One Decade of Online Patient Feedback : A Longitudinal Analysis of Data from a German Physician Rating Website

BACKGROUND: Feedback from patients is an essential element of a patient-oriented health care system. Physician rating websites (PRWs) are a key way patients can provide feedback online. This study analyzes an entire decade of online ratings for all medical specialties on a German PRW. OBJECTIVE: The aim of this study was to examine how ratings posted on a German PRW have developed over the past decade. In particular, it aimed to explore (1) the distribution of ratings according to time-related aspects (year, month, day of the week, and hour of the day) between 2010 and 2019, (2) the number of physicians with ratings, (3) the average number of ratings per physician, (4) the average rating, (5) whether differences exist between medical specialties, and (6) the characteristics of the patients rating physicians. METHODS: All scaled-survey online ratings that were posted on the German PRW jameda between 2010 and 2019 were obtained. RESULTS: In total, 1,906,146 ratings were posted on jameda between 2010 and 2019 for 127,921 physicians. The number of rated physicians increased constantly from 19,305 in 2010 to 82,511 in 2018. The average number of ratings per rated physicians increased from 1.65 (SD 1.56) in 2010 to 3.19 (SD 4.69) in 2019. Overall, 75.2% (1,432,624/1,906,146) of all ratings were in the best rating category of “very good,” and 5.7% (107,912/1,906,146) of the ratings were in the lowest category of “insufficient.” However, the mean of all ratings was 1.76 (SD 1.53) on the German school grade 6-point rating scale (1 being the best) with a relatively constant distribution over time. General practitioners, internists, and gynecologists received the highest number of ratings (343,242, 266,899, and 232,914, respectively). Male patients, those of higher age, and those covered by private health insurance gave significantly (P100 ratings received the best ratings (mean 1.34, SD 0.47). CONCLUSIONS: This study is one of the most comprehensive analyses of PRW ratings to date. More than half of all German physicians have been rated on jameda each year since 2016, and the overall average number of ratings per rated physicians nearly doubled over the decade. Nevertheless, we could also observe a decline in the number of ratings over the last 2 years. Future studies should investigate the most recent development in the number of ratings on both other German and international PRWs as well as reasons for the heterogeneity in online ratings by medical specialty

International Portability of Health-Cost Cover: Mobility, Insurance, and Redistribution

Public health insurance and other arrangements covering health costs effectively provide insurance against changes in health status. These arrangements engage in burden-smoothing over the life cycle and entail various elements of redistribution. Lack of portability regarding this type of cover may impede international mobility and create financial losses or windfall gains on various sides, which can lead to risk segmentation across national health systems. Existing portability rules do not fully address these problems. In this article, we try to clarify the implications of mobility for typical systems covering health costs and the requirements which have to be met to ensure full portability. When individuals are internationally mobile, compensating payments are needed based on changes in expected net costs in both of the health funds involved. Illustrative simulations show that this approach may be operative under real-world conditions. (JEL codes: F22, F55, H51, H73, J6

Developments in the Frequency of Ratings and Evaluation Tendencies: A Review of German Physician Rating Websites

Background: Physician rating websites (PRWs) have been developed to allow all patients to rate, comment, and discuss physicians’ quality online as a source of information for others searching for a physician. At the beginning of 2010, a sample of 298 randomly selected physicians from the physician associations in Hamburg and Thuringia were searched for on 6 German PRWs to examine the frequency of ratings and evaluation tendencies. Objective: The objective of this study was to examine (1) the number of identifiable physicians on German PRWs; (2) the number of rated physicians on German PRWs; (3) the average and maximum number of ratings per physician on German PRWs; (4) the average rating on German PRWs; (5) the website visitor ranking positions of German PRWs; and (6) how these data compare with 2010 results. Methods: A random stratified sample of 298 selected physicians from the physician associations in Hamburg and Thuringia was generated. Every selected physician was searched for on the 6 PRWs (Jameda, Imedo, Docinsider, Esando, Topmedic, and Medführer) used in the 2010 study and a PRW, Arztnavigator, launched by Allgemeine Ortskrankenkasse (AOK). Results: The results were as follows: (1) Between 65.1% (194/298) on Imedo to 94.6% (282/298) on AOK-Arztnavigator of the physicians were identified on the selected PRWs. (2) Between 16.4% (49/298) on Esando to 83.2% (248/298) on Jameda of the sample had been rated at least once. (3) The average number of ratings per physician ranged from 1.2 (Esando) to 7.5 (AOK-Arztnavigator). The maximum number of ratings per physician ranged from 3 (Esando) to 115 (Docinsider), indicating an increase compared with the ratings of 2 to 27 in the 2010 study sample. (4) The average converted standardized rating (1=positive, 2=neutral, and 3=negative) ranged from 1.0 (Medführer) to 1.2 (Jameda and Topmedic). (5) Only Jameda (position 317) and Medführer (position 9796) were placed among the top 10,000 visited websites in Germany. Conclusions: Whereas there has been an overall increase in the number of ratings when summing up ratings from all 7 analyzed German PRWs, this represents an average addition of only 4 new ratings per physician in a year. The increase has also not been even across the PRWs, and it would be advisable for the users of PRWs to utilize a number of PRWs to ascertain the rating of any given physician. Further research is needed to identify barriers for patients to rate their physicians and to assist efforts to increase the number of ratings on PRWs to consequently improve the fairness and practical importance of PRWs

Optimising growth paths of beef cattle in northern Australia for increased profit

This project investigated reducing slaughter age of northern cattle through modifications of growth paths using supplements or improved pasture. In a grazing trial at Swans Lagoon steers grazing native pasture were fed from weaning either at low-plane (urea only - Control) or with high-input molasses-based supplement (MUP) in either one or both dry seasons prior to slaughter. A further group were finished on leucaena. Steers fed in only one dry season reached similar slaughter weight to those fed in both with 22% less supplement intake. Hormonal growth promotants (HGPs) given to half the steers continuously from weaning increased growth rate by 8% in most groups, and by 22% whilst steers grazed leucaena, and increased the net value added to steers despite impeding compliance with Meat Standards Australia (MSA). An economic analysis showed that leucaena, but not high-input supplements, increased profitability - the use of improved forages, combined with manipulation of body composition and associated compensatory gain offer the most cost-effective options for reducing slaughter age. Associated pen-feeding studies established that young (8-12 mo) and older (30-33 mo) steers responded similarly (kg extra gain/kg supplement) to additional nutrients and that responses increased in order of MUP, barley/urea and cottonseed meal. Studies indicated that the Australian feeding standards could not currently be relied upon to predict intake of grazing cattle in the tropics

Efficiency of rumen microbial protein synthesis in cattle grazing tropical pastures as estimated by a novel technique

The efficiency of microbial protein synthesis (EMPS) in cattle grazing a range of tropical pasture types was examined using a new method of intra-jugular infusion of CrEDTA to estimate urinary excretion of purine derivatives (PD). Seven pasture types were studied in south-east Queensland, Australia, over a 13-month period. These included native tropical grass (C4) pasture (major species Heteropogon contortus and Bothriochloa bladhii) studied in the early wet, the wet/dry transition and the dry season; introduced tropical grass (C4) pasture (Bothriochloa insculpta) in the mid wet season; two introduced tropical legume species (C3), (Lablab purpureus and Clitoria ternatea); and the temperate grass (C3) pasture, ryegrass (Lolium multiflorum). There was a large range in EMPS across pasture types: 26-209 g microbial crude protein (MCP)/kg digestible organic matter intake (DOMI). Estimated rumen degradable protein (RDP) supply (42-525 g/kg DOMI) was the major factor associated with EMPS across the range of pasture types studied. EMPS in steers grazing all tropical grass pastures was low (<130 g/kg DOMI) and limited by RDP supply. Negative linear relationships (P<0.05) between EMPS and both neutral detergent fibre (NDF) and acid detergent fibre (ADF) concentrations in extrusa were evident. However, non-fibre carbohydrate in extrusa, total non-structural carbohydrate concentration in plucked pasture leaf, rumen fluid and particle dilution rate, protozoal concentration in rumen fluid and rumen fluid pH were not correlated with EMPS. It was concluded that EMPS was well below 130 g MCP/kg DOMI when cattle grazed unfertilised, tropical grass pastures in south-east Queensland and that RDP was the primary limiting nutrient. High EMPS was associated with very high RDP, vastly in excess of RDP requirements by microbe

Re-defining the animal unit equivalence (AE) for grazing ruminants and its application for determining forage intake, with particular relevance to the northern Australian grazing industries

The adult equivalent (AE) system describes and quantifies, in commonly recognised units, the grazing pressure imposed on the pasture by foraging ruminants. The AE rank assigned to an animal is determined as the ratio of its (metabolisable) energy (ME) requirements relative to that of a ‘standard animal’, where ME requirements are usually determined using the feeding standards. Previous research has indicated that the Australian feeding standards (NRDR 2007) considerably over-estimated the energy requirements of cattle consuming tropical forages in northern Australia. In the current project, modifications were made to the equations of the feeding standards which improved predictions of ME, and so also forage dry matter (DM) intake by cattle. However, these changes were not tested with cattle in temperate regions, or sheep in any region meaning that two systems, one using modified and the other unmodified equations, were required to accommodate this regional demarcation. Simulations carried out using cattle growth data from northern Australia showed that the estimate of AE score was similar using either system providing they were used systematically. Furthermore, it was found that the forage intake predicted by direct calculation using the modified system could be closely matched by calculating an AE rank using the unmodified system and then multiplying this rank by an intake constant. The optimum intake constant fluctuated with regional variations in animal productivity. This agreement between predictions suggested that, for most circumstances, the existing (unmodified) feeding standards could be used across regional boundaries. Recommendations are made for application of the revised animal unit systems to practical grazing scenarios and forms the basis of revising current EDGE (NutritionEDGE) material

Regulating open disclosure: a German perspective

The issue of open disclosure has received growing attention from policy-makers, legal experts and academic researchers, predominantly in a number of English-speaking countries. While implementing open disclosure in practice is still an on-going process, open disclosure now forms an integral part of health policy in various American states, the UK, Canada, Australia and New Zealand, with a number of measures having been put in place to encourage open disclosure and to mitigate some of the barriers to such open communication. In contrast, this issue has received little attention in non-English-speaking countries and there is currently no empirical data relating to actual practice or practitioners' attitudes and views in most countries in continental Europe. This article critically examines Germany's current approach to open disclosure. It finds that the issue plays no significant role in German health policy with very limited measures explicitly concerning such communication currently in place. While a number of aspects of the wider regulatory framework appear to be supportive, Germany is still in the early stages of a systematic approach and additional measures are required to further promote open disclosure within the self-governing German healthcare system. This exploration provides an example of a non-English-speaking country's approach to open disclosure and may be of particular interest to neighbouring German-speaking and civil law countries such as Switzerland and Austri

Public awareness and use of German physician ratings sites: Cross-sectional survey of four north German cities

Background: Physician rating websites (PRWs) allow patients to rate, comment, and discuss physicians’ quality. The ability of PRWs to influence patient decision making and health care quality is dependent, in part, on sufficient awareness and usage of PRWs. However, previous studies have found relatively low levels of awareness and usage of PRWs, which has raised concerns about the representativeness and validity of information on PRWs. Objective: The objectives of this study were to examine (1) participants’ awareness, use, and contribution of ratings on PRWs and how this compares with other rating websites; (2) factors that predict awareness, use, and contribution of ratings on PRWs; and (3) participants’ attitudes toward PRWs in relation to selecting a physician. Methods: A mailed cross-sectional survey was sent to a random sample (N=1542) from four North German cities (Nordhorn, Hildesheim, Bremen, and Hambur g) between April and July 2016. Survey questions explored respondents’ awareness, use, and contribution of ratings on rating websites for service (physicians, hospitals, and hotels and restaurants) and products (media and technical) in general and the role of PRWs when searching for a new physician. Results: A total of 280 completed surveys were returned (280/1542, 18.16% response rate), with the following findings: (1) Overall, 72.5% (200/276) of respondents were aware of PRWs. Of the respondents who were aware of PRWs, 43.6% (86/197) had used PRWs. Of the respondents who had used PRWs, 23% (19/83) had rated physicians at least once. Awareness, use, and contribution of ratings on PRWs were significantly lower in comparison with all other rating websites, except for hospital rating websites. (2) Except for the impact of responders’ gender and marital status on the awareness of PRWs and responders’ age on the use of PRWs, no other predictors had a relevant impact. (3) Whereas 31.8% (85/267) of the respondents reported that PRWs were a very important or somewhat important information source when searching for a new physician, respondents significantly more often reported that family , friends and colleagues (259/277, 93.5%), other physicians (219/274, 79.9%), and practice websites (108/266, 40.6%) were important information sources. Conclusions: Whereas awareness of German PRWs appears to have substantially increased, the use of PRWs and contribution of ratings remains relatively low. Further research is needed to examine the reasons why only a few patients are rating physicians. However, given the information inequality between provider and consumer will always be higher for consumers using the services of physicians, it is possible that people will always rely more on interpersonal recommendations than impersonal public information before selecting a physician