How the internet is accessed by and influences surgical patient's decision making.

The internet shapes and influences many facets of society. Healthcare has been slow to utilize internet for healthcare delivery and education.1, 2 The COVID-19 pandemic has forced a rapid acceleration of internet-based healthcare, but there is limited research assessing internet accessibility and the influence this has on patient health decision making. The abundance of health information on the internet enables patients to play active roles in patient-cantered care, providing immediate patient information in culturally and linguistically diverse ways. Curation of all health information available on the internet is impossible. Patients often use heuristics to judge the quality of a website rather than the quality of the evidence presented.3 On the other end, websites with evidence-based content can be too complex to be understood by the target audience's literacy level.3-5 It is increasingly important for surgeons to understand the online habits of their patients and how these habits influence their patient's decision making. The COVID-19 pandemic has accelerated the usage and implementation of internet-based healthcare globally. We conducted a cohort-controlled study comparing internet access and health-related search habits of private and public patients in a large Metropolitan centre in 2012 and repeated the study design 2019. Low risks ethics approval was obtained (QA2018.16). In 2019, 200 patients from a tertiary metropolitan orthopaedic outpatient clinic and 202 patients from a private surgical clinic were recruited. A 37-question survey was administered in English, with the aid of interpreters when necessary. The results of these questions were compared to those of a survey completed in 2012.6 The chi2 test was used to compare proportions. A two-sided T-test was used to compare means between the 2012 and 2019 results. P-values <0.05 were considered significant. Participant age range was between 17 and 88 years. 94.2% of patients in 2019 reported internet access (n = 379), increased from 79% in 2012 (P < 0.05) (Fig. 1.). The patients over 60, increased their internet access by 44%. Public and private patients have statistically the same internet access in 2019, 91% and 95% respectively (P = 0.7094). Amongst all study patients, education level influenced internet access the most. Internet access amongst people with a primary school education or no formal education was 69% and 99% with university or higher education. In 2019, 64.8% of all patients used the internet to search their medical condition and treatment options. Government websites were the most trusted for health information (public 74.5%, private 66.4%). Private surgeons' websites 15% and social media 3%. Of all internet users in 2019, 94.4% owned a smartphone (public 96.5%, private 92.5%). Patients with lower education levels tended to use smartphones as the primary way to access the internet compared to more educated patients (P < 0.001). 36.4% of private patients researched their surgeon on the internet. Eleven percent of private patients would change their surgeon based upon their internet search. The internet plays an increasingly important role in healthcare. Our study represents the only cohort controlled 7-year follow-up of internet usage amongst public and privately insured surgical patients in Australia. Internet accessibility is the biggest influence on a patient's likelihood of researching their health condition,5 and most patients now use the internet to research and influence their health decision making. It is impossible to control the content of health information on the internet, much of which is of low quality and of limited use to patients due to poor readability.3 Since our original study in 20126 internet access between public and private patients is statistically the same. Historically the determinants of internet access were socioeconomic factors and age.6-11 We demonstrated that socioeconomic status and age no longer predict if a patient will use the internet to research their health condition. The difference is the device each group uses to access the internet. Amongst public and lower education level patient's smartphones were the most used device. This is consistent with previous studies.8 Well-designed patient centred responsive websites could provide the means to close the health literacy gap between public and private patients.12 This would help in the surgical consent process12, 13 in the context of connected health. Surgeons and health organizations can confidently migrate health information and communication to internet-based technology without leaving large groups of the population behind. The change in internet access over time is important, although it may seem obvious, it helps surgeons understand the habits and pre-conceptions their patients may have about their treatment. It also gives evidence to public health organizations and associations to plan for future patient information and engagement with regards to consent and patient related outcome measures. COVID-19 has initiated a revolution in remote healthcare. It appears from our present study results, that patient of all ages and demographics seem ready for this revolution. Authors participated in data collection analysis and drafting of the final submission. The Western Health Low Risk Ethics Panel reviewed this project against the tenets of the National Statement on Ethical Conduct in Research (2007). Approval was granted, reference number QA2018.16. Cohort controlled comparative study. AOA ASM 2019 (Canberra, Australia). All participants signed a consent form before answering the survey. Granted from the Western Health Low Risk Ethics Panel. All data and materials are stored securely within the Western Health Orthopaedic Department office. The data and materials are freely available and will be kept in accordance with all regulations and laws.