Social media refers to a variety of web-based platforms where individuals create and share information, experiences, and ideas. In recent years, social media has transformed into an important form of communication that has led to significant changes across the globe, including political uprisings. The Office of Health Information Technology within the United States Department of Health and Human Services has recognized the significance of social media in healthcare and the opportunities that lie therein for both patients and providers [1]. Medical professionals and organizations utilize social media to promote health through education and advocacy, announce news and events, recruit employees, and communicate with other providers [2]. Similarly, patients use social media to gain medical knowledge, share experiences, and provide feedback [3]. A reported 24-42% of consumers have used social media to access health-related consumer reviews, including reviews of hospitals [3,4].

Twitter is one social media platform that allows individuals or organizations to post messages limited to 280 characters or less. According to Twitter’s official website, there are more than 300 million monthly active users around the world and over 500 million tweets per day [5]. Users may also follow the accounts of peers, public figures, and organizations, whose posts will automatically be displayed in a live, chronological feed. In recent years, more gastroenterologists have joined Twitter and engaged in academic discussions on a daily basis. Social media presence is modifiable and increased professional engagement could potentially impact institutional recognition and reputation. In a case study of a corporate brand, Twitter has been shown to amplify positive brand sentiments, and not only shape brand awareness and recognition but also reflect curiosity surrounding a brand [6]. Increased activity on Twitter has been shown to be correlated with Twitter following among US hospitals [7].

United States News and World Report (USNWR) boasts a reach of over 300 million readers [8]. Since 1990, USNWR annually publishes a Best Hospitals ranking of institutions and subspecialties, with 27.5% of an institution’s overall score determined by reputation score [6]. These rankings are often used as a marketing tool by hospital leaders to attract patients through traditional methods of advertising, as well as on social media [9-11]. USNWR hospital rankings have been shown to have a significant impact on consumer decisions in the form of a greater than 5% change in nonemergency Medicare patients, and an estimated $76 million in revenue transferred from lower ranked hospitals to higher ranked hospitals [9]. Among 42 urology departmental Twitter accounts, there was a significant correlation between Twitter followers with USNWR reputation score [12].

The aim of this study was to determine the degree to which institutional social media involvement, based on number of followers on Twitter, may be associated with USNWR gastroenterology and gastrointestinal (GI) surgery divisional rankings (all rankings henceforth are divisional rankings). A secondary aim was to determine whether social media presence is a predictor of improvement in USNWR rankings, and to attempt to define the growth necessary to achieve improved division rankings.

This was a cohort study of the top 30 institutions listed in the 2014 and 2016 USNWR gastroenterology and GI surgery subspecialty rankings. Data from the 2014 rankings were used to address the first aim, and to address the secondary aims a follow-up study compared data based on the 2014 and the 2016 USNWR rankings. Both the numeric ranking and the institutional reputation score were publicly available on the USNWR webpage. The number of Twitter followers corresponding to the 2014 and 2016 USNWR rankings were accessed in June 2015 and November 2016 at time of analysis, respectively, as displayed on each institution’s Twitter account. The official institutional Twitter accounts were identified using standard internet search tools, and hospital-specific Twitter accounts were included. Twitter accounts that appeared to combine hospital with medical school affairs were included. Medical school–specific, or university-specific accounts distinct from a hospital-based Twitter account, were excluded.

Spearman’s rank correlation coefficient was calculated to evaluate the association between institutional ranking and social media following. Pearson’s correlation coefficients were calculated to determine the association between social media presence and divisional reputation score. Multivariate analysis using linear regression was performed, controlling for number of hospital beds, academic affiliation, city population, and the number of full-time gastroenterologists on staff. SAS software (Cary, North Carolina) was used for statistical analyses. Among the covariates, the number of hospital beds was available online as it was published in the USNWR rankings. Other covariates such as academic affiliation (defined as an associated teaching hospital with gastroenterology fellowship training program) and number of full-time gastroenterologists on staff were obtained from the institutions’ official websites. Local population size of the city in which the institution is located was obtained from the latest United States Census Bureau figures.

For our secondary aim, two-tailed, two-sample t tests were performed to assess the association between 2014 and 2016 institutional rankings, or reputation scores, with changes in numbers of followers between 2014 and 2016. Multivariate analysis was performed using logistic and linear regression to adjust for the aforementioned covariates. Sensitivity analysis was performed by assessing the area under the receiver operating characteristic curve (AUROC) to determine the follower threshold associated with improved or maintained ranking, which was done by dichotomizing changes in followers at the 7000, 8000, 9000, 10,000, and 12,000 follower mark.

Of the top 29 institutions in the 2014 USNWR gastroenterology and GI surgery rankings, there were 28 distinct institutional Twitter accounts and one institution without a Twitter account (John Muir Medical Center). Among these Twitter accounts, the number of followers ranged from 0 to 1.7 million as of June 2015. Spearman’s rank correlation coefficient demonstrated a negative correlation between the number of Twitter followers and the numeric divisional ranking (ρ=–0.582; P<.001). Similarly, there was a positive correlation between Twitter followers and the divisional reputation score (ρ=0.91; P<.001) (Table 1). Twitter follower count was an independent predictor of divisional ranking on multivariate analysis controlling for the number of hospital beds, academic affiliation, local population, and number of full-time gastroenterologists on staff (β=0.00004, P<.001) (Table 1). Quantity of Twitter followers was also an independent predictor of USNWR reputation score after controlling for the same covariates (β=–0.00002, P=0.03) (Table 2 and Figure 1). Academic affiliation was an independent predictor of division ranking (β=5.3; P=0.04) and reputation score (β=–7.3; P=0.03) on USNWR (Table 2 and Table 3).

For the second aim, 39 hospitals were included in the analysis (Figure 2). Of the 2014 ranked institutions, five hospitals were no longer ranked in 2016 and four had rankings that had slipped under 30. Ten hospitals were newly ranked in the top 30 gastroenterology and GI surgery programs, and there were two institutions that were tied at rank #23 and #27. Of note, by 2016 the Mayo Clinic appeared three times in the top 30 ranking despite there being separate entries for the Rochester (MN), Phoenix (AZ), and Jacksonville (FL) campuses. Overall, 12 hospitals showed improved or maintained institutional ranking. Institutions with improved or maintained rankings had a significantly higher increase in followers over 1 year, with a difference of 89,287 versus 2271 (P=.03). On logistic regression, change in Twitter followers remained significantly associated with improved or maintained rankings (OR 14.63; 95% CI 1.08-197.81; P=.04). On sensitivity analysis, an increase of 8000 Twitter followers was associated with significantly higher area under the curve (AUC) (0.765) for prediction of improved or maintained ranking compared to other cutoffs (Figure 3). On multivariate analyses of 2016 rankings controlling for potential confounders using linear regression, the current number of Twitter followers for an institution was significantly associated with higher rank (β=–0.000017; P=.03) and reputation score (β=0.000036; P<.001). Academic status was also a significant predictor (β=3.446; P=.03) for reputation score.