Commercial entities own the online narrative on home care: Impacts on quality, content, and readability

Older adults and caregivers face numerous challenges in identifying and affording home-based care.1 Thus, they often turn to online sources for information,2 and 92% of internet users use Google's search engine.3 Here, our objective was to describe the content, quality, and readability of online content relevant to home-based care. We followed previously published methods.4 In November 2023, we used Google Keyword Planner,5 to create a list of frequently searched terms pertaining to home-based care. After removing the least searched keywords (n = 3545), names of individual home care companies (n = 2), assisted living keywords (n = 4), and keywords with declining annual use (n = 3), we arrived at a final selection of five keywords: "home health aide," "home care services," "home health," "home health care services," and "senior home care." Subsequently, we employed Ahrefs' free Keyword Generator,6 a search engine optimization tool, to identify questions related to these keywords. In December 2023, we used incognito mode to search Google for the top three websites for each question. The top three ranked search results are known to get 54.5% of all clicks.7 We also included the four "People also ask" (PAA) questions for each search query in our analyses, which are Google artificial intelligence-generated questions related to the original search. See Figure 1 for a study schematic. We evaluated website quality using the Journal of the American Medical Association's (JAMA's) benchmark criteria (See Supplementary Material S1),8 which uses four criteria: authorship, attribution of references and sources, disclosure of website ownership, and currency. Then, we used online tools to calculate the Flesch readability ease scores (See Supplementary Material S1).9 Scores ranging from 90 to 100 suggest that the text is very easy to read and accessible to someone at a 5th-grade reading level, which is the recommended standard for public information.10 Over the last year, the most searched questions on home-based care focused on how to afford care (55%), the job responsibilities of home health aides (27%), and the definition of home-based care (18%). The top searched question was "How much does Medicare pay for home care per hour?" which generated 3400 monthly searches (See Supplementary Material S1). Among the top ranked 165 websites for these searched questions, 53% (n = 87) were commercial (e.g., www.humana.com), 31% (n = 52) were governmental (e.g., www.medicare.gov), and 9% (n = 15) were academic websites (e.g., www.hopkinsmedicine.gov) (see Supplementary Material S1). Few were social media, nonprofit (e.g., www.homecare.org), or medical practice websites (4%, 2%, and 1%, respectively). Government and academic website categories had higher quality ratings than commercial websites. Almost all websites averaged readability in the 50–60 range (10th-12th grade reading level), making the material "fairly difficult" to read for the average American (see Figure 2). Our analysis offers several insights. First, we found that users mostly query Google search for costs of home-based care, what is encompassed by these services, and home care aide responsibilities. Second, we found that commercial websites provide most of the discoverable content to users. Third, we highlighted that online information on home-based care is fraught with challenges for the average American, including lacking information to judge quality and "fairly difficult" readability. Overall, this points to a critical need for more investment in publicly accessible materials and communication on home-based care. Importantly, Care Compare (www.medicare.gov/care-compare) was not among the top 165 ranked websites, although it is widely considered the federal government's solution for helping users navigate the healthcare system. A key takeaway from this work is that websites, such as Care Compare, lack effectiveness if website creators do not invest in search engine optimization, as Google will not rank the website relevant enough for users to "find" it. Limitations included that we excluded advertisements or promoted content and our search may have missed state-specific websites which rely on location data. Additionally, the Flesch readability score penalizes excess word count and character count, and the JAMA quality score rates accountability of the webpage but does not assess accuracy of content. In conclusion, payors and policy makers face significant headwinds in ensuring high quality readable information is available to patients and caregivers seeking home-based care. Commercial entities dominate online information on this topic and are not required nor incentivized to provide useful information on federally or state covered services to the public. These data suggest online content presents another roadblock for patients and caregivers in accessing home-based care, and governmental agencies must invest in creating more high quality and readable content, potentially leveraging search engine optimization principles to bring their content to users. National Institutes of Health (National Institute on Aging; K76 AG059983). Supplementay Material S1. The average JAMA benchmark criteria on website quality score and Flesch Readability Ease scores for each searched question and website category, the highest volume questions related to home-based care on Google, supplemental methods, and categories assigned to each identified website. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.