[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
[Skip to Content Landing]
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    February 12, 2020

    Content Analysis of Negative Online Reviews of Hospice Agencies in the United States

    Author Affiliations
    • 1Adult and Child Consortium for Outcomes Research and Delivery Science, Anschutz Medical Campus, University of Colorado School of Medicine, Aurora
    • 2Division of Geriatrics, University of Colorado School of Medicine, Aurora
    • 3VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver
    • 4Division of Cardiology, University of Colorado School of Medicine, Aurora
    JAMA Netw Open. 2020;3(2):e1921130. doi:10.1001/jamanetworkopen.2019.21130
    Key Points español 中文 (chinese)

    Question  What are the most common criticisms found in negative (ie, 1-star) online reviews of hospice agencies?

    Findings  In this qualitative study of 137 unique online reviews of 67 hospice agencies, 2 domains of criticisms emerged: actionable criticisms, which are variables hospice organizations can change and include the themes of expectations, communication, and quality of care, and unactionable criticisms, which are variables that require larger systematic changes and include the themes of misperceptions about the role of hospice and the meaning of a good death.

    Meaning  In this study, many criticisms could have been mitigated through enhanced communication between staff and patients’ families, friends, and caregivers during hospice admission to foster realistic expectations of hospice staff, hospice services, and death.


    Importance  As online reviews of health care become increasingly integral to patient decision-making, understanding their content can help health care practices identify and address patient concerns.

    Objective  To identify the most frequently cited complaints in negative (ie, 1-star) online reviews of hospice agencies across the United States.

    Design, Setting, and Participants  This qualitative study conducted a thematic analysis of online reviews of US hospice agencies posted between August 2011 and July 2019. The sample was selected from a Hospice Analytics database. For each state, 1 for-profit (n = 50) and 1 nonprofit (n = 50) hospice agency were randomly selected from the category of extra-large hospice agencies (ie, serving >200 patients/d) in the database. Data analysis was conducted from January 2019 to April 2019.

    Main Outcomes and Measures  Reviews were analyzed to identify the most prevalent concerns expressed by reviewers.

    Results  Of 100 hospice agencies in the study sample, 67 (67.0%) had 1-star reviews; 33 (49.3%) were for-profit facilities and 34 (50.7%) were nonprofit facilities. Of 137 unique reviews, 68 (49.6%) were for for-profit facilities and 69 (50.4%) were for nonprofit facilities. A total of 5 themes emerged during the coding and analytic process, as follows: discordant expectations, suboptimal communication, quality of care, misperceptions about the role of hospice, and the meaning of a good death. The first 3 themes were categorized as actionable criticisms, which are variables hospice organizations could change. The remaining 2 themes were categorized as unactionable criticisms, which are factors that would require larger systematic changes to address. For both for-profit and nonprofit hospice agencies, quality of care was the most frequently commented-on theme (117 of 212 comments [55.2%]). For-profit hospice agencies received more communication-related comments overall (34 of 130 [26.2%] vs 9 of 82 [11.0%]), while nonprofit hospice agencies received more comments about the role of hospice (23 of 33 [69.7%] vs 19 of 31 [61.3%]) and the quality of death (16 [48.5%] vs 12 [38.7%]).

    Conclusions and Relevance  Regarding actionable criticisms, hospice agencies could examine their current practices, given that reviewers described these issues as negatively affecting the already difficult experience of losing a loved one. The findings indicated that patients and their families, friends, and caregivers require in-depth instruction and guidance on what they can expect from hospice staff, hospice services, and the dying process. Several criticisms identified in this study may be mitigated through operationalized, explicit conversations about these topics during hospice enrollment.