Angstman, MD, a family physician consultant at the Mayo Clinic in Rochester, Minnesota, told Medscape Medical News. "They may have had a great or bad experience with the front desk staff or with the wait."

Several Variables Studied

Murphy and colleagues reviewed 2014 Medicare billing and reimbursement data to determine the number of patients seen, number of services billed, physician sex, and practice setting (academic vs private) for 665 urologists in California. They then looked at those urologists' online patient ratings (range, 1-5, where 1 is lowest and 5 is best) and number of reviews from 4 websites (,,, and

The median number of Medicare patients seen per urologist in 2014 was 426 (interquartile range, 241 - 693), and a median number of services billed was 2293 (interquartile range, 845 - 5139).

Using a Wilcoxon method, they found a significant trend toward higher ratings for urologists who saw fewer Medicare patients.

The average number of reviews in the 4 websites combined was 10 for each urologist, and almost all the urologists (n = 651) had at least 1 rating. Most of the urologists in the sample were male (n = 600), and 581 worked in a nonacademic setting.

Female urologists had average weighted ratings similar to the men (3.9 [95% confidence interval (CI), 3.7 - 4.2] vs 3.8 [95% CI, 3.7 - 3.8]; P = .10).

Data Not Definitive

Angstman notes that the trend of more patients adding up to lower ratings is evident in the data, although there is not much difference in ratings between the low-, moderate-, and high-volume categories when the patient ratings were stratified by practice volumes only.

"The meat of their analysis was looking at the multivariate regression analysis," he said.

In that analysis, the researchers found that mean weighted ratings for academic urologists were 4.2 (95% confidence Interval [CI], 4 - 4.3) compared with 3.7 (95% CI, 3.6 - 3.8) for those in private practice (P < .001).

Researchers said they found that imbalance "surprising" and offered one explanation: "The perception of seeing an expert in a particular subspecialty may be appealing to patients and drive higher ratings," the authors write.

Other Research Has Found No Link

Angstman said the underlying hypothesis is reasonable; that if physicians are less busy and have more time to spend with patients and talk through concerns and care plans, it might follow that patients would be more satisfied.

However, Angstman and colleagues did not find that with their 2016 study, which looked at panel size for family medicine. That study included a look at whether patient satisfaction was related to panel size.

"We did not see any relationship between panel size and satisfaction," he said. "It may depend somewhat on the specialty."

In the current article by Murphy et al, the authors note that many procedures in urology are invasive, which could affect ratings.

Angstman agrees. "If you're meeting someone for the first time and they're doing a prostate biopsy, it's not a great time to develop patient satisfaction."

He added: "One of the reasons we did our study was to try to identify the 'sweet spot,' or the ideal panel size for the primary care physician. That's sort of what [Murphy et al] are getting at here: How busy is too busy? It doesn't quite get there." This study doesn't address outcomes, for one thing, he notes.

Even if the data were more definitive that busyness of a practice has a direct effect on patient satisfaction, the implications for using the data are not clear, Angstman said.

With surgery, for instance, a patient would likely value a surgeon who has had a heavy volume with a particular procedure because that would indicate they have honed their skillset.

"So you wouldn't want to say point-blank that a physician should only have a certain number of visits," Angstman said.

"It would also be tough to put limits on number of patients because of resources in the local environment," he notes.

The authors and Angstman have disclosed no relevant financial relationships. The Alafi Foundation was used to obtain Medicare data

JAMA Surg. Published online March 21, 2018. Extract

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