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Ann R Coll Surg Engl. 2009 September; 91(6): 460–463.
PMCID: PMC2966195

Use of the Internet by Patients Undergoing Elective Hernia Repair or Cholecystectomy

Abstract

INTRODUCTION

Patient-directed information available on the internet is not always regulated; it may be confusing and sometimes just overwhelming. We aimed to establish the proportion of patients undergoing two common surgical procedures, who searched the internet for information about their operations and to assess the usefulness of the information they received.

PATIENTS AND METHODS

A total of 105 consecutive patients undergoing elective abdominal wall hernia repair (n = 54) or laparoscopic cholecystectomy (n = 51) in a single surgical firm were included in the study. Patients were counselled about their operation in pre-operative assessment clinics and standard trust information leaflets were provided without any mention of this study. Patients were then asked to complete a questionnaire on the morning of their operation.

RESULTS

All patients completed the questionnaire. Of the patients, 59% stated that they had access to the internet and 77% of these accessed the internet over 2 h a week. Of the patients with internet access, 31% used it to acquire additional information about their operations and 58% used internet search engines. Of the patients who searched the internet regarding their operations, 26% were confused and/or worried by the information they received.

CONCLUSIONS

A significant proportion of patients undergoing common surgical procedures used the internet and about one-third of them specifically sought information about their operation on the internet. Such information can cause worry and confusion in patients. Our study highlights the need for regulated, comprehensible, patient information on hospital websites to which patients should be directed.

Keywords: Internet, Hernia, Cholecystectomy

Internet use by the general population is rapidly increasing. UK Government data released by the Office for National Statistics revealed that between 2001/02 and 2006 the proportion of adults in Great Britain who used the internet increased from 48% to 60% with internet connection being present in about 61% of households in 2007.1 It is also well recognised that people frequently use the internet for health-related information with about 80% of American internet users going online for health information.2 Such online information is unregulated, sometimes sponsored and often overwhelming to the patients. It has been shown that the available health-related information on the internet is often deficient or unreliable.36

Being a relatively new technology, the use of internet for health information is associated with younger age and higher income and education levels.79 Internet use for personal disease-related information has been found to be high in certain subgroups of surgical patients such as bariatric patients and patients suffering from inflammatory bowel disease.9,10 However, not much is known about the pattern of internet use amongst patients undergoing abdominal wall hernia repair and cholecystectomy. Hernia repair and cholecystectomy are two of the commonest general surgical procedures performed, with over 167,000 cases performed within the NHS trusts in England in the financial year 2005–2006.11 Pattern of internet use by this large subgroup of general surgical patients has not been previously studied and hence its effect or potential is unknown.

In this study, we aimed to establish the proportion of patients undergoing these two common surgical procedures, who searched the internet for information about their operations and to assess the usefulness of the information they received.

Patients and Methods

A total of 105 consecutive patients undergoing elective abdominal wall hernia repair (n = 54) or laparoscopic cholecystectomy (n = 51) in a single surgical firm were included in the study. Maintaining usual practice, all patients were counselled about their operations in the out-patient and the pre-operative assessment clinics and standard trust information leaflets were provided without any mention of this study. Patients were then asked to complete a questionnaire, on the morning of their operation on arrival to the ward, by one of the authors. No patient-identifying data were recorded on the questionnaire (Appendix 1).

Data were examined as a single group combining patients having hernia repair and cholecystectomy. Statistical analysis was performed using GraphPad InStat v.3.06 for Windows (GraphPad Software, San Diego, CA, USA).

Results

Study group

All consecutive 105 patients undergoing elective abdominal wall or groin hernia repair (n = 54) and laparoscopic cholecystectomy (n = 51) completed and returned the questionnaires. As expected, and in contrast to patients having cholecystectomy, patients having hernia repair had a predominance of males and were generally older in age (Table 1).

Table 1
Patient demographics

The majority of patients in the study population were aged < 65 years (19% aged 16–40 years; 53.3% aged 41–65 years; and 27.6% aged > 65 years).

Of the study cohort, 103 (98%) patients received the printed trust information leaflets during their pre-operative assessment. Of these, 95.1% (98 of 103) found the information in the leaflet very good (82 of 103) or good (16 of 103). Five patients (4.9%) found the information in the leaflet satisfactory. None rated the leaflet as poor or very poor.

Patients with internet access

Internet access was available to 59% (62 of 105) patients. Of these, 77% accessed the internet for over 2 h a week. Of the patients with internet access, 31% used it to acquire additional information about their operations and 58% used internet search engines to acquire additional information.

Internet access was more frequently available for the younger age groups with 65% and 68% of patients aged 16–40 years and 41–65 years, respectively, having access to internet. In contrast, only 38% of the patients aged over 65 years had access to the internet. Among patients who used the internet to acquire additional information there was a significant inverse trend with increasing age groups (P = 0.0169, chi-squared test for trend; Fig. 1).

Figure 1
Inverse trend in the use of internet for additional information (P = 0.0169, chi-squared test for trend).

Level of education had no influence on the likelihood of using the internet for additional information with 30.8% of patients with education level at graduate or above using the internet for this purpose compared to 30.6% of patients with less than graduate level education (P = 1, Fischer's exact test; Fig. 2).

Figure 2
Of patients, 30.6% with less than graduate education used internet for additional information versus 30.8% of patients with graduate or above level of education (P = 1, Fischer's Exact test).

The average weekly duration of internet use had no influence on the likelihood of using the internet for additional information. The median weekly duration of internet use in patients who used it to acquire additional information was 3 h/week in contrast to 2 h/week in patients who did not access internet for additional information (P = 0.23, Mann–Whitney U-test).

Of the patients who searched the internet regarding their operations, 79% rated the information they had found as either very good or good; however, 26% were also confused and/or worried by the information they received.

Discussion

Internet use has rapidly increased in the community and is likely to increase with time. Data from a British population survey revealed that 61% of households had internet connection in 2007 with 60% of people aged 16 years and older using internet everyday.1 Though internet usage is known to reduce with age, this British population survey showed that a sizeable proportion (52%) of 55–64-year-olds used the internet.1

We decided to study the pattern of internet use for procedure-related information in patients undergoing abdominal wall (epigastric, para-umbilical, incisional and groin) hernia repair and cholecystectomy as these are common, standardised, general surgical procedures performed. Data from the NHS Information Centre, Hospital Episode Statistics (2005–06) for NHS Trusts in England alone revealed that over 167,000 such procedures were performed.11 Over 52% of these patients were in the age group of 15–55 years.11 Thus, a substantial number of these people fall in the age group most likely to use the internet.

Our study population had access to the internet comparable to the national average. As expected, we found that the use of internet to search additional information declined with increasing age. However, we found that level of education did not influence such use of internet. This is in contrast to previous population studies and might be explained by the fact that as the internet becomes more easily available, it is no longer a tool for the educated few.

Almost all of our patients (98%) were provided with printed trust information leaflets regarding their operation and over 95% of them found that information ‘very good’ or ‘good’. Nevertheless, a significant proportion of these patients went on to search further information about their procedure on the internet.

Of the patients who searched the internet for additional information, 58% did so using a search engine. The prioritisation of websites found by search engines is not only confusing but also subject to bias, some of which is commercial. Google search performed separately for key words ‘hernia repair’ and ‘cholecystectomy’ in July 2008 resulted in 714,000 and 711,000 web pages, respectively. It has been demonstrated that most people looking for health-related information through search engines use short, often mis-spelled search phrases and seldom go beyond the first page of search results.12 Various studies have also shown that the quality of information available through such search web pages is often sub-optimal.36 Poor results were also seen in web searches for a simple surgical search phrase like ‘inguinal hernia’.13 There is much variability in the available information with regards to surgical treatment options and surgical complications.14 It comes as no surprise, therefore, that 26% of our patients who searched the internet were left confused or worried.

Thorough pre-operative counselling of patients is often associated with better subjective results from a procedure. Sjöling et al.15 demonstrated that delivering specific pre-operative information to patients resulted in better pain control, decreased anxiety and improved satisfaction with the procedure. In a study by Danquah and colleagues,16 patients who were advised to look up pre-selected internet sites prior to inguinal hernia repair had higher satisfaction rates with the procedure and felt that their expectations were met about the procedure when compared to control patients. It is, therefore, easy to conceive that patients who have confusing or worrying pre-operative information may not be well satisfied with the outcome.

Conclusions

This study has shown that a substantial number of patients undergoing common surgical procedures seek further information from the internet. We expect that this number will only rise with time. Such information available on the internet can cause worry and confusion in patients. Our study highlights the need for regulated, comprehensible, patient information on hospital websites to which patients should be actively made aware.

Appendix 1: Questionnaire

Section 1 – About you

  1. What is your age? Please circle the correct answer:
    16–17 years old18–24 years old
    25–40 years old41–50 years old
    51–65 years old65+ years old
  2. What is your sex?
  3. What is your level of education?
    • O level/GCSE (or equivalent)
    • A level
    • Graduate
    • Postgraduate
    • None
  4. What is your current occupation (or previous occupation if not working at the moment/retired)?
    • Please state: ___________________________
  5. Which surgical procedure are you having?
    • Cholecystectomy
    • Hernia

Section 2 – Information

  • 6
    Did you receive any written information (e.g. leaflet) from staff at the hospital about your surgical procedure?
    YesNoNot sure/can't remember
    If yes, how would you rate this information?
    Very goodGoodSatisfactoryPoorVery poor
  • 8
    How many hours per week do you spend on the internet?
    Please state approximate time: _____________________
  • 9
    Did you use the internet to find out more information about your condition/surgical procedure?
    YesGo to Question 10
    NoGo to Question 16
  • 10
    How much time did you spend on the internet looking for more information? Please state approximate time:_____________
  • 11
    Did you use a particular search engine on the internet to find out more information (e.g. Google, Yahoo, MSN)?
    If yes, please state: ______________________________
  • 12
    Did you use a particular website(s) to find out more information?
    If yes, please state which website(s) you used: ______________________________________
  • 15
    Did you have any worries or concerns after reading the information on the website?
  • If yes, did you do anything to clarify your concerns?
    ______________________________________________

Section 3 – Overall

  • 16
    Was there any information that you were not told but would have found helpful?
    If yes, please comment:
    ________________________________________________
  • 17
    How do you think we could improve patient information?
    __________________________________________________
    __________________________________________________
    __________________________________________________

References

1. Office for National Statistics. Internet Access and Use of the Internet. National Statistics Omnibus Survey, 2007 < www.statistics.gov.uk>.
2. Fox S. Internet & American Life Project. Washington DC: PEW; 2006. Online Health Search 2006. < www.pewinternet.org>.
3. Kunst H, Groot D, Latthe PM, Latthe M, Khan KS. Accuracy of information on apparently credible websites: survey of five common health topics. BMJ. 2002;324:581–2. [PMC free article] [PubMed]
4. Berland GK, Elliott MN, Morales LS, Algazy JI, Kravitz RL, et al. Health information on the internet: accessibility, quality, and readability in English and Spanish. JAMA. 2001;285:2612–21. [PubMed]
5. Gordon JB, Barot LR, Fahey AL, Matthews MS. The internet as a source of information on breast augmentation. Plast Reconstr Surg. 2001;107:171–6. [PubMed]
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7. PEW. Internet & American Life Project. Washington DC: PEW; 2008. Demographics of Internet Users: Tracking Survey. < www.pewinternet.org/trends.asp>.
8. Gupte CM, Hassan AN, McDermott ID, Thomas RD. The internet – friend or foe? A questionnaire study of orthopaedic out-patients. Ann R Coll Surg Engl. 2002;84:187–92. [PMC free article] [PubMed]
9. Cima RR, Anderson KJ, Larson DW, Dozois EJ, Hassan I, et al. Internet use by patients in an inflammatory bowel disease specialty clinic. Inflamm Bowel Dis. 2007;13:1266–70. [PubMed]
10. Hamoui N, Lake J, Beart RW, Anthone GJ, Crookes PF. Patterns of internet use: bariatric versus colorectal patients in a private institution. J Am Coll Surg. 2004;199:223–8. [PubMed]
11. NHS. 2007. Main Operations: Summary 2005–06. The NHS Information Centre, Hospital Episodes Statistics, < www.hesonline.nhs.uk>.
12. Morahan-Martin JM. How internet users find, evaluate, and use online health information: a cross-cultural review. Cyberpsychol Behav. 2004;7:497–510. [PubMed]
13. Krones CJ, Böhm G, Ruhl KM, Stumpf M, Klinge U, Schumpelick V. Inguinal hernia on the internet: a critical comparison of Germany and the UK. Hernia. 2004;8:47–52. [PubMed]
14. Murphy MA, Joyce WP. Information for surgical patients: implications of the world wide web. Eur J Surg. 2001;167:728–33. [PubMed]
15. Sjöling M, Nordahl G, Olofsson N, Asplund K. The impact of preoperative information on state anxiety, postoperative pain and satisfaction with pain management. Patient Educ Couns. 2003;51:169–76. [PubMed]
16. Danquah G, Mittal V, Solh M, Kolachalam RB. Effect of internet use on patient's surgical outcomes. Int Surg. 2007;92:339–43. [PubMed]

Articles from Annals of The Royal College of Surgeons of England are provided here courtesy of The Royal College of Surgeons of England