Patient DOI 10.1007/s40271-014-0072-1
ORIGINAL RESEARCH ARTICLE
Effect of Internet on Chinese Patients Undergoing Elective Laparoscopic Cholecystectomy Xiequn Xu • Tao Hong • Binglu Li Wei Liu
•
Ó Springer International Publishing Switzerland 2014
Abstract Background It is a growing trend that patients seek health information on the internet to self-educate and self-diagnose, which impacts their health decisions. Objective The aim of the study was to investigate how Chinese patients undergoing elective laparoscopic cholecystectomy (LC) sought information about their disease and treatment, how they preferred the information to be presented, and how it influenced them. Methods A descriptive, cross-sectional-designed questionnaire was employed to obtain information from 248 Chinese patients undergoing elective LC in Peking Union Medical College Hospital. Results A total of 223 patients (89.9 %) sought health information from the internet. Patients searching the internet for information about LC were younger than those who did not. It varied with employment status, educational level, and household average income. Among patients searching the internet for LC information, 35.4 % felt more worried and 37.2 % felt more assured; 15.2 % went to visit other doctors and 8.5 % considered changing their treatment because of internet use. Conclusions A significant proportion of patients used the internet to obtain information about their disease. Age, employment status, educational level, and household average monthly income had an effect on internet usage for
Electronic supplementary material The online version of this article (doi:10.1007/s40271-014-0072-1) contains supplementary material, which is available to authorized users. X. Xu (&) T. Hong B. Li W. Liu Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China e-mail: [email protected]
LC information. The use of the internet could cause mixed emotional outcomes among patients. Physicians should guide Chinese patients to professional websites of high quality and take time to discuss the information with patients during their visits and consultations.
Key Points for Decision Makers This study shows that age, employment status, educational level, and household average monthly income have an effect on internet usage for laparoscopic cholecystectomy information. The use of the internet could cause mixed emotional outcomes among Chinese patients.
1 Introduction Internet use by the general population has been rapidly increasing since the early 1990s. By the end of 2009, the number of netizens in China had reached 384 million, 618 times that of 1997, with an annual increase of 31.95 million users; this is the largest population of netizens in the world. The internet had reached 28.9 % of the total population by the end of 2009, higher than the world average. Its accessibility was predicted to rise to 45 % of the population by 2014 [1]. It has been estimated that about 80 % of American and 66 % of European internet users frequently use the internet to seek online health-related information [2], but there are no available data showing how many internet users do this in China. A conservative estimate is that over 50 % of internet users now frequently
X. Xu et al.
seek online health-related information. The internet has provided a novel method for patients to seek health information and play a greater role in decisions ultimately affecting their own health. More and more patients turn to the internet to gain health information and understand their condition [3]. Many of them use this information to make decisions regarding their choice of physicians or healthcare institutions [4]. However, it has been shown that the online information is often unregulated, inaccurate, deficient, incomplete, or out of date [5]. Some studies have been carried out on the information needs of patients in Europe and North America. There is no information available on internet use by Chinese patients. There is research showing that there are gender, educational, and socio-economic differences among people who sought health information on the internet. The use of internet health information is associated with younger age and higher income and educational levels [6], but the research studying the pattern of internet use in Chinese general surgical patients is absent. In this study, we aimed to profile the Chinese patients undergoing elective laparoscopic cholecystectomy (LC) in our hospital who looked for internet information about their operations, determine the factors related to patients’ use of internet health information before their laparoscopic cholecystectomies, identify the impact of internet information on patients’ decision-making, and review the favorable and adverse effects of online information on these patients. We wanted to investigate whether and how the widely used internet influences patients’ understanding of their condition and perception of their doctors.
An English version of the questionnaire is provided in the Electronic Supplementary Material. 2.2 Statistical Analyses The data included patient demographics and frequency of internet use and use of internet medical information. The data were summarized using descriptive statistics, with frequency distribution generated for patient characteristics and survey responses on internet use. The association analysis between patient characteristics and internet use was done by Chi square tests or Fisher’s exact tests. Descriptive statistics were calculated for continuous variables using mean (SD) and for categorical data using n (%). A two-sided P value of \0.05 was considered to indicate statistical significance.
3 Results 3.1 Patient Characteristics A total of 248 consecutive patients undergoing elective LC were included in this study from September 1, 2011 to Table 1 Patient characteristics Sociodemographic variables
n (%) (N = 248)
Age \59 (42.3 ± 8.7)
182 (73.4)
[59 (65.8 ± 6.9)
66 (26.6)
Gender Male
2 Methods 2.1 Data Source and Study Design
Female Marital status Partner (married or living together) No partner (single, divorced or widowed)
This study was approved by the Medicine Institutional Review Board of Peking Union Medical College (PUMC) Hospital. We conducted a survey on use of internet health information for preoperative patients undergoing elective LC. The questions used in this survey were developed on the basis of our patients’ practical situation, not on previous research. A total of 248 consecutive patients were included in this study from September 1, 2011 to September 31, 2012. All preoperative patients aged 18 years or above undergoing elective LC participated in this anonymous questionnaire survey when they came as outpatients for a consultation on their operations and a preoperative assessment, or when they were admitted to the ward before their operation. The staff explained the study design and its purpose. The survey was in the Chinese language. Completion of this questionnaire was taken as implied consent.
90 (36.3) 158 (63.7) 221 (89.1) 27 (10.9)
Occupation Employed Unemployed/retired
190 (74.0) 58 (26.0)
Education Primary Secondary/university
45 (18.1) 203 (81.9)
Area of residence Rural
69 (27.8)
Urban
179 (72.2)
Monthly income \2,000 RMB (\US$250) 2,000–5,000 RMB (US$250–US$800) 5,000–10,000 RMB (US$800–US$1,600) [10,000 RMB ([US$1,600) RMB Chinese Yuan
9 (3.6) 63 (25.4) 127 (51.2) 49 (19.8)
Internet in Laparoscopic Cholecystectomy Table 2 Relationship between use of the internet for health information and sociodemographic variables
Sociodemographic variable
Seeking internet health information, n (%)
Age (N = 248) (51.3 ± 7.9)
Did not seek internet health information, n (%)
P value
\0.001
223 (89.9)
25 (10.1)
\59
165 (92.1)
17 (7.9)
[59
58 (76.5)
8 (23.5)
82 (91.1)
8 (8.9)
141 (89.2)
17 (10.8)
196 (89.9)
22 (10.1)
27 (85.7)
3 (14.3)
195 (98.5)
3 (1.5)
28 (56.0)
22 (44.0)
15 (46.9)
17 (53.1)
208 (96.3)
8 (3.7)
Gender
0.847
Male Female Marital status Partner (married or living together) No partner (single, divorced, or widowed)
0.634
\0.001
Employment status Employed Unemployed/retired
\0.001
Education Primary Secondary/university Area of residence
1.00
Rural
69 (88.5)
Urban
154 (90.6)
9 (11.5) 16 (9.4) \0.001
Household average monthly income \2,000 RMB (\US$250) 2,000–5,000 RMB (US$250–US$800)
RMB Chinese Yuan
5,000–10,000 RMB (US$800–US$1,600) [10,000 RMB ([US$1,600)
September 31, 2012. They completed the questionnaire when they were admitted in the ward before their operation. The patient characteristics are summarized in Table 1. The mean age was 51.3 ± 7.9 years, with a range of 20–81 years. Of these 248 patients, there were 90 males (36.3 %) and 158 females (63.7 %), and 223 of the 248 patients (89.9 %) (82 males and 141 females) had sought health information on the internet. There was a significant age difference among patients who used the internet to seek health information in the different age groups of below 59 years of age and 59 years and older, respectively (P \ 0.001). Among patients below 59 years of age, 92.1 % reported searching the internet for information on LC, compared with 76.5 % of those aged 59 years or older. There was a significant difference found with regard to employment statuses (employed vs. unemployed/retired, 98.5 vs. 56.0 %, P \ 0.001). Internet use for LC information also differed by educational level; the percentage was greater among patients with a higher level of education (96.3 vs. 46.9 %, P \ 0.001) and higher income (P \ 0.001). There were no significant differences found for the use of the internet for information on LC in groups
6 (66.7)
3 (33.3)
45 (71.4)
18 (28.6)
124 (97.6) 49 (100)
3 (2.4) 0 (0)
of different gender, marital status, or area of residence (Table 2). 3.2 Reasons for Searching the Internet for Health Information Why did the patients who would undergo elective LC search the internet for health information? What kind of health information would they focus on? Of the 223 patients who sought health information on the internet, 202 (90.6 %) reported they wanted to verify the information regarding their condition received from their doctors; 196 (87.9 %) stated they wanted to understand further details of the procedure of LC; 112 (50.2 %) wanted to know whether there were alternative options for their disease; and 76 (34.1 %) said they still had questions after visiting the doctors, so they wanted to find the answers from the internet. The most common types of information sought on the internet were ‘‘What is LC and how is the LC performed?’’ (100 %), ‘‘the surgical outcome of LC’’ (100 %), ‘‘side effects/complications of the operation’’ (89.2 %), ‘‘postoperative recovery’’ (51.6 %), and ‘‘preparations for the
X. Xu et al. Table 3 Reasons for searching internet for health information n (%) (n = 223) Main reason for searching internet health information Verify information received from doctor
202 (90.6)
Understand the undergoing procedure
196 (87.9)
Look for alternative options
112 (50.2)
Still have questions after seeing doctor
76 (34.1)
Common information sought What is LC and how is the LC performed?
223 (100)
The surgical outcome
223 (100)
Side effects/complications
199 (89.2)
Postoperative recovery
115 (51.6)
Preparations for the operation Importance of type of information on website
86 (38.6)
Description of the operation
95 (42.6)
Pre-and postoperative pictures
69 (30.9)
Experience shared from other doctors
37 (16.6)
Experience shared from other patients
22 (9.9)
Decision changed after searching the internet Saw another doctor
34 (15.2)
Considered changing treatment
19 (8.5)
Table 4 Characteristics and consequences of seeking internet health information P value
Resulting feeling from the internet health information More worried
79 (35.4)
More reassured
83 (37.2)
Don’t know
61 (27.4)
3.3 Characteristics and Consequences of Internet Health Information on Patients’ Decisions Reassurance, increased worries, and mixed feelings were reported by around a third of patients who searched the internet for health information (37.2, 35.4, and 27.4 %, respectively). Less than 10 % reported that the online information often contradicted their physicians’ words. About half of patients were not satisfied with the information received from their doctors, while the other half were satisfied. About two-thirds of patients discussed the online information they got with their physicians. Most of the patients would not like to participate in an online forum, but would just browse it (Table 4). 3.4 Valuable Characteristics of Websites for Health Information
LC laparoscopic cholecystectomy
N (%) (n = 223)
(30.9 %), questions and answers from other doctors about LC (16.6 %), and experience from other patients who had received LC (9.9 %). The information obtained from the internet impacted the patients’ decision-making as follows: 34 (15.2 %) went to see other doctors and 19 (8.5 %) considered changing the treatment option (Table 3).
0.767
When patients were asked to rate the valuable characteristics of websites for health information, they thought the following were important to them: patient-friendly language and easy to understand (69.5 %), professional source (65.5 %), and recommended by physicians (75.6 %). Less important to them were the following: well-designed website (35 %), websites with interactive communication (36.3 %), and recommended by friends (20.2 %) (Table 5).
Contradicting physician Very often
1 (0.4)
Often Sometimes
16 (7.2) 56 (25.1)
Rarely
135 (60.5)
Never
15 (6.7)
\0.001
Satisfaction with information received from doctors Yes
104 (46.6)
No
119 (53.4)
0.738
Discuss with physician using the internet information Yes
149 (66.8)
No
74 (33.2)
\0.05
operation’’ (38.6 %). These types of information regarding LC were essential to the patients. For the most important information on the websites, patients selected a description of the LC procedures (42.6 %), pictures of pre- and postoperative appearance
4 Discussion Internet searching for health information has grown quite substantially in the last few years. Several studies have shown a number of patients use the internet to obtain additional health information because of its wide availability, frequently updated content, and multimedia forms of presenting data [2–5]. More than 80 % of American patients asked physicians questions derived from their web searches [2]. Although there are no accurate data on such issues in China, it is a common feeling that doctors and general surgeons are increasingly questioned by patients as a result of internet searches. Our study confirmed such findings in an LC-specific population. In this study, it was shown that among the patients who would undergo elective LC in our hospital, 89.9 % (223/248) searched the internet for information related to their disease condition, which was higher than
Internet in Laparoscopic Cholecystectomy Table 5 Valuable characteristics of websites for health information Characteristic
Importance Very n (%)
Somewhat n (%)
Not at all n (%)
Patient-friendly language and easy understanding
155 (69.5)
46 (20.6)
22 (9.9)
Professional source
146 (65.5)
63 (28.3)
14 (6.3)
78 (35.0)
87 (39.0)
58 (26.0)
Well-designed website Websites with interactive communication Recommended by physicians Recommended by friends
81 (36.3)
74 (33.2)
68 (30.5)
169 (75.6)
43 (19.3)
11 (4.9)
45 (20.2)
74 (33.2)
104 (46.6)
the usage shown in other reports [7], perhaps reflecting a growing prevalence of internet access in the general population compared with previous years. Age and educational level were associated with internet use, while there was no significant association with sex, marital status or area of residence, which is consistent with some reports [7–9]. We also found that employment status and household income were associated with internet use, which was not shown in some other studies [2, 10]. A possible explanation might be that China is a developing country and the expense of a computer and internet use is relatively high for a low-income family, although China has the largest population of netizens in the world. This indicated a barrier for patients in lower socioeconomic groups regarding their ability to benefit from online health information, which raises concerns about a ‘‘digital divide’’ [11]. Physicians remain the primary information source despite newly available media [12]. In addition to obtaining information from physicians, patients due to undergo elective LC searched the internet for health information and did so for various reasons. The primary one was to verify information received from their doctors (90.6 %). The high percentage of patients seeking online verification of doctors’ words derives from the very short discussion time a physician can spend on each patient. In China, one patient usually only has 5–10 min with his physician when there are many other patients waiting to see the doctor. It is, therefore, hard for them to understand their disease and condition in every detail, or to be satisfied with the information provided by their physician [2], but the internet could fulfill such a need. Actually, patients (87.6 %) seemed to be eager to use the internet to understand procedures before admission, probably because they could not fully comprehend what their physicians had said about their disease in the outpatient clinics and physicians could not answer all patient questions in one visit, so patients had many unanswered questions (34.1 %) [13]. The internet was a good education tool, with which they searched for information on diagnosis, treatment options, side effects and complications of LC, perioperative management, and
other relevant aspects of LC, with the aim of better understanding their disease and condition and knowing how to better cooperate with doctors. Patients preferred information on what LC is, how it is performed, the postoperative recovery, and what other patients who received LC experienced. They preferred websites with information they could understand easily. Our study showed internet use may have some impacts on the physician–patient relationship. 15.2 % of patients chose to visit other doctors and considered changing their doctors while waiting for their admissions; seeing another doctor had the potential to improve the physician–patient relationship if that doctor ended up having a better relationship with the patient. 8.5 % of patients had their decisions on treatments affected or changed because of internet use. Most of our patients stated they would like to get further information about their disease after their first visit to an outpatient clinic. It was obvious that the internet had the power to impact the patients’ choices in physicians and treatments in our study. The patients felt the need to pursue better treatment by themselves rather than relying solely on the doctors to get one, which showed the impact of the internet on patients’ participation in decisionmaking. Internet searching for information about elective LC had mixed positive and negative outcomes [14], which was confirmed in our study. It may encourage some patients to participate in shared decision-making when they find valuable information about their disease and read about the personal experiences of others. They might also feel reassured when they find confirmation of physician information [15, 16]. However, internet searches could also increase some patients’ anxiety, also called ‘‘cyberchondriasis’’, when they get incorrect or poor-quality information or the information does not apply to them, or is confusing, conflicting, or incomplete [17, 18]. Only 17 patients (7.6 %) reported the information they got from the internet contradicted that from their physicians. The main reason patients searched the internet in our study was to verify information received from their doctors; verification seems to be an important motivation for
X. Xu et al.
searching online health information. It is very reasonable that the patients searched the internet for health information because they were not satisfied with the information from doctors. But in our study, although about half of patients were not satisfied with the information offered by the doctors, they reported that they had other motivations or worries that made them want to learn more and thereby better understand their disease condition. Most of the patients did not question the judgment of doctors; they merely wanted more information [2, 19, 20]. Their consultation with the internet may be associated with considering more treatment options [21]. About two-thirds of patients wanted to discuss internet information with their physicians. They reported that the anxiety created by reading the internet information was reduced by discussion with doctors. In those who did not want to, patients reported that it was not necessary to discuss the information with doctors who they strongly trusted. These findings mirrored the literature [19]. The internet is a valuable and relatively viable resource to offer patients information about their diagnosis, treatment options and other relevant aspects. Patients thought they preferred websites with patient-friendly language, straightforward contents, and professional sources, and those recommended by physicians. Of all surveyed, 76.5 % patients would browse the websites recommended by their physicians. They found that there was pointed information in these websites that could give them favorable answers without seeing their doctors. It showed they thought the websites recommended by their physicians were reliable with accurate and high-quality information to get them better informed. These data could provide references for health websites.
information on the internet, it was difficult to appreciate the differences between those who used the internet and those who did not. Even though some of the factors were statistically significant, it is not clear that they are meaningfully different in the real world. This study did not investigate how patients changed their behavior because of seeking health information on the internet. This would be an interesting issue for future studies. Future studies should investigate how to best educate patients on health information with the internet.
4.1 Limitations
Conflict of interest peting interests.
The present study did have some possible biases and limitations. This study may have the biases inherent to selfadministered cross-sectional surveys. About one-third of patients were from rural area, with limited education. This could create a bias as more educated urban patients may have better access to a computer at work or at home than rural patients with less education. The same thing may happen regarding the aspects of household income and access to computers. This study had a small sample size; it would have been more powerful with a larger sample size. Another limitation to our study was that this study was conducted in a single institution, so the results may not reflect the internet use patterns in the general LC patient population. Regional data are often useful to compare with a large area or even national data to identify the similarities and differences within China, promoting further inquiries and results. Because almost all patients did seek
Authors’ contribution Xu X. was involved in designing and conducting the study, in analyzing and interpreting the data, and drafting the article. Hong T. and Li B. were involved in the supervision of the statistical methods and data analysis. Liu W. made substantial contributions to the article and critically revised it. All authors approved the final manuscript.
5 Conclusion In the age of information, the internet is definitely a significant source. More and more of our patients use the internet to seek information to further understand their disease. Doctors could make better use of the internet by developing current evidence-based information for the internet, guiding patients toward high-quality websites, and teaching them how to locate information and check its credibility. Sharing our findings with more physicians will help improve the education of patients; reduce confusing, conflicting, or overwhelming information; facilitate the information exchange between physicians and patients; and boost the doctor–patient relationship. People who would undergo elective LC prefer to find information about the operation and experiences from doctors and patients, and value the inclusion of such on information-based websites. Health professionals can help patients by referring them to appropriate websites and discussing the information during visits and consultations. The authors declare that they have no com-
References 1. Information Office of the State Council of the People’s Republic of China. China issues white paper on Internet policy; 2012. http:// www.china.org.cn/china/2010-06/08/content_20206978.htm. 2. Valero-Aguilera B, Bermu´dez-Tamayo C, Garcı´a-Gutie´rrez JF, Jime´nez-Pernett J, Va´zquez-Alonso F, Sua´rez-Charneco A, et al. Factors related to use of the Internet as a source of health information by urological cancer patients. Support Care Cancer. 2012;20(12):3087–94.
Internet in Laparoscopic Cholecystectomy 3. Ilic D. The role of the internet on patient knowledge management, education, and decision-making. Telemed J E Health. 2010;16(6):664–9. 4. Hartzband P, Groopman J. Untangling the Web—patients, doctors, and the Internet. N Engl J Med. 2010;362(12):1063–6. 5. Cline RJ, Haynes KM. Consumer health information seeking on the Internet: the state of the art. Health Educ Res. 2001;16(6): 671–92. 6. Wald HS, Dube CE, Anthony DC. Untangling the Web—the impact of Internet use on health care and the physician–patient relationship. Patient Educ Couns. 2007;68(3):218–24. 7. Castleton K, Fong T, Wang-Gillam A, Waqar MA, Jeffe DB, Kehlenbrink L, et al. A survey of Internet utilization among patients with cancer. Support Care Cancer. 2011;19(8):1183–90. 8. Laurent MR, Cremers S, Verhoef G, Dierickx D. Internet use for health information among haematology outpatients: a cross-sectional survey. Inform Health Soc Care. 2012;37(2):62–73. 9. AlGhamdi KM, Moussa NA. Internet use by the public to search for health-related information. Int J Med Inform. 2012;81(6): 363–73. 10. Szychta P, Zielin´ski T, Rykała J, Witmanowski H, Kruk-Jeromin J. Role of the internet in communication between patient and surgeon before rhinoplasty. J Plast Surg Hand Surg. 2012; 46(3–4):248–51. 11. Brodie M, Flournoy RE, Altman DE, Blendon RJ, Benson JM, Rosenbaum MD. Health information, the Internet, and the digital divide. Health Aff (Millwood). 2000;19(6):255–65. 12. Couper MP, Singer E, Levin CA, Fowler FJ Jr, Fagerlin A, Zikmund-Fisher BJ. Use of the Internet and ratings of information sources for medical decisions: results from the DECISIONS survey. Med Decis Making. 2010;30(5):106S–14S.
13. Helft PR, Hlubocky F, Daugherty CK. American oncologists’ views of internet use by cancer patients: a mail survey of American Society of Clinical Oncology members. J Clin Oncol. 2003;21(5):942–7. 14. Kim J, Kim S. Physicians’ perception of the effects of Internet health information on the doctor-patient relationship. Inform Health Soc Care. 2009;34(3):136–48. 15. van de Poll-Franse LV, van Eenbergen MC. Internet use by cancer survivors: current use and future wishes. Support Care Cancer. 2008;16(10):1189–95. 16. McCaw B, McGlade K, McElnay J. The impact of the internet on the practice of general practitioners and community pharmacists in Northern Ireland. Inform Prim Care. 2007;15(4):231–7. 17. Baumgartner SE, Hartmann T. The role of health anxiety in online health information search. Cyberpsychol Behav Soc Netw. 2011;14(10):613–8. 18. Muse K, McManus F, Leung C, Meghreblian B, Williams JM. Cyberchondriasis: fact or fiction? A preliminary examination of the relationship between health anxiety and searching for health information on the Internet. J Anxiety Disord. 2012;26(1): 189–96. 19. Bylund CL, Gueguen JA, D’Agostino TA, Imes RS, Sonet E. Cancer patients’ decisions about discussing Internet information with their doctors. Psychooncology. 2009;18(11):1139–46. 20. Bylund CL, Gueguen JA, D’Agostino TA, Li Y, Sonet E. Doctor– patient communication about cancer-related internet information. J Psychosoc Oncol. 2010;28(2):127–42. 21. Ramsey SD, Zeliadt SB, Arora NK, Potosky AL, Blough DK, Hamilton AS, et al. Access to information sources and treatment considerations among men with local stage prostate cancer. Urology. 2009;74(3):509–15.
ORIGINAL RESEARCH ARTICLE
Effect of Internet on Chinese Patients Undergoing Elective Laparoscopic Cholecystectomy Xiequn Xu • Tao Hong • Binglu Li Wei Liu
•
Ó Springer International Publishing Switzerland 2014
Abstract Background It is a growing trend that patients seek health information on the internet to self-educate and self-diagnose, which impacts their health decisions. Objective The aim of the study was to investigate how Chinese patients undergoing elective laparoscopic cholecystectomy (LC) sought information about their disease and treatment, how they preferred the information to be presented, and how it influenced them. Methods A descriptive, cross-sectional-designed questionnaire was employed to obtain information from 248 Chinese patients undergoing elective LC in Peking Union Medical College Hospital. Results A total of 223 patients (89.9 %) sought health information from the internet. Patients searching the internet for information about LC were younger than those who did not. It varied with employment status, educational level, and household average income. Among patients searching the internet for LC information, 35.4 % felt more worried and 37.2 % felt more assured; 15.2 % went to visit other doctors and 8.5 % considered changing their treatment because of internet use. Conclusions A significant proportion of patients used the internet to obtain information about their disease. Age, employment status, educational level, and household average monthly income had an effect on internet usage for
Electronic supplementary material The online version of this article (doi:10.1007/s40271-014-0072-1) contains supplementary material, which is available to authorized users. X. Xu (&) T. Hong B. Li W. Liu Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China e-mail: [email protected]
LC information. The use of the internet could cause mixed emotional outcomes among patients. Physicians should guide Chinese patients to professional websites of high quality and take time to discuss the information with patients during their visits and consultations.
Key Points for Decision Makers This study shows that age, employment status, educational level, and household average monthly income have an effect on internet usage for laparoscopic cholecystectomy information. The use of the internet could cause mixed emotional outcomes among Chinese patients.
1 Introduction Internet use by the general population has been rapidly increasing since the early 1990s. By the end of 2009, the number of netizens in China had reached 384 million, 618 times that of 1997, with an annual increase of 31.95 million users; this is the largest population of netizens in the world. The internet had reached 28.9 % of the total population by the end of 2009, higher than the world average. Its accessibility was predicted to rise to 45 % of the population by 2014 [1]. It has been estimated that about 80 % of American and 66 % of European internet users frequently use the internet to seek online health-related information [2], but there are no available data showing how many internet users do this in China. A conservative estimate is that over 50 % of internet users now frequently
X. Xu et al.
seek online health-related information. The internet has provided a novel method for patients to seek health information and play a greater role in decisions ultimately affecting their own health. More and more patients turn to the internet to gain health information and understand their condition [3]. Many of them use this information to make decisions regarding their choice of physicians or healthcare institutions [4]. However, it has been shown that the online information is often unregulated, inaccurate, deficient, incomplete, or out of date [5]. Some studies have been carried out on the information needs of patients in Europe and North America. There is no information available on internet use by Chinese patients. There is research showing that there are gender, educational, and socio-economic differences among people who sought health information on the internet. The use of internet health information is associated with younger age and higher income and educational levels [6], but the research studying the pattern of internet use in Chinese general surgical patients is absent. In this study, we aimed to profile the Chinese patients undergoing elective laparoscopic cholecystectomy (LC) in our hospital who looked for internet information about their operations, determine the factors related to patients’ use of internet health information before their laparoscopic cholecystectomies, identify the impact of internet information on patients’ decision-making, and review the favorable and adverse effects of online information on these patients. We wanted to investigate whether and how the widely used internet influences patients’ understanding of their condition and perception of their doctors.
An English version of the questionnaire is provided in the Electronic Supplementary Material. 2.2 Statistical Analyses The data included patient demographics and frequency of internet use and use of internet medical information. The data were summarized using descriptive statistics, with frequency distribution generated for patient characteristics and survey responses on internet use. The association analysis between patient characteristics and internet use was done by Chi square tests or Fisher’s exact tests. Descriptive statistics were calculated for continuous variables using mean (SD) and for categorical data using n (%). A two-sided P value of \0.05 was considered to indicate statistical significance.
3 Results 3.1 Patient Characteristics A total of 248 consecutive patients undergoing elective LC were included in this study from September 1, 2011 to Table 1 Patient characteristics Sociodemographic variables
n (%) (N = 248)
Age \59 (42.3 ± 8.7)
182 (73.4)
[59 (65.8 ± 6.9)
66 (26.6)
Gender Male
2 Methods 2.1 Data Source and Study Design
Female Marital status Partner (married or living together) No partner (single, divorced or widowed)
This study was approved by the Medicine Institutional Review Board of Peking Union Medical College (PUMC) Hospital. We conducted a survey on use of internet health information for preoperative patients undergoing elective LC. The questions used in this survey were developed on the basis of our patients’ practical situation, not on previous research. A total of 248 consecutive patients were included in this study from September 1, 2011 to September 31, 2012. All preoperative patients aged 18 years or above undergoing elective LC participated in this anonymous questionnaire survey when they came as outpatients for a consultation on their operations and a preoperative assessment, or when they were admitted to the ward before their operation. The staff explained the study design and its purpose. The survey was in the Chinese language. Completion of this questionnaire was taken as implied consent.
90 (36.3) 158 (63.7) 221 (89.1) 27 (10.9)
Occupation Employed Unemployed/retired
190 (74.0) 58 (26.0)
Education Primary Secondary/university
45 (18.1) 203 (81.9)
Area of residence Rural
69 (27.8)
Urban
179 (72.2)
Monthly income \2,000 RMB (\US$250) 2,000–5,000 RMB (US$250–US$800) 5,000–10,000 RMB (US$800–US$1,600) [10,000 RMB ([US$1,600) RMB Chinese Yuan
9 (3.6) 63 (25.4) 127 (51.2) 49 (19.8)
Internet in Laparoscopic Cholecystectomy Table 2 Relationship between use of the internet for health information and sociodemographic variables
Sociodemographic variable
Seeking internet health information, n (%)
Age (N = 248) (51.3 ± 7.9)
Did not seek internet health information, n (%)
P value
\0.001
223 (89.9)
25 (10.1)
\59
165 (92.1)
17 (7.9)
[59
58 (76.5)
8 (23.5)
82 (91.1)
8 (8.9)
141 (89.2)
17 (10.8)
196 (89.9)
22 (10.1)
27 (85.7)
3 (14.3)
195 (98.5)
3 (1.5)
28 (56.0)
22 (44.0)
15 (46.9)
17 (53.1)
208 (96.3)
8 (3.7)
Gender
0.847
Male Female Marital status Partner (married or living together) No partner (single, divorced, or widowed)
0.634
\0.001
Employment status Employed Unemployed/retired
\0.001
Education Primary Secondary/university Area of residence
1.00
Rural
69 (88.5)
Urban
154 (90.6)
9 (11.5) 16 (9.4) \0.001
Household average monthly income \2,000 RMB (\US$250) 2,000–5,000 RMB (US$250–US$800)
RMB Chinese Yuan
5,000–10,000 RMB (US$800–US$1,600) [10,000 RMB ([US$1,600)
September 31, 2012. They completed the questionnaire when they were admitted in the ward before their operation. The patient characteristics are summarized in Table 1. The mean age was 51.3 ± 7.9 years, with a range of 20–81 years. Of these 248 patients, there were 90 males (36.3 %) and 158 females (63.7 %), and 223 of the 248 patients (89.9 %) (82 males and 141 females) had sought health information on the internet. There was a significant age difference among patients who used the internet to seek health information in the different age groups of below 59 years of age and 59 years and older, respectively (P \ 0.001). Among patients below 59 years of age, 92.1 % reported searching the internet for information on LC, compared with 76.5 % of those aged 59 years or older. There was a significant difference found with regard to employment statuses (employed vs. unemployed/retired, 98.5 vs. 56.0 %, P \ 0.001). Internet use for LC information also differed by educational level; the percentage was greater among patients with a higher level of education (96.3 vs. 46.9 %, P \ 0.001) and higher income (P \ 0.001). There were no significant differences found for the use of the internet for information on LC in groups
6 (66.7)
3 (33.3)
45 (71.4)
18 (28.6)
124 (97.6) 49 (100)
3 (2.4) 0 (0)
of different gender, marital status, or area of residence (Table 2). 3.2 Reasons for Searching the Internet for Health Information Why did the patients who would undergo elective LC search the internet for health information? What kind of health information would they focus on? Of the 223 patients who sought health information on the internet, 202 (90.6 %) reported they wanted to verify the information regarding their condition received from their doctors; 196 (87.9 %) stated they wanted to understand further details of the procedure of LC; 112 (50.2 %) wanted to know whether there were alternative options for their disease; and 76 (34.1 %) said they still had questions after visiting the doctors, so they wanted to find the answers from the internet. The most common types of information sought on the internet were ‘‘What is LC and how is the LC performed?’’ (100 %), ‘‘the surgical outcome of LC’’ (100 %), ‘‘side effects/complications of the operation’’ (89.2 %), ‘‘postoperative recovery’’ (51.6 %), and ‘‘preparations for the
X. Xu et al. Table 3 Reasons for searching internet for health information n (%) (n = 223) Main reason for searching internet health information Verify information received from doctor
202 (90.6)
Understand the undergoing procedure
196 (87.9)
Look for alternative options
112 (50.2)
Still have questions after seeing doctor
76 (34.1)
Common information sought What is LC and how is the LC performed?
223 (100)
The surgical outcome
223 (100)
Side effects/complications
199 (89.2)
Postoperative recovery
115 (51.6)
Preparations for the operation Importance of type of information on website
86 (38.6)
Description of the operation
95 (42.6)
Pre-and postoperative pictures
69 (30.9)
Experience shared from other doctors
37 (16.6)
Experience shared from other patients
22 (9.9)
Decision changed after searching the internet Saw another doctor
34 (15.2)
Considered changing treatment
19 (8.5)
Table 4 Characteristics and consequences of seeking internet health information P value
Resulting feeling from the internet health information More worried
79 (35.4)
More reassured
83 (37.2)
Don’t know
61 (27.4)
3.3 Characteristics and Consequences of Internet Health Information on Patients’ Decisions Reassurance, increased worries, and mixed feelings were reported by around a third of patients who searched the internet for health information (37.2, 35.4, and 27.4 %, respectively). Less than 10 % reported that the online information often contradicted their physicians’ words. About half of patients were not satisfied with the information received from their doctors, while the other half were satisfied. About two-thirds of patients discussed the online information they got with their physicians. Most of the patients would not like to participate in an online forum, but would just browse it (Table 4). 3.4 Valuable Characteristics of Websites for Health Information
LC laparoscopic cholecystectomy
N (%) (n = 223)
(30.9 %), questions and answers from other doctors about LC (16.6 %), and experience from other patients who had received LC (9.9 %). The information obtained from the internet impacted the patients’ decision-making as follows: 34 (15.2 %) went to see other doctors and 19 (8.5 %) considered changing the treatment option (Table 3).
0.767
When patients were asked to rate the valuable characteristics of websites for health information, they thought the following were important to them: patient-friendly language and easy to understand (69.5 %), professional source (65.5 %), and recommended by physicians (75.6 %). Less important to them were the following: well-designed website (35 %), websites with interactive communication (36.3 %), and recommended by friends (20.2 %) (Table 5).
Contradicting physician Very often
1 (0.4)
Often Sometimes
16 (7.2) 56 (25.1)
Rarely
135 (60.5)
Never
15 (6.7)
\0.001
Satisfaction with information received from doctors Yes
104 (46.6)
No
119 (53.4)
0.738
Discuss with physician using the internet information Yes
149 (66.8)
No
74 (33.2)
\0.05
operation’’ (38.6 %). These types of information regarding LC were essential to the patients. For the most important information on the websites, patients selected a description of the LC procedures (42.6 %), pictures of pre- and postoperative appearance
4 Discussion Internet searching for health information has grown quite substantially in the last few years. Several studies have shown a number of patients use the internet to obtain additional health information because of its wide availability, frequently updated content, and multimedia forms of presenting data [2–5]. More than 80 % of American patients asked physicians questions derived from their web searches [2]. Although there are no accurate data on such issues in China, it is a common feeling that doctors and general surgeons are increasingly questioned by patients as a result of internet searches. Our study confirmed such findings in an LC-specific population. In this study, it was shown that among the patients who would undergo elective LC in our hospital, 89.9 % (223/248) searched the internet for information related to their disease condition, which was higher than
Internet in Laparoscopic Cholecystectomy Table 5 Valuable characteristics of websites for health information Characteristic
Importance Very n (%)
Somewhat n (%)
Not at all n (%)
Patient-friendly language and easy understanding
155 (69.5)
46 (20.6)
22 (9.9)
Professional source
146 (65.5)
63 (28.3)
14 (6.3)
78 (35.0)
87 (39.0)
58 (26.0)
Well-designed website Websites with interactive communication Recommended by physicians Recommended by friends
81 (36.3)
74 (33.2)
68 (30.5)
169 (75.6)
43 (19.3)
11 (4.9)
45 (20.2)
74 (33.2)
104 (46.6)
the usage shown in other reports [7], perhaps reflecting a growing prevalence of internet access in the general population compared with previous years. Age and educational level were associated with internet use, while there was no significant association with sex, marital status or area of residence, which is consistent with some reports [7–9]. We also found that employment status and household income were associated with internet use, which was not shown in some other studies [2, 10]. A possible explanation might be that China is a developing country and the expense of a computer and internet use is relatively high for a low-income family, although China has the largest population of netizens in the world. This indicated a barrier for patients in lower socioeconomic groups regarding their ability to benefit from online health information, which raises concerns about a ‘‘digital divide’’ [11]. Physicians remain the primary information source despite newly available media [12]. In addition to obtaining information from physicians, patients due to undergo elective LC searched the internet for health information and did so for various reasons. The primary one was to verify information received from their doctors (90.6 %). The high percentage of patients seeking online verification of doctors’ words derives from the very short discussion time a physician can spend on each patient. In China, one patient usually only has 5–10 min with his physician when there are many other patients waiting to see the doctor. It is, therefore, hard for them to understand their disease and condition in every detail, or to be satisfied with the information provided by their physician [2], but the internet could fulfill such a need. Actually, patients (87.6 %) seemed to be eager to use the internet to understand procedures before admission, probably because they could not fully comprehend what their physicians had said about their disease in the outpatient clinics and physicians could not answer all patient questions in one visit, so patients had many unanswered questions (34.1 %) [13]. The internet was a good education tool, with which they searched for information on diagnosis, treatment options, side effects and complications of LC, perioperative management, and
other relevant aspects of LC, with the aim of better understanding their disease and condition and knowing how to better cooperate with doctors. Patients preferred information on what LC is, how it is performed, the postoperative recovery, and what other patients who received LC experienced. They preferred websites with information they could understand easily. Our study showed internet use may have some impacts on the physician–patient relationship. 15.2 % of patients chose to visit other doctors and considered changing their doctors while waiting for their admissions; seeing another doctor had the potential to improve the physician–patient relationship if that doctor ended up having a better relationship with the patient. 8.5 % of patients had their decisions on treatments affected or changed because of internet use. Most of our patients stated they would like to get further information about their disease after their first visit to an outpatient clinic. It was obvious that the internet had the power to impact the patients’ choices in physicians and treatments in our study. The patients felt the need to pursue better treatment by themselves rather than relying solely on the doctors to get one, which showed the impact of the internet on patients’ participation in decisionmaking. Internet searching for information about elective LC had mixed positive and negative outcomes [14], which was confirmed in our study. It may encourage some patients to participate in shared decision-making when they find valuable information about their disease and read about the personal experiences of others. They might also feel reassured when they find confirmation of physician information [15, 16]. However, internet searches could also increase some patients’ anxiety, also called ‘‘cyberchondriasis’’, when they get incorrect or poor-quality information or the information does not apply to them, or is confusing, conflicting, or incomplete [17, 18]. Only 17 patients (7.6 %) reported the information they got from the internet contradicted that from their physicians. The main reason patients searched the internet in our study was to verify information received from their doctors; verification seems to be an important motivation for
X. Xu et al.
searching online health information. It is very reasonable that the patients searched the internet for health information because they were not satisfied with the information from doctors. But in our study, although about half of patients were not satisfied with the information offered by the doctors, they reported that they had other motivations or worries that made them want to learn more and thereby better understand their disease condition. Most of the patients did not question the judgment of doctors; they merely wanted more information [2, 19, 20]. Their consultation with the internet may be associated with considering more treatment options [21]. About two-thirds of patients wanted to discuss internet information with their physicians. They reported that the anxiety created by reading the internet information was reduced by discussion with doctors. In those who did not want to, patients reported that it was not necessary to discuss the information with doctors who they strongly trusted. These findings mirrored the literature [19]. The internet is a valuable and relatively viable resource to offer patients information about their diagnosis, treatment options and other relevant aspects. Patients thought they preferred websites with patient-friendly language, straightforward contents, and professional sources, and those recommended by physicians. Of all surveyed, 76.5 % patients would browse the websites recommended by their physicians. They found that there was pointed information in these websites that could give them favorable answers without seeing their doctors. It showed they thought the websites recommended by their physicians were reliable with accurate and high-quality information to get them better informed. These data could provide references for health websites.
information on the internet, it was difficult to appreciate the differences between those who used the internet and those who did not. Even though some of the factors were statistically significant, it is not clear that they are meaningfully different in the real world. This study did not investigate how patients changed their behavior because of seeking health information on the internet. This would be an interesting issue for future studies. Future studies should investigate how to best educate patients on health information with the internet.
4.1 Limitations
Conflict of interest peting interests.
The present study did have some possible biases and limitations. This study may have the biases inherent to selfadministered cross-sectional surveys. About one-third of patients were from rural area, with limited education. This could create a bias as more educated urban patients may have better access to a computer at work or at home than rural patients with less education. The same thing may happen regarding the aspects of household income and access to computers. This study had a small sample size; it would have been more powerful with a larger sample size. Another limitation to our study was that this study was conducted in a single institution, so the results may not reflect the internet use patterns in the general LC patient population. Regional data are often useful to compare with a large area or even national data to identify the similarities and differences within China, promoting further inquiries and results. Because almost all patients did seek
Authors’ contribution Xu X. was involved in designing and conducting the study, in analyzing and interpreting the data, and drafting the article. Hong T. and Li B. were involved in the supervision of the statistical methods and data analysis. Liu W. made substantial contributions to the article and critically revised it. All authors approved the final manuscript.
5 Conclusion In the age of information, the internet is definitely a significant source. More and more of our patients use the internet to seek information to further understand their disease. Doctors could make better use of the internet by developing current evidence-based information for the internet, guiding patients toward high-quality websites, and teaching them how to locate information and check its credibility. Sharing our findings with more physicians will help improve the education of patients; reduce confusing, conflicting, or overwhelming information; facilitate the information exchange between physicians and patients; and boost the doctor–patient relationship. People who would undergo elective LC prefer to find information about the operation and experiences from doctors and patients, and value the inclusion of such on information-based websites. Health professionals can help patients by referring them to appropriate websites and discussing the information during visits and consultations. The authors declare that they have no com-
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