Objective
We analyzed the content, quality, and accuracy of information provided on hospital web sites about robotic gynecologic surgery.
Study Design
An analysis of hospitals with more than 200 beds from a selection of states was performed. Hospital web sites were analyzed for the content and quality of data regarding robotic-assisted surgery.
Results
Among 432 hospitals, the web sites of 192 (44.4%) contained marketing for robotic gynecologic surgery. Stock images (64.1%) and text (24.0%) derived from the robot manufacturer were frequent. Although most sites reported improved perioperative outcomes, limitations of robotics including cost, complications, and operative time were discussed only 3.7%, 1.6%, and 3.7% of the time, respectively. Only 47.9% of the web sites described a comparison group.
Conclusion
Marketing of robotic gynecologic surgery is widespread. Much of the content is not based on high-quality data, fails to present alternative procedures, and relies on stock text and images.
Over the last decade, robotic surgery has been introduced as an alternative minimally invasive surgical approach to traditional laparoscopy. Purported benefits of robotic surgery include 3-dimensional visualization, increased range of movement, enhanced surgeon comfort, and the ability to perform more difficult procedures without laparotomy. Although initially utilized for prostatectomy, robotic surgery is now increasingly used for a variety of applications including gynecologic surgery.
In spite of Food and Drug Administration approval of robotic gynecologic surgery, data describing the effectiveness of these procedures are limited and are often derived from single-institution reports. Many of these studies have found no benefit or clinically insignificant benefits for robotic compared to laparoscopic surgery. Of greater concern, a number of studies have suggested that the cost of robotic procedures is substantially greater than for laparoscopy. Despite these concerns, the use of robotic gynecologic surgery appears to be increasing rapidly. The total number of robot-assisted procedures increased to more than 200,000 in 2009, and reports have demonstrated that more than 1900 robotic surgical systems have been installed worldwide.
Whereas a multitude of factors are likely driving the dissemination of robotic gynecologic surgery, marketing influences appear to play a dominant role. Marketing by the manufacturer of the surgical robot to hospitals as well as direct-to-consumer marketing are widespread. Much of the marketing for robotic surgery is web based and derives from not only industry but also a variety of other sources. Because patients are now more frequently turning to the Internet for health-related issues, hospitals and physicians are increasingly using the Internet to disseminate medical information. Patients often rely on these web sites and assume that hospital web sites provide unbiased, factually correct information. Given the importance of hospital web sites in patient decision making, we examined the quality of the content of hospital web sites describing robotic gynecologic surgery.
Materials and Methods
We analyzed the use of web-based marketing of robotic gynecologic surgery on hospitals in the United States. A list of all acute care medical centers was generated from the American Hospital Directory. The American Hospital Directory is a privately owned online database that provides data and statistics about more than 6000 hospitals nationwide. It utilizes information from both private and public sources including Medicare claims data, hospital cost reports, and commercial licensors.
A priori we chose to include only hospitals with 200 or more beds because these are the hospitals that are most likely to provide surgical services. Our analysis included a sample of states chosen by the investigators from throughout the United States: New York, Pennsylvania, Illinois, Georgia, Colorado, and California. The ZIP code and bed size of each hospital were noted.
The main web site of each hospital listed on the American Hospital Directory was then examined to determine the presence of marketing of robotic gynecologic surgery. We first determined whether any online content was focused on robotic surgery. Because the specific intent of our analysis was to examine the use of marketing for gynecologic surgery, we considered only hospitals with web content specifically directed to a gynecologic surgical procedure. The methodology for the analysis was similar to that reported by Jin et al, who analyzed overall robotic marketing.
For those web sites that contained gynecologic robotic surgical content, we examined a number of parameters including: number of clicks to robotic content (0, 1, or ≥2), type of gynecologic robotic surgery displayed (benign, cancer, or both), use of stock images or text from the manufacturer of the surgical robot, and use of the trade name daVinci hysterectomy. We analyzed the reporting of claims of decreased perioperative morbidity including less pain, shorter recovery time, less scarring, less blood loss, and less infection. We also examined claims of clinical superiority including reporting that the robotic surgery was overall better, the most effective treatment, the ideal treatment, and allows the completion of the more difficult procedures.
For web sites that described robotic gynecologic oncology surgery, we analyzed claims of oncologic superiority including improved lymph node yield and improved cancer control. Claims of institutional superiority such as statements that the given hospital had the first robot in the region, performed the most robotic procedures, and was a leader in robotics were examined. We also analyzed how often potential limitations of robotic surgery were described including description of any risks, reference to costs, reference to operative times, and reference to any data and whether a comparison group (either open or laparoscopic) was specifically described. Lastly, we examined emotional claims.
We also explored the influence of regional variation and local markets on web-based marketing of robotic surgery. To quantify regional practice patterns, we utilized the Dartmouth Atlas Project. The Dartmouth Atlas Project is an online informational and analytic tool that utilizes Medicare data to describe national, regional, and local markets as well as hospitals and affiliated physicians. Its predominant source of information is through the Center for Medicare and Medicaid Services. Although information included is for the over-65 population, there is no similar counterpart to this database for the commercially insured population and additional studies by the Dartmouth group performed on a statewide basis showed similar trends in the under-65 population. As such, it is anticipated that these findings can accurately be extrapolated to a much broader population.
All ZIP codes from hospitals ascertained through the American Hospital Directory for use in our analysis were subsequently subdivided into 1 of the 306 predetermined hospital referral regions (HRRs) through the Dartmouth Atlas Project. These HRRs represent regional health care markets for tertiary medical care that generally require the services of a major referral center as determined by referrals for major cardiovascular and neurosurgical procedures. All data collected per HRR reflects the experience of Medicare patients living in that designated region.
Information was collected for each hospital HRR with regard to the number of total, female, and black Medicare enrollees; numbers of beds; full-time employees; and nurses per 1000 residents and physicians, primary care physicians, medical specialists, and surgeons per 100,000 residents. Total Medicare reimbursement and reimbursements for all professional and laboratory services as well as surgical services and inpatient short-term stays were also examined. Discharge information, including overall and surgical discharges per 1000 Medicare enrollees, and rates of inpatient procedures, such as knee replacement and coronary artery bypass graft, were also included.
The hospitals in our sample were derived from 90 unique hospital referral regions. For each of the HRR characteristics cited in previous text, we computed descriptive statistics for all 90 HRRs. For each characteristic, the HRRs under study were grouped into tertiles. The individual hospitals in our data set were then linked to these HRRs for analysis. We were unable to link 1 hospital to an HRR, and this facility was excluded from this portion of the analysis. Descriptive data are reported for the overall patterns of marketing of robotic gynecologic surgery. The association between each marketing question and the characteristics of the HRRs were then compared using χ 2 tests. All analyses were performed with SAS version 9.2 (SAS Institute Inc, Cary, NC). A P < .05 was considered statistically significant.
Results
A total of 432 hospitals were identified. The web sites of 192 hospitals (44.4%) contained marketing for robotic gynecologic surgery. Although the majority of hospital web sites required at least 2 clicks to reach information on robotic surgery, a notable number were advertised directly on the home page (15.6%) or 1 click away (18.8%) ( Table 1 ). Marketing was for benign indications in 89.6% of the hospitals and for oncologic procedures in 54.1%. Stock images (64.1%) and stock text (24.0%) derived from the manufacturer of the robot were frequent, whereas 62 of the sites (32.3%) contained the term, daVinci hysterectomy.
| Variable | n | (%) |
|---|---|---|
| Type of indication marketed | ||
| Benign | 172 | (89.6) |
| Cancer | 104 | (54.2) |
| Use of stock advertising material | ||
| Text | 46 | (24.0) |
| Images | 123 | (64.1) |
| Use of trade names | ||
| daVinci hysterectomy | 62 | (32.3) |
| Perioperative outcomes | ||
| Less pain | 169 | (88.0) |
| Shorter recovery | 175 | (91.2) |
| Less scarring | 144 | (75.0) |
| Less blood loss | 146 | (76.0) |
| Less infection | 112 | (58.3) |
| Claims of superiority | ||
| Overall better | 79 | (41.2) |
| Most effective treatment | 50 | (26.0) |
| Ideal treatment | 21 | (10.9) |
| Completion of more difficult procedures | 98 | (51.0) |
| Oncologic superiority | ||
| Improved lymph node yield | 18 | (9.4) |
| Improved cancer control | 12 | (6.3) |
| Potential limitations | ||
| Description of risks | 3 | (1.6) |
| Description of comparison group(s) | 92 | (47.9) |
| Reference to any data | 28 | (14.6) |
| Reference to cost | 7 | (3.7) |
| Reference to operating time | 7 | (3.7) |
| Claims of institutional superiority | ||
| First robot in the region | 49 | (25.5) |
| Most robotic procedures performed | 5 | (2.6) |
| Leader in robotics | 31 | (16.2) |
| Emotional claims | ||
| Cutting-edge treatment | 89 | (46.4) |
| Owe it to yourself for robotics | 31 | (16.2) |
| You or your loved one need robotic procedure | 30 | (15.6) |
| Ease of access (clicks to marketing) | ||
| 0 | 30 | (15.6) |
| 1 | 36 | (18.8) |
| ≥2 | 126 | (65.6) |
The majority of web sites reported claims of less pain (88.0%), shorter recovery time (91.2%), and less blood loss (76.0%) for robotic surgery ( Figure , A). Decreased incidence of scarring (75.0%) and infection (58.3%) were also frequently mentioned. A notable number of sites also described robotic surgery as overall better (41.2%) or the most effective option (26.0%), whereas 10.9% of hospitals marketed robotic options as the ideal treatment for certain surgical conditions, and 51% stated that the robotic surgical system allowed for completion of more complex procedures ( Figure , B). Web sites that promoted use of robotics in oncology described improved cancer outcomes in 6.3% and a higher lymph node yield in 9.4%. Despite efficacy claims, only 47.9% of the web sites described the comparison group (laparoscopy or open surgery) for the claims.
A minority of hospitals made reference to any evidence-based data to support claims (14.6%). Potential limitations of robotic surgery including cost (3.7%), complications (1.6%), and operative time (3.7%) were rarely discussed. Additionally, claims of institutional superiority, such as being a leader in robotic surgery (16.2%) and having one of the first robots in the area (25.5%) were also points of marketing. Similarly, use of provocative language could also be seen on numerous hospital web sites, with the phrases, state of the art or cutting edge (46.4%) and you owe it to yourself (16.2%) often noted. Emotional pleas to the phrase, you or your loved one, were also seen (15.6%).
Hospital size correlated with marketing of robotic surgery. Web-based marketing was identified for 32.9% of hospitals with less than 300 beds, 48.2% for facilities with 300-550 beds, and 64.1% in those centers with more than 550 beds ( Table 2 ). Although population density had no significant association with marketing, hospitals with a higher concentration of black patients were less likely to market robotic surgery (46.6% for hospitals with less than 2% black patients vs 39.1% for centers with more than 5% black patients) ( P = .02). Among hospitals with the lowest concentration of surgeons per 100,000 residents, 41.4% marketed the robot compared with 53.1% of hospitals with an intermediate and 37.1% of hospitals with a high concentration of surgeons ( P = .008).
| No | Yes | ||||
|---|---|---|---|---|---|
| Variable | n | (%) | n | (%) | P value |
| 239 | (55.5) | 192 | (44.6) | ||
| Hospital size (beds) | < .0001 | ||||
| <300 | 114 | (67.1) | 56 | (32.9) | |
| 300-550 | 102 | (51.8) | 95 | (48.2) | |
| >550 | 23 | (35.9) | 41 | (64.1) | |
| Medicare enrollees | .41 | ||||
| <49,572 | 24 | (58.5) | 17 | (41.5) | |
| 49,572-97,118 | 47 | (49.5) | 48 | (50.5) | |
| >97,118 | 168 | (57.0) | 127 | (43.1) | |
| Female Medicare enrollees | .41 | ||||
| <28,113 | 24 | (58.5) | 17 | (41.5) | |
| 28,113-54,326 | 47 | (49.5) | 48 | (50.5) | |
| >54,326 | 168 | (57.0) | 127 | (43.1) | |
| Percentage of black Medicare patients | .02 | ||||
| <2% | 31 | (53.5) | 27 | (46.6) | |
| 2-5% | 57 | (45.6) | 68 | (54.4) | |
| >5% | 151 | (60.9) | 97 | (39.1) | |
| Hospital beds per 1000 residents | .02 | ||||
| <2.1 | 62 | (46.6) | 71 | (53.4) | |
| 2.1-2.6 | 109 | (62.6) | 65 | (37.4) | |
| >2.6 | 63 | (57.3) | 47 | (42.7) | |
| Unknown | 5 | (35.7) | 9 | (64.3) | |
| Hospital employees per 1000 residents | .26 | ||||
| <12.7 | 83 | (52.5) | 75 | (47.5) | |
| 12.7-14.8 | 63 | (60.6) | 41 | (39.4) | |
| >14.8 | 88 | (56.8) | 67 | (43.2) | |
| Unknown | 5 | (35.7) | 9 | (64.3) | |
| Nurses per 1000 residents | .20 | ||||
| <3.4 | 74 | (51.0) | 71 | (49.0) | |
| 3.4-3.8 | 77 | (58.3) | 55 | (41.7) | |
| >3.8 | 83 | (59.3) | 57 | (40.7) | |
| Unknown | 5 | (35.7) | 9 | (64.3) | |
| Physicians per 100,000 residents | .07 | ||||
| <185.0 | 30 | (48.4) | 32 | (51.6) | |
| 185.0-213.2 | 108 | (58.1) | 78 | (41.9) | |
| >213.2 | 93 | (58.5) | 66 | (41.5) | |
| Unknown | 8 | (33.3) | 16 | (66.7) | |
| Primary care physicians per 100,000 residents | .11 | ||||
| <68.1 | 81 | (53.6) | 70 | (46.4) | |
| 68.1-74.1 | 50 | (58.1) | 36 | (41.9) | |
| >74.1 | 100 | (58.8) | 70 | (41.2) | |
| Unknown | 8 | (33.3) | 16 | (66.7) | |
| Specialists per 100,000 residents | .12 | ||||
| <39.1 | 39 | (54.2) | 33 | (45.8) | |
| 39.1-46.7 | 96 | (55.5) | 77 | (44.5) | |
| >46.7 | 96 | (59.3) | 66 | (40.7) | |
| Unknown | 8 | (33.3) | 16 | (66.7) | |
| Surgeons per 100,000 residents | .008 | ||||
| <40.5 | 95 | (58.6) | 67 | (41.4) | |
| 40.5-44.5 | 53 | (46.9) | 60 | (53.1) | |
| >44.5 | 83 | (62.9) | 49 | (37.1) | |
| Unknown | 8 | (33.3) | 16 | (66.7) | |
| Discharges per 1000 Medicare enrollees | .02 | ||||
| <301.4 | 38 | (42.7) | 51 | (57.3) | |
| 301.4-349.0 | 95 | (57.2) | 71 | (42.8) | |
| >349.0 | 106 | (60.2) | 70 | (39.8) | |
| Surgical discharges per 1000 Medicare enrollees | .36 | ||||
| <92.4 | 100 | (58.1) | 72 | (41.9) | |
| 92.4-103.0 | 98 | (56.0) | 77 | (44.0) | |
| >103.0 | 41 | (48.8) | 43 | (51.2) | |
| Medicare reimbursement per enrollee | .007 | ||||
| <7637 | 38 | (46.9) | 43 | (53.1) | |
| 7637-8920 | 55 | (47.4) | 61 | (52.6) | |
| >8920 | 146 | (62.4) | 88 | (37.6) | |
| Professional services reimbursement | .02 | ||||
| <1760 | 29 | (45.3) | 35 | (54.7) | |
| 1760-2120 | 75 | (50.3) | 74 | (49.7) | |
| >2120 | 136 | (61.9) | 83 | (38.1) | |
| Professional reimbursement for surgical services | .03 | ||||
| <374 | 53 | (54.6) | 44 | (45.4) | |
| 374-420 | 56 | (46.3) | 65 | (53.7) | |
| >420 | 130 | (61.0) | 83 | (39.0) | |
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