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Customer-oriented health care management and patient satisfaction have become important for physicians to attract patients in an increasingly competitive environment. Satisfaction influences patients’ choice of physician and leads to higher patient retention and higher willingness to engage in positive word of mouth. In addition, higher satisfaction has positive effects on patients’ willingness to follow the advice given by the physician. In recent years, physician-rating websites (PRWs) have emerged in the health care sector and are increasingly used by patients. Patients’ usage includes either posting an evaluation to provide feedback to others about their own experience with a physician or reading evaluations of other patients before choosing a physician. The emergence of PRWs offers new avenues to analyze patient satisfaction and its key drivers. PRW data enable both satisfaction analyses and implications on the level of the individual physician as well as satisfaction analyses and implications on an overall level.
This study aimed to identify linear and nonlinear effects of patients’ perceived quality of physician appointment service attributes on the overall evaluation measures that are published on PRWs.
We analyzed large-scale survey data from a German PRW containing 84,680 surveys of patients rating a total of 7038 physicians on 24 service attributes and 4 overall evaluation measures. Elasticities are estimated from regression models with perceived attribute quality as explanatory variables and overall evaluation measures as dependent variables. Depending on the magnitude of the elasticity, service attributes are classified into 3 categories: attributes with diminishing, constant, or increasing returns to overall evaluation.
The proposed approach revealed new insights into what patients value when visiting physicians and what they take for granted. Improvements in the physicians’ pleasantness and friendliness have increasing returns to the publicly available overall evaluation (b=1.26). The practices’ cleanliness (b=1.05) and the communication behavior of a physician during a visit (b level between .97 and 1.03) have constant returns. Indiscretion in the waiting rooms, extended waiting times, and a lack of modernity of the medical equipment (b level between .46 and .59) have the strongest diminishing returns to overall evaluation.
The categorization of the service attributes supports physicians in identifying potential for improvements and prioritizing resource allocation to improve the publicly available overall evaluation ratings on PRWs. Thus, the study contributes to patient-centered health care management and, furthermore, promotes the utility of PRWs through large-scale data analysis.
Patients are taking a more active role in the decision-making process concerning their medical care [
From a physician’s point of view, PRWs are important because patients’ perceptions of the physician’s service quality are made publicly available. This fact substantially increases the relevance of patient satisfaction to generate positive word of mouth [
The emergence of PRWs offers new avenues to analyze patient satisfaction and its key drivers. Existing studies on key drivers of patient satisfaction are usually based on small sample sizes [
A broad base of literature has been published so far to investigate PRWs by researchers in many countries worldwide, such as Germany [
Several points of criticism, however, can be addressed toward PRWs. The literature is inconsistent with regard to the link between information revealed on rating sites and quality of care [
Text mining approaches [
Holliday et al [
Information posted on PRWs and especially data in numerical rating scales can be valuable for different stakeholders. Information delivered on PRWs should be of interest not only for patients but also for physicians and other health care providers. Finally, information based on PRW data can help (noncommercial) PRW providers to justify their business model.
Customer-oriented health care management and patient satisfaction have become important for physicians in their attempt to attract patients in an increasingly competitive environment [
Diminishing returns mean that improvements in perceived attribute quality have a positive impact on overall evaluation but to a decreasing extent. This means that the contribution to an increase in the overall evaluation gets smaller with increasing perceived attribute quality (following a monotonically increasing and concave function). These service attributes are labeled
Constant returns mean that improvements in perceived attribute quality have a positive impact on overall evaluation and that the contribution to the improvements remains the same along the scale of possible levels of perceived attribute quality (following a monotonically increasing and linear function). Service attributes with constant returns are denominated as
Increasing returns hold that improvements in perceived attribute quality have a positive impact on overall evaluation, but now the contribution to an increase in the overall evaluation expands in size with increasing perceived attribute quality (following a monotonically increasing and convex function). Service attributes with increasing returns are denominated as
Beyond satisfaction or any kind of overall attitude, perceived service quality can also influence repeated purchases [
To the best of our knowledge, no study has conducted a key driver analysis of patient satisfaction using online physician-rating data and thus has taken a comprehensive perspective on the utility of PRWs. Our study aimed to fill this research gap.
In our study, we used the database of the German noncommercial PRW
The online and offline surveys were identical. In the survey, patients were asked several questions related to the following service dimensions: office and staff, communication, and medical treatment by the chosen physician. The questions were worded in the form of 24 different statements, which can be answered on a 4-point scale with 1 as
Means and standard deviations of the service attributes and overall evaluations.
Service attributes and overall evaluations | Values, mean (SD) | |
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||
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The physician has a pleasant and friendly manner | 3.84 (0.45) |
|
The physician listens to me carefully | 3.77 (0.55) |
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The physician handles my questions, concerns, and fears in an empathetic way | 3.74 (0.58) |
|
The physician’s office is clean and neat | 3.85 (0.39) |
|
The physician indicates clearly how to take prescribed medication | 3.80 (0.48) |
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The physician explains diagnoses, causes, and treatments so that I understand everything | 3.72 (0.58) |
|
The physician does not hurry during the medical treatment | 3.68 (0.61) |
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I have the impression that the physician will refer me to a specialist if this is medically necessary | 3.78 (0.52) |
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The physician explains exactly the benefits and associated risks of proposed medical treatments | 3.67 (0.62) |
|
Personal medical records are handled with confidentiality | 3.78 (0.48) |
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In case of disease, the physician explains various treatment options | 3.64 (0.65) |
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The physician involves me in decisions about upcoming examinations and treatments | 3.66 (0.63) |
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The physician conducts physical examinations of me thoroughly | 3.63 (0.66) |
|
The physician’s office creates a well-organized impression | 3.70 (0.57) |
|
The protection of my privacy is respected in the office | 3.74 (0.53) |
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The staff makes me feel welcome | 3.71 (0.56) |
|
The physician’s office is nicely decorated | 3.63 (0.58) |
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Consultation time and absences are clearly communicated | 3.75 (0.52) |
|
The physician regularly enquires about my tolerance of the prescribed medication | 3.40 (0.81) |
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The period between the first contact and the medical appointment is appropriate | 3.57 (0.65) |
|
The medical equipment in the office creates a modern impression | 3.37 (0.71) |
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The waiting time before entering the physician’s office is adequate | 3.38 (0.76) |
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The waiting area offers enough space to maintain a distance from other patients | 3.33 (0.77) |
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Mentioning the reason for my visit in front of other patients is avoided | 3.50 (0.74) |
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Overall impression | 3.11 (0.85) |
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Experience with results | 2.98 (0.86) |
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Willingness to recommend | 3.57 (0.82) |
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Willingness to revisit | 3.80 (0.62) |
In summary, we had access to a representative random sample containing 84,680 surveys of patients rating a total of 7038 general practitioners collected up to September 2014 (the PRW was launched in May 2011). The number of completed surveys for each physician is between 5 as a minimum and 82 as maximum. In the sample, the average number of completed surveys for each physician is 12 (SD 7). In
A number of methods for identification of the 3-factor structure of customer satisfaction have been developed and applied outside health care research (for a review of these methods and their application, see the study by Arbore and Busacca [
We used log-log regression models for our analyses. This modeling approach draws from econometric models of demand [
To empirically identify the 3 different types of response patterns (ie, diminishing, constant, or increasing returns) using the log-log regression model, we first took the natural logarithm (
Depending on the magnitude of the parameter estimate
Importantly, our proposed approach of a multiattribute model with nonlinear slope coefficients held a number of relevant assumptions. First, following previous research [
To test the robustness of the results from our approach, additional calculations were carried out: to show that our empirical findings do not rely on the log-log regression model only, we analyzed the data with 2 alternative approaches (the results of the robustness checks are available on request). In our first robustness check, we estimated elasticities from a standard linear-linear regression model by multiplying the resulting linear slope coefficients with the ratio of
To assess the relationship between each service attribute and each overall evaluation, we estimated the log-log regression models with each service attribute in a single equation as proposed in the Methods section. This procedure offers 2 further advantages besides providing a different starting point of the curve for each service attribute and each physician. First, because of many service attributes in our setting that are correlated in their ratings, 1 multiple regression equation will produce severe multicollinearity problems. Second, as the answers
Classification of a service attribute depends on 2 determinants: the size of
Parameter estimates and model diagnostics of log-log regression models 1 (sorted by the size of b).
Service attributes | Overall impression | ||
b (bsa 95% CI) | R2 | Number of observations used, N | |
The physician has a pleasant and friendly manner | 1.26 (1.19-1.34) | 0.33 | 83,697 |
The physician listens to me carefully | 1.09 (1.05-1.14) | 0.4 | 82,887 |
The physician handles my questions, concerns, and fears in an empathetic way | 1.05 (1.02-1.09) | 0.43 | 83,509 |
The physician’s office is clean and neat | 1.05 (0.97-1.15) | 0.14 | 82,924 |
The physician indicates clearly how to take prescribed medication | 1.03 (0.97-1.09) | 0.27 | 82,697 |
The physician explains diagnoses, causes, and treatments so that I understand everything | 1.01 (0.97-1.05) | 0.38 | 83,341 |
The physician does not hurry during the medical treatment | .97 (0.93-1.01) | 0.39 | 83,393 |
I have the impression that the physician will refer me to a specialist if this is medically necessary | .93 (0.87-0.99) | 0.27 | 83,123 |
The physician explains exactly the benefits and associated risks of proposed medical treatments | .92 (0.88-0.95) | 0.39 | 81,536 |
Personal medical records are handled with confidentiality | .88 (0.81-0.96) | 0.19 | 82,541 |
In case of disease, the physician explains various treatment options | .87 (0.84-0.91) | 0.4 | 80,961 |
The physician involves me in decisions about upcoming examinations and treatments | .87 (0.84-0.91) | 0.37 | 80,343 |
The physician conducts physical examinations of me thoroughly | .86 (0.82-0.90) | 0.38 | 82,936 |
The physician’s office creates a well-organized impression | .85 (0.80-0.91) | 0.25 | 82,937 |
The protection of my privacy is respected in the office | .82 (0.75-0.88) | 0.21 | 82,095 |
The staff makes me feel welcome | .80 (0.74-0.86) | 0.22 | 83,254 |
The physician’s office is nicely decorated | .72 (0.66-0.77) | 0.16 | 82,928 |
Consultation time and absences are clearly communicated | .71 (0.66-0.77) | 0.15 | 81,931 |
The physician regularly enquires about my tolerance of the prescribed medication | .63 (0.60-0.66) | 0.34 | 79,255 |
The period between the first contact and the medical appointment is appropriate | .59 (0.53-0.63) | 0.17 | 81,183 |
The medical equipment in the office creates a modern impression | .59 (0.55-0.63) | 0.21 | 74,618 |
The waiting time before entering the physician’s office is adequate | .52 (0.48-0.56) | 0.18 | 82,839 |
The waiting area offers enough space to maintain a distance from other patients | .46 (0.43-0.50) | 0.15 | 82,948 |
Mentioning the reason for my visit in front of other patients is avoided | .46 (0.42-0.50) | 0.14 | 81,753 |
abs: bootstrapped.
Parameter estimates and model diagnostics of log-log regression models 2 (sorted by the size of b for overall impression).
Service attributes | Experience with results | ||
b (bsa 95% CI) | R2 | Number of observations used, N | |
The physician has a pleasant and friendly manner | 1.18 (1.10-1.26) | 0.27 | 83,625 |
The physician listens to me carefully | 1.06 (1.01-1.11) | 0.35 | 82,824 |
The physician handles my questions, concerns, and fears in an empathetic way | 1.02 (0.98-1.07) | 0.38 | 83,450 |
The physician’s office is clean and neat | 1.03 (0.94-1.13) | 0.13 | 82,857 |
The physician indicates clearly how to take prescribed medication | 1.04 (0.98-1.10) | 0.26 | 82,645 |
The physician explains diagnoses, causes, and treatments so that I understand everything | 1.00 (0.95-1.04) | 0.36 | 83,277 |
The physician does not hurry during the medical treatment | .95 (0.91-0.99) | 0.35 | 83,332 |
I have the impression that the physician will refer me to a specialist if this is medically necessary | .94 (0.89-1.01) | 0.26 | 83,068 |
The physician explains exactly the benefits and associated risks of proposed medical treatments | 0.92 (0.88-0.96) | 0.37 | 81,490 |
Personal medical records are handled with confidentiality | .87 (0.80-0.94) | 0.18 | 82,483 |
In case of disease, the physician explains various treatment options | .88 (0.85-0.92) | 0.38 | 80,922 |
The physician involves me in decisions about upcoming examinations and treatments | .87 (0.84-0.91) | 0.35 | 80,298 |
The physician conducts physical examinations of me thoroughly | .87 (0.84-0.91) | 0.37 | 82,877 |
The physician’s office creates a well-organized impression | .83 (0.78-0.89) | 0.23 | 82,883 |
The protection of my privacy is respected in the office | .80 (0.74-0.86) | 0.19 | 82,034 |
The staff makes me feel welcome | .78 (0.72-0.83) | 0.2 | 83,188 |
The physician’s office is nicely decorated | .71 (0.65-0.76) | 0.15 | 82,860 |
Consultation time and absences are clearly communicated | .72 (0.66-0.78) | 0.15 | 81,879 |
The physician regularly enquires about my tolerance of the prescribed medication | .64 (0.61-0.67) | 0.34 | 79,206 |
The period between the first contact and the medical appointment is appropriate | .60 (0.55-0.64) | 0.16 | 81,133 |
The medical equipment in the office creates a modern impression | .60 (0.56-0.64) | 0.2 | 74,581 |
The waiting time before entering the physician’s office is adequate | .52 (0.49-0.56) | 0.17 | 82,779 |
The waiting area offers enough space to maintain a distance from other patients | .47 (0.43-0.50) | 0.14 | 82,888 |
Mentioning the reason for my visit in front of other patients is avoided | .46 (0.42-0.50) | 0.13 | 81,703 |
abs: bootstrapped.
Parameter estimates and model diagnostics of log-log regression models 3 (sorted by the size of b for overall impression).
Service attributes | Willingness to recommend | ||
b (bsa 95% CI) | R2 | Number of observations used, N | |
The physician has a pleasant and friendly manner | 1.33 (1.25-1.42) | 0.37 | 83,786 |
The physician listens to me carefully | 1.16 (1.11-1.21) | 0.46 | 82,978 |
The physician handles my questions, concerns, and fears in an empathetic way | 1.12 (1.08-1.17) | 0.49 | 83,606 |
The physician’s office is clean and neat | 1.08 (0.99-1.17) | 0.15 | 83,022 |
The physician indicates clearly how to take prescribed medication | 1.09 (1.03-1.15) | 0.31 | 82,795 |
The physician explains diagnoses, causes, and treatments so that I understand everything | 1.06 (1.02-1.11) | 0.43 | 83,445 |
The physician does not hurry during the medical treatment | 1.00 (0.96-1.05) | 0.42 | 83,480 |
I have the impression that the physician will refer me to a specialist if this is medically necessary | 1.00 (0.94-1.05) | 0.31 | 83,212 |
The physician explains exactly the benefits and associated risks of proposed medical treatments | .96 (0.92-1.01) | 0.44 | 81,633 |
Personal medical records are handled with confidentiality | .91 (0.83-0.99) | 0.21 | 82,628 |
In case of disease, the physician explains various treatment options | .92 (0.89-0.96) | 0.45 | 81,056 |
The physician involves me in decisions about upcoming examinations and treatments | .92 (0.88-0.95) | 0.42 | 80,432 |
The physician conducts physical examinations of me thoroughly | .90 (0.86-0.94) | 0.41 | 83,025 |
The physician’s office creates a well-organized impression | .91 (0.85-0.97) | 0.29 | 83,033 |
The protection of my privacy is respected in the office | .85 (0.79-0.91) | 0.23 | 82,173 |
The staff makes me feel welcome | .87 (0.81-0.93) | 0.26 | 83,349 |
The physician’s office is nicely decorated | .74 (0.68-0.79) | 0.17 | 83,020 |
Consultation time and absences are clearly communicated | .74 (0.68-0.81) | 0.17 | 82,028 |
The physician regularly enquires about my tolerance of the prescribed medication | .64 (0.61-0.68) | 0.37 | 79,346 |
The period between the first contact and the medical appointment is appropriate | .60 (0.55-0.65) | 0.18 | 81,268 |
The medical equipment in the office creates a modern impression | .58 (0.53-0.62) | 0.2 | 74,712 |
The waiting time before entering the physician’s office is adequate | .54 (0.50-0.59) | 0.2 | 82,932 |
The waiting area offers enough space to maintain a distance from other patients | .47 (0.43-0.51) | 0.16 | 83,040 |
Mentioning the reason for my visit in front of other patients is avoided | .47 (0.43-0.51) | 0.15 | 81,854 |
abs: bootstrapped.
Parameter estimates and model diagnostics of log-log regression models 4 (sorted by the size of b for overall impression).
Service attributes | Willingness to revisit | ||
b (bsa 95% CI) | R2 | Number of observations used, N | |
The physician has a pleasant and friendly manner | 1.03 (0.96-1.10) | 0.37 | 83,757 |
The physician listens to me carefully | .87 (0.82-0.92) | 0.43 | 82,938 |
The physician handles my questions, concerns, and fears in an empathetic way | .84 (0.79-0.88) | 0.46 | 83,572 |
The physician’s office is clean and neat | .77 (0.68-0.85) | 0.13 | 83,008 |
The physician indicates clearly how to take prescribed medication | .79 (0.73-0.85) | 0.28 | 82,767 |
The physician explains diagnoses, causes, and treatments so that I understand everything | .76 (0.72-0.81) | 0.38 | 83,421 |
The physician does not hurry during the medical treatment | .72 (0.67-0.77) | 0.36 | 83,449 |
I have the impression that the physician will refer me to a specialist if this is medically necessary | .74 (0.68-0.80) | 0.29 | 83,198 |
The physician explains exactly the benefits and associated risks of proposed medical treatments | .68 (0.63-0.73) | 0.38 | 81,604 |
Personal medical records are handled with confidentiality | .67 (0.59-0.74) | 0.19 | 82,622 |
In case of disease, the physician explains various treatment options | .65 (0.60-0.69) | 0.38 | 81,032 |
The physician involves me in decisions about upcoming examinations and treatments | .65 (0.61-0.70) | 0.37 | 80,410 |
The physician conducts physical examinations of me thoroughly | .62 (0.57-0.66) | 0.33 | 83,004 |
The physician’s office creates a well-organized impression | .65 (0.59-0.71) | 0.25 | 83,016 |
The protection of my privacy is respected in the office | .61 (0.55-0.67) | 0.2 | 82,170 |
The staff makes me feel welcome | .64 (0.58-0.70) | 0.24 | 83,325 |
The physician’s office is nicely decorated | .50 (0.45-0.55) | 0.14 | 83,001 |
Consultation time and absences are clearly communicated | .52 (0.46-0.58) | 0.14 | 82,007 |
The physician regularly enquires about my tolerance of the prescribed medication | .41 (0.38-0.45) | 0.27 | 79,322 |
The period between the first contact and the medical appointment is appropriate | .40 (0.36-0.45) | 0.14 | 81,262 |
The medical equipment in the office creates a modern impression | .36 (0.32-0.40) | 0.14 | 74,689 |
The waiting time before entering the physician’s office is adequate | .35 (0.32-0.40) | 0.14 | 82,914 |
The waiting area offers enough space to maintain a distance from other patients | .30 (0.26-0.34) | 0.11 | 83,035 |
Mentioning the reason for my visit in front of other patients is avoided | .32 (0.28-0.36) | 0.11 | 81,826 |
abs: bootstrapped.
On the one hand, for
For
Collecting information reported by patients is necessary to make health care more customer oriented [
The first important result of our study is that the more patients perceive the physician’s manner as being pleasant and friendly, the better is their overall impression as well as perceived experience with the results of the medical treatment. This relationship also applies to
Van Oerle et al [
Another finding of our study is that the service attribute “The physician’s office is clean and neat” has constant returns with respect to all overall evaluations (except
The results of our study also show that improving communication behaviors of physicians that increase knowledge for patients has constant returns. The service attribute “The physician indicates clearly how to take prescribed medication” and “The physician explains diagnoses, causes, and treatments so that I understand everything” shows constant returns for
The results displayed at the lower end of
The number of PRWs is on the rise [
Implications from our results for the service attributes with diminishing returns to the overall evaluation are as follows: a physician and his or her staff are well advised to work toward efficient patient scheduling, modern medical equipment, and a generously appointed waiting room to deliver personal space between the patients; and to ensure sufficient discretion at the reception desk to allow patients to state their reason for the visit without being overheard.
If physicians want to improve their measures of overall evaluation on PRWs and aim to stand out from competitors, they are well advised to improve those service attributes that were shown to have constant and increasing returns. Many service attributes have diminishing returns with respect to patients’ overall evaluation of the physician. These factors still have great relevance for patients’ satisfaction because they lead to dissatisfaction if the perceived attribute quality is below the average level. All these service attributes should be seen as expected by patients to be at a satisfactory level, and therefore, delivering these standards is a prerequisite for patient satisfaction. However, further improvement of the perceived attribute quality beyond the average satisfaction level does not lead to substantial increases in overall evaluation because of the diminishing returns.
In line with the claim to protect the
This study has the following limitations that set the stage for future research opportunities. First, it should be recognized that the implications of our study are limited to a fixed set of attributes. This may have the potential to divert physicians’ attention away from other important aspects of health care [
With regard to the time frame of the data collection, the focus was set on the introductory phase of the PRW (May 2011 to September 2014), and the large-scale data were drawn from the PRW in September 2014. In the meantime, patients can only post their rating on the PRW and not offline as was possible during the earlier phase of the PRW. Thus, data available in the introductory phase should cover the evaluation and spectrum of opinions of a large range of patients throughout the whole population. This specific point of data collection, therefore, reflects the broad range of experiences of the patient-physician encounter from a representative sample of the total population quite well (both online and offline population segments). This provides the opportunity to use this initial phase of a PRW’s large-scale data as a reference point for further studies. Especially, a longitudinal setting would deliver fruitful insights into developments of categorization over time, bearing in mind that the introductory phase was also characterized by an additional opportunity for patients to rate physicians through mail. Thus, using the large-scale data, the results of this study deliver an important reference point to monitor patients’ evaluation of physicians over time.
Regardless of the limitations discussed previously, the relevance of all derived implications is still high for health care management because of the fact that all the ratings on PRWs are publicly available and can influence patients in their choice of a physician.
bootstrapped
physician-rating website
The authors are grateful to Prof Martin Emmert for connecting their research team with Weisse Liste gemeinnützige GmbH, Gütersloh, Germany (Weisse Liste). The authors are especially thankful to Dr Marko Queitsch from Weisse Liste for providing the data and helpful comments for their study.
None declared.