Abstract
Background
To study the influence of the internet on the patient’s choice about Total Knee Replacement surgery and about their choice of surgeon for their Total Knee Replacement procedure.
Significance
Insight into patient’s decision making will help the surgeon to increase his/her visibility and also will help in providing true and reliable information about the patient’s ailment.
Materials and methods
We studied 200 patients who were operated by a single surgeon. They were given a questionnaire which had various questions regarding their name, age, sex, date of operation. It also had leading questions like did you or your relative searched the net about the operation and the operating surgeon? The information was collected by self filled questionnaire form.
Results
There were 166 females and 34 males. 70% of to be operated patients or their relatives searched the net before undergoing the Total knee replacement. Also 36% of patient relatives (mainly son or daughter) searched the surgeon on the net before finalizing the operation. 10% of patients searched the operating surgeon on the internet. 15% of patients or their relatives chose the operating surgeon based on their net search.
Conclusion
Our study shows that a sizable number of decision makers (patients and their children) search the information about the operation and about their operating surgeon. Hence it is recommended that the surgeon should have an information portal to increase his/her visibility, patient reach and imparting proper information to the prospective patients regarding the operative procedure.
Keywords: Patient search, Internet access, Orthopedic surgeon, Total knee replacement
Abbreviations: Total Knee Replacement, TKR
1. Introduction
Twenty first century is typically known by information explosion and is dominated by Google search engine. In USA there are various physician rating sites such as vitals.com, healthgrades.com, webmd.com. In India there are sites such as justdial.com, practo.com, lybrate.com, sehat.com, vitals.com, healthgrades.com, webmd.com. Increasing number of patients and their close relatives are surfing the net prior to their healthcare decisions.1 The internet penetration is increasing in developing countries like India.2 Social media and social networking on the Internet has revolutionized healthcare over the past ten years.3 Many innovative tools based on the Internet are used in hospitals, medical schools, and private clinics. These include electronic medical records, online medical courses, patient education modules, monitoring of patients status in the Intensive Care Unit.4, 5, 6 Historically, patients learned about physicians through primary care referrals and word of mouth; however, paths to surgeon identification today are much more widespread since the advent of the internet and the spike in social media outlets. Furthermore, communications between patients and surgeon have also shifted from the traditional telephone calls to emails, blogs, and internet-based methods. There are studies about the usage of the internet in pediatric orthopedic patients and in sports medicine specialty.7,8 To the best of our knowledge there are no studies about the influence of internet on patient’s choice about their TKR procedure and on choosing their operating surgeon. The purpose of the study is to analyze how much percent of patients or their close relatives searched the internet for their TKR procedure and about finalizing their operating surgeon. We started the study with null hypothesis i.e. internet does not influence the patient’s/decision makers choice of the operating surgeon. P value < 0.05 was considered significant.
2. Materials and methods
Assuming the alpha error of 0.05 and beta error of 0.05 and power of study of 95%, the sample size was calculated to be 185. Considering the dropouts, the sample size was rounded to 200. The study was started with null hypothesis; I.e. internet does not play important role in patients/decision makers’ decision of choosing their surgeon for their Total Knee Arthroplasty surgery. After obtaining local ethics committee approval and proper informed consent, we invited 220 patients to participate in the study. The respondents/study group population consisted of patients attending a joint replacement surgeon’s out-patient department prior to their Total Knee Replacement (TKR) surgery. The study period was between February 2016 and August 2018. The patients were given a questionnaire which comprised of 13 questions (Fig. 1). The questionnaire was available in four different languages (English, Hindi, Marathi and Gujarati) to cater the different mother tongues of the patients. The questions were devised to know whether the patients or their relatives have used the internet to learn about their orthopedic condition i.e. advanced osteoarthritis requiring TKR and deciding the choice of operating orthopedic surgeon. Depending upon the mother tongue, the patient was given the appropriate questionnaire. An inclusion criterion was patients attending joint replacement surgeon’s clinic just before their TKR procedure. Exclusion criteria included patients who refuse to participate in the study. 20 patients refused to participate in the study. Overall 200 patients filled the questionnaire. The questionnaire was designed using the metrics that had used before and had been found to be reliable in another outpatient orthopedic patient group.8 Patients were recruited by and provided consent to the independent study coordinator. The patient filled the questionnaire prior to meeting the surgeon before their proposed TKR operation. Fig. 1 shows the pro-forma of the questionnaire. The independent study coordinator administered and collected the questionnaire. The evaluation of the results was done by the independent study coordinator with the statistician. The MedCalc version 19 software was used to assess and analyze the results.
Fig. 1.
Sample form of questionnaire.
3. Results
Total study population was 200 patients. 166 patients were female with a mean age of 67 year, 34 were male with a mean age of 71 year. 152 patients (76%) had a college degree. 36% of patients had either a complete or partial insurance cover. 92% of patients had internet access at home mainly through mobile phones. Seventy percent of the patients or their relatives (32% patients and 38% of their relatives) searched the net for information on TKR before undergoing the TKR surgery. Regarding choosing the orthopedic surgeon, fifteen percent of the patients/decision makers relied on the internet (statistically significant p value = 0.009), 55% relied on word of mouth/family, friends and 30% via the physician referral. 34% of patients/relatives use physician rating sites for reviewing orthopedic surgeon. 36% of patient relatives (mainly son or daughter) on patient behalf searched the surgeon on the net before finalizing the operation. 10% of patients themselves searched the operating surgeon on the internet before undergoing TKR surgery. Of these 46% of patients/patient relatives who searched the orthopedic surgeon on internet, 15% responded that they chose the operating surgeon based on their internet search (Table 1).
Table 1.
Answers to the survey (percentage).
| Variables | Percentage | Total number |
|---|---|---|
| Graduation degree | 76 | 152 |
| Insurance cover | 36 | 72 |
| Patient searched information on Internet about TKR | 32 | 64 |
| Relative searched information on Internet about TKR | 38 | 76 |
| Chose the surgeon by Internet | 15 | 30 |
| Chose surgeon by word of mouth | 55 | 110 |
| Chose surgeon by physician reference | 30 | 60 |
| Patient searched the surgeons website | 10 | 20 |
| Relative searched the surgeons website | 36 | 72 |
As regards the graduation degree and insurance cover there was no statistically significant difference between male and female patients. Male patients searched the internet about their TKR procedure more than the female patients (67.64% versus 25%, statistically significant, p value = 0.0001). When it comes to relatives searching the internet for TKR procedure, the relatives of female patients searched the internet more than that of male patients (43.29% versus 14.71%, statistically significant, p value = 0.0014). There was no difference between male and female patients about their choosing the operating surgeon by internet (17.64% versus 14.64%, p value = 0.6505), word of mouth (55.88% versus 55.49%, p value = 0.9661) and physician reference (26.47% versus 31.10%, p value = 0.5849). Male patients searched the surgeons website more than the female patients (20.59% versus 7.93%, p value = 0.0234). There was no difference in the search of the surgeon’s website between the relatives of male and female patients (23.53% versus 39.02%, p value = 0.807) (Table 2). Patients/patient’s relatives who have searched the internet information are more likely to choose the surgeon based on internet information (21.43% vs. 0%, statistically significant p value 0.0001). Conversely patients/patient’s relatives who have not searched the internet information are more likely to choose the surgeon based on word of mouth information (71.67% vs. 47.86% statistically significant p value = 0.002) (Table 3). Comparison of variables between patients with college graduate degree versus patients without college degree shows that 18.42% of patients with college degree chose the surgeon based on internet information as against 4.16% of patients without college degree (statistically significant p value = 0.0161) (Table 4).
Table 2.
Comparison of various parameters between male and females.
| Variables | Males | Females | P value |
|---|---|---|---|
| Graduation degree | 26 (76.47%) | 126 (76.83%) | 0.9632 |
| Insurance cover | 19 (52.78%) | 53 (32.32%) | 0.0209 |
| Patient searched information on Internet about TKR | 23 (67.64%) | 41 (25%) | 0.0001 |
| Relative searched information on Internet about TKR | 5 (14.71%) | 71 (43.29%) | 0.0014 |
| Chose the surgeon by Internet | 6 (17.64%) | 24 (14.64%) | 0.6505 |
| Chose surgeon by word of mouth | 19 (55.88%) | 91 (55.49%) | 0.9661 |
| Chose surgeon by physician reference | 9 (26.47%) | 51 (31.10%) | 0.5849 |
| Patient Searched the surgeons website | 7 (20.59%) | 13 (7.93%) | 0.0234 |
| Relative Searched the surgeons website | 8 (23.53%) | 64 (39.02%) | 0.0807 |
Table 3.
Comparison of variables among the two groups (those using internet vs. those not using internet).
| Patient/Patient’s relative using internet for information on TKR | Patient/Patient’s relative not using internet for information on TKR | p Value | |
|---|---|---|---|
| Total Number | 140 (70%) | 60 (30%) | |
| Chose surgeon by internet | 30 (21.43%) | 0 (0%) | 0.0001 |
| Chose surgeon by word of mouth | 67 (47.86%) | 43 (71.67%) | 0.002 |
| Chose surgeon by physician reference | 43 (30.71%) | 17 (28.33%) | 0.7381 |
Table 4.
Comparison of variables among the two groups (college graduates vs. non graduates).
| Patients with college graduate degree | Patients without college graduate degree | p Value | |
|---|---|---|---|
| Total Number | 152 (76%) | 48 (24%) | |
| Searched information on internet | 52 (34.21%) | 12 (25%) | 0.2342 |
| Chose surgeon by internet | 28 (18.42%) | 2 (4.16%) | 0.0161 |
| Chose surgeon by word of mouth | 81 (53.28%) | 29 (60.42%) | 0.7934 |
| Chose surgeon by physician reference | 43 (28.29%) | 17 (35.42%) | 0.3486 |
4. Discussion
The aim of the present study was to study how much percent of patients or their close relatives searched the internet for their TKR procedure and about finalizing their operating surgeon. There have been few studies in orthopedics namely pediatrics orthopedics and sports medicine specialty to understand the internet search pattern in orthopedic patients. Aslam et al.7 observed that parents frequently use internet based information before pediatric orthopedic consultations. Koenig et al.8 observed that 54% patients read internet information about their condition while 32% surfed for surgeons before their visit. They found that most patients were either neutral toward or did not trust the internet-based information. They suggested in order helping patients avoid misleading information, sports medicine providers should understand how patients are using the internet and guide patients in selecting high-quality, peer-reviewed sources of information. Matzkin et al.9 showed that over 50% of all orthopedic patients use social media or Internet for work or personal communication and up to 26% of all patients have seen or used a physician review site prior to their initial visit. Kevin Koo et al.10 demonstrated that patients with higher education were more likely to do background reading and to use the internet when compared to those with no graduation degrees. More interestingly, different education levels may result in different reactions from the patients. In their study, though education level was not a factor in causing confusion following internet reading, individuals with no graduation degrees were shown to have more anxiety after reading when compared to their counterparts. In our study seventy six percent of the patients held a graduation degree. When assessing outpatients’ use and perceptions of the internet, Burrus et al.11 found that 64.7% of patients with access to the internet used it to research orthopedic information prior to their office visit. In addition, they found that younger male patients were more likely to reference internet-based sources of orthopedic information. In our study, seventy percent of the patients or their relatives (32% patients and 38% of their relatives) searched the net for information on TKR before undergoing the TKR surgery. Regarding choosing the orthopedic surgeon, fifteen percent of the patients relied on the internet (statistically significant p value = 0.009), 55% relied on word of mouth/family, friends and 30% via the physician referral. 15% of patients in our study group used the internet to find information about their condition, and overall 46% (10% patients and 36% relatives) accessed surgeon-rating websites. These findings are significant as internet usage percentage in India is still low as compared to developed world. The Current internet usage percentage in India is 55.40%. The percentage for USA is 96.26%, Canada 92.70%, United Kingdom 94.62%, and Germany is 86%.2 Internet usage in India is likely to rise by 40% by 2023.12 So correspondingly the percentage of patients using the internet based resources for their health care decisions is also likely to increase.
Our study had few limitations. First limitation is the study group consists of elderly population. Elderly population is less active on social media as against the younger population who visited sports medicine clinic in a previous mentioned study.8 This is understandable as advanced osteoarthritis of the knee requiring TKR occurs in elderly population. This limitation is of set by the fact that patient’s children, who also play an important role in decision making, are net savvy. Second limitation is higher percentage of female patients in the study group, 166 female and 34 male patients. This is not unusual as numerous studies have shown that women are more prone to have advanced symptomatic osteoarthritis.13, 14, 15 Third limitation is there could be some bias in decision making on part of the patients when searching the internet. This is due to probable influence of search engine optimization. To the best of our knowledge, ours is the first study of its kind which analyzes the online resources Indian patients utilize to approach an orthopedic surgeon before undergoing total knee replacement. Few other studies like Shen et al.,16 Fraval et al.,5 Meneghini et al.17 and Carlin et al.18 have analyzed the trends of the internet usage by the orthopedic outpatients. In the current study, seventy percent (32% patients themselves and 38% relatives) of our patients searched information on internet about TKR before approaching the surgeon for getting the procedure done. This is the only study about the Indian patients undergoing knee replacement, to show how patients and their relatives utilize various influencers such as internet information, other physician reference and word of mouth before making the clinical visit and finalizing their TKR procedure.
5. Conclusion
In our study 70% of patients or their relatives searched the internet about information on the TKR. Also 15% of patients/decision makers based their decision of choosing the operating surgeon on the internet search. This clearly demonstrates that internet has a sizable influence on the decision making process of the patients and their relatives about their TKR operation. Hence it will be useful that the surgeon should have an information portal to increase his visibility and patient reach. To help patients avoid misleading information, orthopedic surgeons should understand how patients are using the internet and guide patients in selecting high-quality, peer-reviewed sources of information. Doing so will allow them to proactively educate their patients even after the clinic visit.
Funding
There is no funding source.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Declaration of competing interest
The authors do not have any conflict of interest related to this work.
Contributor Information
Sanjay Bhalchandra Londhe, Email: sanlondhe@yahoo.com.
Ravi Vinod Shah, Email: rvsorth@yahoo.co.in.
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