- Email: [email protected]
Assessment of the quality of Internet information on sleeve gastrectomy
Surgery for Obesity and Related Diseases ] (2014) 00–00
Original article
Assessment of the quality of internet information on sleeve gastrectomy Ricard Corcelles, M.D., Ph.D.a,b, Christopher R. Daigle, M.D.a, Hector Romero Talamas, M.D.a, Stacy A. Brethauer, M.D.a,*, Philip R. Schauer, M.D.a b
a Bariatric and Metabolic Institute, Cleveland Clinic, Ohio Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic of Barcelona, Barcelona, Spain Received May 28, 2014; accepted August 25, 2014
Abstract
Background: The Internet is an important source of information for morbidly obese patients who are potential candidates for bariatric procedures. Over the past few years, there is growing demand for sleeve gastrectomy because of perceived technical ease balanced with excellent outcomes. The aim of this study was to assess the quality and content of available internet information pertaining to sleeve gastrectomy. Our hypothesis is that this information is inconsistent and inaccurate. Methods: A total of 50 websites were analyzed in September 2013. We used the search term “sleeve gastrectomy” to identify sites on the most common internet search engines: Google, Yahoo, Bing, and Ask. Based on popularity of use, 20 websites were obtained through the Google engine and 10 sites by each of the others. Websites were classified as academic, physician, health professional, commercial, social media, and unspecified. Quality of information was evaluated using the DISCERN score, the Journal of the American Medical Association (JAMA) benchmark criteria, and the Health on the Net code (HONcode) seal accreditation. The DISCERN score varies from 0–80 points and is based on 16 questions that evaluate publication quality and reliability. The JAMA benchmark criteria range from 0–4 points assessing website authorship, attribution, disclosure, and currency. HONcode certification was assessed as present or absent website accreditation. Duplicate and inaccessible websites were excluded from the analysis. Results: We identified 43 websites from the United States, 6 from Mexico, and 1 from Australia. The average DISCERN and JAMA benchmark scores for all websites were 46.3 ⫾ 14.5 and 1.6 ⫾ 1.1, respectively, with a median DISCERN of 48.5 (range, 16–76) and JAMA score of 2.0 (range, 0–4). Website classification distribution was 21 physician, 11 academic, 7 commercial, 5 social media, 4 unspecified, and 2 health professional. The average DISCERN and JAMA benchmark scores were 55.4 ⫾ 13.4 and 2.4 ⫾ 1.0 in the academic group, 49.5 ⫾ 10.0 and 1.9 ⫾ .9 in the physician group, 46.9 ⫾ 14.2 and .2 ⫾ .4 in social media sites, 44.0 ⫾ 2.8 and 1.0 ⫾ .0 in health professional pages, 41.3 ⫾ 14.2 and 1.0 ⫾ 1.0 in commercial sites, and 39.8 ⫾ 19.5 and 1.0 ⫾ 1.1 in the unspecified group. The HONcode seal was present in 2 (4%) of the websites analyzed. Conclusion: The results of this study suggest poor quality and content of information on the internet viewed by potential bariatric candidates. Only 4% of the websites demonstrated HONcode seal accreditation. The global mean DISCERN and JAMA benchmark scores reported in this study were significantly lower than one would expect. Academic and physician websites offer the best information content whereas the worst was observed in the commercial and unspecified groups. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
sleeve gastrectomy; internet; quality; bariatric
* Correspondence: Stacy A. Brethauer, M.D., Bariatric and Metabolic Institute, Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH 44195. E-mail: [email protected]
http://dx.doi.org/10.1016/j.soard.2014.08.014 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
R. Corcelles et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
The Internet’s enormous growth has changed the way we obtain information [1]. It is estimated that approximately 1,319,872,109 people use the Internet and more than 270 million are Americans [2]. The Internet has become a useful tool for the sharing of medical knowledge and its use in this manner is increasing [3]. As individuals take a more active role in the management of their own health, more consumers are independently searching health information via the Internet. In the year 2011, 480% of adults reported using Internet resources to support healthcare decisions [4]. Physicians are also turning to the Internet to stay informed and interact with their patients. Given the vast amount of healthcare data available on the Internet, there are several concerns about the quality and content of this medical information [3,5]. Different reports claim inaccurate and inconsistent information contained in many health websites [6,7]. Over 100 million American adults are currently overweight or obese. The Internet is an important source of information for morbidly obese patients who are potential candidates for bariatric procedures. Although physician advice significantly affects a patient’s choice of weight loss modality, people also make health choices based on information they find on the Internet [8,9]. Laparoscopic sleeve gastrectomy (SG) is an established surgical approach, with a surge in popularity because of its perceived technical simplicity, feasibility, and excellent outcomes. Several studies have shown SG to be a durable procedure that achieves sustained weight loss and resolution of comorbidities up to 5 years follow-up [10]. Likely because of this supportive evidence, we have seen dramatic growth in the number of SG performed in recent years. The aim of this study was to assess the quality of information about SG on the Internet using recognized scoring systems such as the Journal of the American Medical Association (JAMA) benchmark, the DISCERN criteria, and the Health on the Net code (HONcode) accreditation. Methods A total of 50 websites were analyzed in September 2013. The search term “sleeve gastrectomy” was used on the most common Internet search engines: Google, Yahoo, Bing, and Ask. The total number of websites returned by the search was: 818,000 results for Google (www.google.com); 899,000 results for Yahoo (www.yahoo.com); and 901,000 for Bing (www.bing.com). Of note, the total hit number for the Ask (www.ask.com) search engine was not available. Google sites led the U.S. explicit core search market in September 2013 with 66.9% market share, followed by Bing sites (Microsoft) with 18% and Yahoo sites with 11.3%. The Ask network accounted for 2.5% of explicit core searches, followed by other search engines (AOL) with 1.3% [1]. Based on this popularity of use, 20 websites were obtained through the Google engine and 10
sites by each of the others. Popularity of use was determined using “the internet world statistics” website (http:// www.internetworldstats.com), which is an international website that features up to date world internet usage, population statistics, and internet data for over 200 countries. Websites were selected based on the order they appeared when using the various search engines. Duplicated websites and those that were inaccessible were excluded from our analysis (Fig. 1). We classified websites into different categories: academic, physician, nonphysician health professionals (therapists, alternative medical providers, etc.), commercial, social media (YouTube, Facebook, Twitter, etc.), and unspecified websites. Academic websites were those associated with a university or medical school. Physician websites were those sites for individual professionals without academic affiliation. Websites described as commercial were those displaying advertisements and/or different products for sale. Social media websites were any derived from social media platforms. Unspecified websites were those not matching any of the above described categories (National Institutes of Health, Wikipedia, patients’ forums, etc.). Quality of information was evaluated using the DISCERN score [11], the JAMA benchmark criteria [7], and the HONcode certification [12]. The DISCERN was developed by an expert group at the University of Oxford (United Kingdom) as an instrument to judge the quality of written consumer health information and treatment choices [11]. The DISCERN score varies from 0–80 points and is based on 3 sections that include 16 questions (each question ranges from 0–5 points). Section 1 (8 questions) evaluates publication reliability, section 2 (7 questions) is focused on the quality of information on different treatment choices, and section 3 is 1 unique question about the overall rating of the publication. The JAMA benchmark criteria ranges from 0–4 and was described by Silberg et al. [7]. The endpoint was to critically judge the credibility, reasonability, and utility of medical information read on the Internet. The JAMA benchmark criteria assess the following core standards: website authorship (authors, contributors, affiliations, and credentials), attribution (references and sources used for the content, copyright information), disclosures (sponsorship, advertising, commercial funding, potential conflicts of interests), and currency (dates of posted and updated information). The DISCERN and JAMA scores impart some degree of bias from the person who is evaluating a website. With the aim of reducing the bias, each website was evaluated by 3 different researchers from the Bariatric and Metabolic Institute at the Cleveland Clinic Foundation who were blinded to each other’s score. The score used was a mean of the 3 scores, rounded to the nearest absolute DISCERN and JAMA values. For each website, we checked for the HONcode seal [12]. The HONcode is the oldest and most widely used ethical
Quality of Internet Information for Sleeve Gastrectomy / Surgery for Obesity and Related Diseases ] (2014) 00–00
3
Fig. 1. Search flow diagram.
and trust seal for medical and health-related information available on the Internet. HON was founded to encourage the dissemination of quality health information for patients, professionals, and the general public and to facilitate access to the latest and most relevant medical data on the internet. HONcode certification is a voluntary act on the part of the site applicant and then HON experts evaluate the website. The HONcode seal accredits websites based on strict standards and the publication of transparent health-related information. All HONcode sites are certified for 1 year and are reviewed annually. Data were presented as mean ⫾ standard deviation for continuous variables and frequency percentages for categorical variables. ANOVA was used for DISCERN score mean comparison between website groups. Statistical analyses were performed using JMP pro 10 version for Windows (SAS, USA). Results Of the 50 websites included, we identified 43 websites from the United States, 6 from Mexico, and 1 from Australia (Table 1). The website distribution was: 42% (n ¼ 21) physician, 22% (n ¼ 11) academic, 14% (n ¼ 7) commercial, 10% (n ¼ 5) social media, 8% (n ¼ 4) unspecified, and 4% (n ¼ 2) health professional. The average DISCERN and JAMA benchmark scores for all websites were 46.3 ⫾ 14.5 and 1.6 ⫾ 1.1, respectively, with a median of 48.5 (range, 16–76) and 2.0 (range, 0– 4), respectively. Academic websites had the highest DISCERN and JAMA scores, while commercial and unspecified website groups demonstrated the lowest scores. The average DISCERN and JAMA benchmark scores calculated were
55.4 ⫾ 13.4 and 2.4 ⫾ 1.0 in the academic group; 49.5 ⫾ 10.0 and 1.9 ⫾ .9 in the physician; 46.9 ⫾ 14.2 and .2 ⫾ .4 in social media; 44.0 ⫾ 2.8 and 1.0 ⫾ .0 in health professional; 41.3 ⫾ 14.2 and 1.0 ⫾ 1.0 in commercial; and 39.8 ⫾ 19.5 and 1.0 ⫾ 1.1 in the unspecified group (Table 2). The ANOVA analysis demonstrated statistically significant differences in the mean DISCERN and JAMA benchmark scores between website categories; P ¼ .002 and P ¼ .0005, respectively. Twenty-one (42%) websites had a DISCERN score over 50, whereas only 6 (12%) had a JAMA benchmark of 3 and only 3 websites (5.8%) a JAMA benchmark of 4. The HONcode seal was only present on 2 (4%) websites within the study group. Discussion According to the Pew Research Internet Project data, 70%–80% of U.S. adults use the Internet for health information [2]. Findings from the First Health Information National Trends Survey suggest that U.S. adults are 5 times more likely to first seek health information from the Internet rather than from a healthcare provider [13]. Weight loss has been reported as 1 of the most popular search topics among users; 8 in 10 Internet users have looked for health information online, with increased interest in diet, fitness, health insurance, experimental treatments, doctors, and hospitals [2]. SG is gaining popularity in the United States at a trajectory that parallels the aforementioned trends. Furthermore, the use of SG as a primary bariatric procedure has increased dramatically [14]. Excellent mid-term weight loss outcomes balanced with a low morbidity/mortality profile are likely factors that explain this change in the volume of SG cases being performed. However, the potential effect of
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R. Corcelles et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
Table 1 List of websites evaluated Search engine
n
Website
Google
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
http://www.endobariatric.com/ http://www.weightlossmex.com/gastric-sleeve/ http://www.santafemedicalgroup.com http://www.alighterme.com/10-Yrs-Experience http://en.wikipedia.org/wiki/Sleeve_gastrectomy http://www.youtube.com/watch?v = dl1 w8 bxItT0 http://www.nlm.nih.gov/medlineplus/ency/article/007435.htm http://www.realize.com/gastric-sleeve-surgery.htm http://weightloss.clevelandclinic.org/Sleevegastrectomy.aspx http://www.realself.com/sleeve-gastrectomy/reviews http://www.uhhospitals.org/services/gastroenterology/ http://www.lakehealth.org/bariatric/index http://www.lapband.com/ http://bariatrics.stonybrookmedicalcenter.org/ http://umm.edu/programs/weight-management/ http://www.beliteweight.com/ http://www.mayoclinic.com/health/sleevegastrectomy/MM00812 http://www.obesityhelp.com/ http://asmbs.org/2012/06/sleeve-gastrectomy-as-a-bariatric-procedure-update/ http://mdvideocenter.brighamandwomens.org/specialties/.../sleeve-gastrectomy http://surgerync.reachlocal.net/sleevegastrectomy.php http://bariatricweightloss-surgery.com/gastrectomy-stomach-sleeve/ http://www.verticalsleevetalk.com/ http://www.obeseinfo.com/vertical-gastric-sleeve.htm http://gastricbypassfacts.com/gastric-bypass-questions/how-does-the-sleeve-gastrectomy-work/ http://www.yourbariatricsurgeryguide.com/gastric-sleeve/ http://www.weightlossagents.com/ http://www.bariatricguide.org/what-is-gastric-sleeve-surgery-or-sleeve-gastrectomy/ http://www.surgicallyslim.com/sleeve.htm http://www.drfeiz.com/office-locations/office-locations-a-maps.html http://bariatriccentercarolinas.reachlocal.net/#!sleeve-gastrectomy/cv0 h http://www.bing.com/videos/search http://www.thesleevecenter.com/Index.cfm http://surgery.about.com/od/proceduresaz/a/VSGWLSSurgery.htm http://www.ehow.com/about_5347996_lap-sleeve-gastrectomy.html http://www.trueresults.com/sleeve-gastrectomy http://www.ethicon.com/healthcareprofessionals/specialties/bariatric/sleeve-gastrectomy http://www.ssmhealth.com/weightloss/sleevegastrectomy http://www.buzzle.com/articles/sleeve-gastrectomy-complications.html http://www.oliakcenter.com/sleeve-gastrectomy/testimonials/ http://www.stvincentcharity.com/programs-services/centers-excellence/bariatric/ http://rocalabs.com/gastric-bypass-surgery-guide http://www.virginiamason.org/weightloss http://www.tallahassee.com/article/20130717/HEALTH/307170008/Bariatric-procedure http://bariatric.templehealth.org/content/SleeveGastrectomy.htm#content http://drvictorliew.com/sleeve-gastrectomy-faq/&adt = 0 http://www.surgicalhealingarts.com/what-is-obesity/ http://stanfordhospital.org/clinicsmedServices/COE/surgicalServices/generalSurgery/ http://www.sharp.com/weight-loss/bariatric-surgery/ http://www.chrias.com/
Yahoo
Bing
Ask
the available Internet information on SG case volumes and patient preference is unclear. We aimed to critically evaluate the quality and accuracy of the Internet information available pertaining to SG. In general, our findings suggest that the information obtained is typically of low quality. Within the 50 websites analyzed, the average DISCERN score was 46.3 ⫾ 14.5 points and only 14% of sites had a DISCERN score 460 points and
2% 470 points. With regard to the JAMA benchmark score, the results follow the same poor trend, with an overall JAMA benchmark score of 1.6 ⫾ 1.1. Six websites (12%) had a JAMA benchmark of 3 and only 3 (5.8%) had a JAMA benchmark score of 4. Similar results have been published within a heterogeneous group of studies evaluating various health quality information topics on the Internet using the DISCERN, JAMA, and the LIDA tool (an online
Quality of Internet Information for Sleeve Gastrectomy / Surgery for Obesity and Related Diseases ] (2014) 00–00 Table 2 DISCERN and Journal of the American Medical Association (JAMA) benchmark scores by websites type DISCERN (0–80) Websites type
Mean ⫾ SD
Physician Academic Commercial Social network Unspecified Health professional Overall
49.5 ⫾ 10.0 55.4 ⫾ 13.4 41.3 ⫾ 14.2 46.9 ⫾ 14.2 39.8 ⫾ 19.5 44.0 ⫾ 2.8 46.3 ⫾ 14.5 JAMA (0–4)
Physician Academic Commercial Social network Unspecified Health professional Overall
1.9 ⫾ .8 2.4 ⫾ 1.0 1.0 ⫾ 1.0 0.2 ⫾ .4 1.0 ⫾ 1.1 1.0 ⫾ .0 1.6 ⫾ 1.1
validation instrument used to measure the design and content of health information on the Internet) [5,15,16]. Academic and physician sites represented 64% (n = 32) of the websites assessed in our study. Consistent with previous reports, we found that academic institutions provide superior quality information than other websites types [17,18]. The ANOVA analysis showed significantly better DISCERN (P = .002) and JAMA (P = .0005) scores for this group. Interestingly, O’Neill et al. [15] studied the quality of information on a nonbariatric topic (spine) within a total of 52 websites using the same scoring systems as our study and found suboptimal results within the physician website class. In our study, physician websites were the predominant type (42%), and we found similar scores to those reported by O’Neill et al. In our study, commercial, social media, and unspecified group websites had the poorest results. This is consistent with studies on various medical topics by Hanif et al. [18], Fraquelli et al. [19], and Khazaal et al. [20]. For example, social media websites (n ¼ 5) represented 10% of all sites identified in our study and had mean DISCERN and JAMA score of 46.9 ⫾ 14.2 and .2 ⫾ .4, respectively. Another study by Maher et al. [21] systematically reviewed the effectiveness and quality of online social network health behavior interventions. The studies involved a total of 113,988 participants and concluded that there was only modest quality evidence on social network websites. Contrary to that, other researchers have shown efficacious websites and programs through social media platforms [22]. Makar et al. [23] prospectively evaluated the role of the Internet in 100 patients undergoing bariatric surgery. For this study, patients that were scheduled for surgery filled out a 10 question survey about bariatric surgery information available on the Internet. Forty-two percent of patients obtained their bariatric surgery information from the Internet initially and 58% of the websites utilized did not
5
provide technical details (laparoscopic option, for instance); 25% of visited websites had confusing information. Studies investigating the quality of information on other healthcare topics available on the Internet suggest that the HONcode seal certification is associated with the highest quality websites [5,24]. The HONcode seal certification was observed in 4% (n ¼ 2) of the websites analyzed in our study (both were in the academic group and had the highest scores). The scarcity of HONcode seals further indicates suboptimal quality of information available about SG. Conclusion Our study indicates that the most common available internet information on a “laparoscopic sleeve gastrectomy” search is poor. Patients seeking information on this bariatric approach (and others) should be directed to sites provided by academic institutions with HONcode certification seals whenever possible. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Internet World Stats [homepage on the Internet]. Usage and population statistics. [cited 2012 June 30]. Available from: http://www. internetworldstats.com/. [2] Pew Research Internet Project [homepage on the Internet]. Health fact sheet. Available from: http://www.pewinternet.org. [3] Murray E, Lo B, Pollack L, et al. The impact of health information on the internet on health care and the physician-patient relationship: National U.S. survey among 1,050 U.S. physicians. J Med Internet Res 2003;5:e17. [4] Reid P, Borycki EM. Emergence of a new consumer health informatics framework: Introducing the healthcare organization. Stud Health Technol Inform 2011;164:353–7. [5] Kaicker J, Debono VB, Dang W, Buckley N, Thabane L. Assessment of the quality and variability of health information on chronic pain websites using the DISCERN instrument. BMC Med. Epub 2010 Oct 12. [6] Meric F, Bernstam EV, Mirza NQ, et al. Breast cancer on the World Wide Web: Cross sectional survey of quality of information and popularity of websites. BMJ 2002;324:577–81. [7] Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the internet: Caveant lector et viewor–let the reader and viewer beware. JAMA 1997;277:1244–5. [8] Fox S, Rainie L, Horrigan J, et al. The online health care revolution: how the web helps Americans take better care of themselves. Pew Internet and American Life Project [cited 2006 March 3]. Available from: http://www.pewinternet.org/pdfs/PIP_Health_Report.pdf. [9] Diamantis T, Apostolou KG, Alexandrou A, Griniatsos J, Felekouras E, Tsigris C. Review of long-term weight loss results after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2014;10:177–83. [10] Rosenthal RJ. International Sleeve Gastrectomy Expert Panel, Diaz AA, et al. International sleeve gastrectomy expert panel consensus statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8:8–19.
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[11] Charnock D, Shepperd S, Needham G, Gann R. DISCERN: An instrument for judging the quality of written consumer health information on treatment choices. J Epidemiol Community Health 1999;53:105–11. [12] Boyer C, Baujard V, Geissbuhler A. Evolution of health web certification through the HONcode experience. Stud Health Technol Inform 2011;169:53–7. [13] Hesse BW, Nelson DE, Kreps GL, et al. Trust and sources of health information: the impact of the internet and its implications for health care providers: findings from the first health information national trends survey. Arch Intern Med 2005;165:2618–24. [14] Nguyen NT, Nguyen B, Gebhart A, Hohmann S. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg 2013;216:252–7. [15] O’Neill SC, Baker JF, Fitzgerald C, et al. Cauda equina syndrome: assessing the readability & quality of patient information on the internet. Spine (Phila Pa 1976). Epub 2014 May 1. [16] Grewal P, Alagaratnam S. The quality and readability of colorectal cancer information on the internet. Int J Surg 2013;11:410–3. [17] Bruce-Brand RA, Baker JF, Byrne DP, Hogan NA, McCarthy T. Assessment of the quality and content of information on anterior
[18]
[19] [20]
[21]
[22] [23] [24]
cruciate ligament reconstruction on the internet. Arthroscopy 2013;29:1095–100. Hanif F, Abayasekara K, Willcocks L, et al. The quality of information about kidney transplantation on the World Wide Web. Clin Transplant 2007;21:371–6. Fraquelli M, Conte D, Camma C, et al. Quality-related variables at hepatological websites. Dig Liver Dis 2004;36:533–8. Khazaal Y, Chatton A, Zullino D, Khan R. HON label and DISCERN as content quality indicators of health-related websites. Psychiatr Q 2012;83:15–27. Maher CA, Lewis LK, Ferrar K, Marshall S, De Bourdeaudhuij I, Vandelanotte C. Are health behavior change interventions that use online social networks effective? A systematic review. J Med Internet Res 2014;16:e40. Saperstein SL, Atkinson NL, Gold RS. The impact of internet use for weight loss. Obes Rev 2007;8:459–65. Makar B, Quilliot D, Zarnegar R, et al. What is the quality of information about bariatric surgery on the internet? Obes Surg 2008;18:1455–9. Tavare AN, Alsafi A, Hamady MS. Analysis of the quality of information obtained about uterine artery embolization from the internet. Cardiovasc Intervent Radiol 2012;35:1355–62.
Original article
Assessment of the quality of internet information on sleeve gastrectomy Ricard Corcelles, M.D., Ph.D.a,b, Christopher R. Daigle, M.D.a, Hector Romero Talamas, M.D.a, Stacy A. Brethauer, M.D.a,*, Philip R. Schauer, M.D.a b
a Bariatric and Metabolic Institute, Cleveland Clinic, Ohio Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic of Barcelona, Barcelona, Spain Received May 28, 2014; accepted August 25, 2014
Abstract
Background: The Internet is an important source of information for morbidly obese patients who are potential candidates for bariatric procedures. Over the past few years, there is growing demand for sleeve gastrectomy because of perceived technical ease balanced with excellent outcomes. The aim of this study was to assess the quality and content of available internet information pertaining to sleeve gastrectomy. Our hypothesis is that this information is inconsistent and inaccurate. Methods: A total of 50 websites were analyzed in September 2013. We used the search term “sleeve gastrectomy” to identify sites on the most common internet search engines: Google, Yahoo, Bing, and Ask. Based on popularity of use, 20 websites were obtained through the Google engine and 10 sites by each of the others. Websites were classified as academic, physician, health professional, commercial, social media, and unspecified. Quality of information was evaluated using the DISCERN score, the Journal of the American Medical Association (JAMA) benchmark criteria, and the Health on the Net code (HONcode) seal accreditation. The DISCERN score varies from 0–80 points and is based on 16 questions that evaluate publication quality and reliability. The JAMA benchmark criteria range from 0–4 points assessing website authorship, attribution, disclosure, and currency. HONcode certification was assessed as present or absent website accreditation. Duplicate and inaccessible websites were excluded from the analysis. Results: We identified 43 websites from the United States, 6 from Mexico, and 1 from Australia. The average DISCERN and JAMA benchmark scores for all websites were 46.3 ⫾ 14.5 and 1.6 ⫾ 1.1, respectively, with a median DISCERN of 48.5 (range, 16–76) and JAMA score of 2.0 (range, 0–4). Website classification distribution was 21 physician, 11 academic, 7 commercial, 5 social media, 4 unspecified, and 2 health professional. The average DISCERN and JAMA benchmark scores were 55.4 ⫾ 13.4 and 2.4 ⫾ 1.0 in the academic group, 49.5 ⫾ 10.0 and 1.9 ⫾ .9 in the physician group, 46.9 ⫾ 14.2 and .2 ⫾ .4 in social media sites, 44.0 ⫾ 2.8 and 1.0 ⫾ .0 in health professional pages, 41.3 ⫾ 14.2 and 1.0 ⫾ 1.0 in commercial sites, and 39.8 ⫾ 19.5 and 1.0 ⫾ 1.1 in the unspecified group. The HONcode seal was present in 2 (4%) of the websites analyzed. Conclusion: The results of this study suggest poor quality and content of information on the internet viewed by potential bariatric candidates. Only 4% of the websites demonstrated HONcode seal accreditation. The global mean DISCERN and JAMA benchmark scores reported in this study were significantly lower than one would expect. Academic and physician websites offer the best information content whereas the worst was observed in the commercial and unspecified groups. (Surg Obes Relat Dis 2014;]:00–00.) r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
Keywords:
sleeve gastrectomy; internet; quality; bariatric
* Correspondence: Stacy A. Brethauer, M.D., Bariatric and Metabolic Institute, Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH 44195. E-mail: [email protected]
http://dx.doi.org/10.1016/j.soard.2014.08.014 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
R. Corcelles et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
The Internet’s enormous growth has changed the way we obtain information [1]. It is estimated that approximately 1,319,872,109 people use the Internet and more than 270 million are Americans [2]. The Internet has become a useful tool for the sharing of medical knowledge and its use in this manner is increasing [3]. As individuals take a more active role in the management of their own health, more consumers are independently searching health information via the Internet. In the year 2011, 480% of adults reported using Internet resources to support healthcare decisions [4]. Physicians are also turning to the Internet to stay informed and interact with their patients. Given the vast amount of healthcare data available on the Internet, there are several concerns about the quality and content of this medical information [3,5]. Different reports claim inaccurate and inconsistent information contained in many health websites [6,7]. Over 100 million American adults are currently overweight or obese. The Internet is an important source of information for morbidly obese patients who are potential candidates for bariatric procedures. Although physician advice significantly affects a patient’s choice of weight loss modality, people also make health choices based on information they find on the Internet [8,9]. Laparoscopic sleeve gastrectomy (SG) is an established surgical approach, with a surge in popularity because of its perceived technical simplicity, feasibility, and excellent outcomes. Several studies have shown SG to be a durable procedure that achieves sustained weight loss and resolution of comorbidities up to 5 years follow-up [10]. Likely because of this supportive evidence, we have seen dramatic growth in the number of SG performed in recent years. The aim of this study was to assess the quality of information about SG on the Internet using recognized scoring systems such as the Journal of the American Medical Association (JAMA) benchmark, the DISCERN criteria, and the Health on the Net code (HONcode) accreditation. Methods A total of 50 websites were analyzed in September 2013. The search term “sleeve gastrectomy” was used on the most common Internet search engines: Google, Yahoo, Bing, and Ask. The total number of websites returned by the search was: 818,000 results for Google (www.google.com); 899,000 results for Yahoo (www.yahoo.com); and 901,000 for Bing (www.bing.com). Of note, the total hit number for the Ask (www.ask.com) search engine was not available. Google sites led the U.S. explicit core search market in September 2013 with 66.9% market share, followed by Bing sites (Microsoft) with 18% and Yahoo sites with 11.3%. The Ask network accounted for 2.5% of explicit core searches, followed by other search engines (AOL) with 1.3% [1]. Based on this popularity of use, 20 websites were obtained through the Google engine and 10
sites by each of the others. Popularity of use was determined using “the internet world statistics” website (http:// www.internetworldstats.com), which is an international website that features up to date world internet usage, population statistics, and internet data for over 200 countries. Websites were selected based on the order they appeared when using the various search engines. Duplicated websites and those that were inaccessible were excluded from our analysis (Fig. 1). We classified websites into different categories: academic, physician, nonphysician health professionals (therapists, alternative medical providers, etc.), commercial, social media (YouTube, Facebook, Twitter, etc.), and unspecified websites. Academic websites were those associated with a university or medical school. Physician websites were those sites for individual professionals without academic affiliation. Websites described as commercial were those displaying advertisements and/or different products for sale. Social media websites were any derived from social media platforms. Unspecified websites were those not matching any of the above described categories (National Institutes of Health, Wikipedia, patients’ forums, etc.). Quality of information was evaluated using the DISCERN score [11], the JAMA benchmark criteria [7], and the HONcode certification [12]. The DISCERN was developed by an expert group at the University of Oxford (United Kingdom) as an instrument to judge the quality of written consumer health information and treatment choices [11]. The DISCERN score varies from 0–80 points and is based on 3 sections that include 16 questions (each question ranges from 0–5 points). Section 1 (8 questions) evaluates publication reliability, section 2 (7 questions) is focused on the quality of information on different treatment choices, and section 3 is 1 unique question about the overall rating of the publication. The JAMA benchmark criteria ranges from 0–4 and was described by Silberg et al. [7]. The endpoint was to critically judge the credibility, reasonability, and utility of medical information read on the Internet. The JAMA benchmark criteria assess the following core standards: website authorship (authors, contributors, affiliations, and credentials), attribution (references and sources used for the content, copyright information), disclosures (sponsorship, advertising, commercial funding, potential conflicts of interests), and currency (dates of posted and updated information). The DISCERN and JAMA scores impart some degree of bias from the person who is evaluating a website. With the aim of reducing the bias, each website was evaluated by 3 different researchers from the Bariatric and Metabolic Institute at the Cleveland Clinic Foundation who were blinded to each other’s score. The score used was a mean of the 3 scores, rounded to the nearest absolute DISCERN and JAMA values. For each website, we checked for the HONcode seal [12]. The HONcode is the oldest and most widely used ethical
Quality of Internet Information for Sleeve Gastrectomy / Surgery for Obesity and Related Diseases ] (2014) 00–00
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Fig. 1. Search flow diagram.
and trust seal for medical and health-related information available on the Internet. HON was founded to encourage the dissemination of quality health information for patients, professionals, and the general public and to facilitate access to the latest and most relevant medical data on the internet. HONcode certification is a voluntary act on the part of the site applicant and then HON experts evaluate the website. The HONcode seal accredits websites based on strict standards and the publication of transparent health-related information. All HONcode sites are certified for 1 year and are reviewed annually. Data were presented as mean ⫾ standard deviation for continuous variables and frequency percentages for categorical variables. ANOVA was used for DISCERN score mean comparison between website groups. Statistical analyses were performed using JMP pro 10 version for Windows (SAS, USA). Results Of the 50 websites included, we identified 43 websites from the United States, 6 from Mexico, and 1 from Australia (Table 1). The website distribution was: 42% (n ¼ 21) physician, 22% (n ¼ 11) academic, 14% (n ¼ 7) commercial, 10% (n ¼ 5) social media, 8% (n ¼ 4) unspecified, and 4% (n ¼ 2) health professional. The average DISCERN and JAMA benchmark scores for all websites were 46.3 ⫾ 14.5 and 1.6 ⫾ 1.1, respectively, with a median of 48.5 (range, 16–76) and 2.0 (range, 0– 4), respectively. Academic websites had the highest DISCERN and JAMA scores, while commercial and unspecified website groups demonstrated the lowest scores. The average DISCERN and JAMA benchmark scores calculated were
55.4 ⫾ 13.4 and 2.4 ⫾ 1.0 in the academic group; 49.5 ⫾ 10.0 and 1.9 ⫾ .9 in the physician; 46.9 ⫾ 14.2 and .2 ⫾ .4 in social media; 44.0 ⫾ 2.8 and 1.0 ⫾ .0 in health professional; 41.3 ⫾ 14.2 and 1.0 ⫾ 1.0 in commercial; and 39.8 ⫾ 19.5 and 1.0 ⫾ 1.1 in the unspecified group (Table 2). The ANOVA analysis demonstrated statistically significant differences in the mean DISCERN and JAMA benchmark scores between website categories; P ¼ .002 and P ¼ .0005, respectively. Twenty-one (42%) websites had a DISCERN score over 50, whereas only 6 (12%) had a JAMA benchmark of 3 and only 3 websites (5.8%) a JAMA benchmark of 4. The HONcode seal was only present on 2 (4%) websites within the study group. Discussion According to the Pew Research Internet Project data, 70%–80% of U.S. adults use the Internet for health information [2]. Findings from the First Health Information National Trends Survey suggest that U.S. adults are 5 times more likely to first seek health information from the Internet rather than from a healthcare provider [13]. Weight loss has been reported as 1 of the most popular search topics among users; 8 in 10 Internet users have looked for health information online, with increased interest in diet, fitness, health insurance, experimental treatments, doctors, and hospitals [2]. SG is gaining popularity in the United States at a trajectory that parallels the aforementioned trends. Furthermore, the use of SG as a primary bariatric procedure has increased dramatically [14]. Excellent mid-term weight loss outcomes balanced with a low morbidity/mortality profile are likely factors that explain this change in the volume of SG cases being performed. However, the potential effect of
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Table 1 List of websites evaluated Search engine
n
Website
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
http://www.endobariatric.com/ http://www.weightlossmex.com/gastric-sleeve/ http://www.santafemedicalgroup.com http://www.alighterme.com/10-Yrs-Experience http://en.wikipedia.org/wiki/Sleeve_gastrectomy http://www.youtube.com/watch?v = dl1 w8 bxItT0 http://www.nlm.nih.gov/medlineplus/ency/article/007435.htm http://www.realize.com/gastric-sleeve-surgery.htm http://weightloss.clevelandclinic.org/Sleevegastrectomy.aspx http://www.realself.com/sleeve-gastrectomy/reviews http://www.uhhospitals.org/services/gastroenterology/ http://www.lakehealth.org/bariatric/index http://www.lapband.com/ http://bariatrics.stonybrookmedicalcenter.org/ http://umm.edu/programs/weight-management/ http://www.beliteweight.com/ http://www.mayoclinic.com/health/sleevegastrectomy/MM00812 http://www.obesityhelp.com/ http://asmbs.org/2012/06/sleeve-gastrectomy-as-a-bariatric-procedure-update/ http://mdvideocenter.brighamandwomens.org/specialties/.../sleeve-gastrectomy http://surgerync.reachlocal.net/sleevegastrectomy.php http://bariatricweightloss-surgery.com/gastrectomy-stomach-sleeve/ http://www.verticalsleevetalk.com/ http://www.obeseinfo.com/vertical-gastric-sleeve.htm http://gastricbypassfacts.com/gastric-bypass-questions/how-does-the-sleeve-gastrectomy-work/ http://www.yourbariatricsurgeryguide.com/gastric-sleeve/ http://www.weightlossagents.com/ http://www.bariatricguide.org/what-is-gastric-sleeve-surgery-or-sleeve-gastrectomy/ http://www.surgicallyslim.com/sleeve.htm http://www.drfeiz.com/office-locations/office-locations-a-maps.html http://bariatriccentercarolinas.reachlocal.net/#!sleeve-gastrectomy/cv0 h http://www.bing.com/videos/search http://www.thesleevecenter.com/Index.cfm http://surgery.about.com/od/proceduresaz/a/VSGWLSSurgery.htm http://www.ehow.com/about_5347996_lap-sleeve-gastrectomy.html http://www.trueresults.com/sleeve-gastrectomy http://www.ethicon.com/healthcareprofessionals/specialties/bariatric/sleeve-gastrectomy http://www.ssmhealth.com/weightloss/sleevegastrectomy http://www.buzzle.com/articles/sleeve-gastrectomy-complications.html http://www.oliakcenter.com/sleeve-gastrectomy/testimonials/ http://www.stvincentcharity.com/programs-services/centers-excellence/bariatric/ http://rocalabs.com/gastric-bypass-surgery-guide http://www.virginiamason.org/weightloss http://www.tallahassee.com/article/20130717/HEALTH/307170008/Bariatric-procedure http://bariatric.templehealth.org/content/SleeveGastrectomy.htm#content http://drvictorliew.com/sleeve-gastrectomy-faq/&adt = 0 http://www.surgicalhealingarts.com/what-is-obesity/ http://stanfordhospital.org/clinicsmedServices/COE/surgicalServices/generalSurgery/ http://www.sharp.com/weight-loss/bariatric-surgery/ http://www.chrias.com/
Yahoo
Bing
Ask
the available Internet information on SG case volumes and patient preference is unclear. We aimed to critically evaluate the quality and accuracy of the Internet information available pertaining to SG. In general, our findings suggest that the information obtained is typically of low quality. Within the 50 websites analyzed, the average DISCERN score was 46.3 ⫾ 14.5 points and only 14% of sites had a DISCERN score 460 points and
2% 470 points. With regard to the JAMA benchmark score, the results follow the same poor trend, with an overall JAMA benchmark score of 1.6 ⫾ 1.1. Six websites (12%) had a JAMA benchmark of 3 and only 3 (5.8%) had a JAMA benchmark score of 4. Similar results have been published within a heterogeneous group of studies evaluating various health quality information topics on the Internet using the DISCERN, JAMA, and the LIDA tool (an online
Quality of Internet Information for Sleeve Gastrectomy / Surgery for Obesity and Related Diseases ] (2014) 00–00 Table 2 DISCERN and Journal of the American Medical Association (JAMA) benchmark scores by websites type DISCERN (0–80) Websites type
Mean ⫾ SD
Physician Academic Commercial Social network Unspecified Health professional Overall
49.5 ⫾ 10.0 55.4 ⫾ 13.4 41.3 ⫾ 14.2 46.9 ⫾ 14.2 39.8 ⫾ 19.5 44.0 ⫾ 2.8 46.3 ⫾ 14.5 JAMA (0–4)
Physician Academic Commercial Social network Unspecified Health professional Overall
1.9 ⫾ .8 2.4 ⫾ 1.0 1.0 ⫾ 1.0 0.2 ⫾ .4 1.0 ⫾ 1.1 1.0 ⫾ .0 1.6 ⫾ 1.1
validation instrument used to measure the design and content of health information on the Internet) [5,15,16]. Academic and physician sites represented 64% (n = 32) of the websites assessed in our study. Consistent with previous reports, we found that academic institutions provide superior quality information than other websites types [17,18]. The ANOVA analysis showed significantly better DISCERN (P = .002) and JAMA (P = .0005) scores for this group. Interestingly, O’Neill et al. [15] studied the quality of information on a nonbariatric topic (spine) within a total of 52 websites using the same scoring systems as our study and found suboptimal results within the physician website class. In our study, physician websites were the predominant type (42%), and we found similar scores to those reported by O’Neill et al. In our study, commercial, social media, and unspecified group websites had the poorest results. This is consistent with studies on various medical topics by Hanif et al. [18], Fraquelli et al. [19], and Khazaal et al. [20]. For example, social media websites (n ¼ 5) represented 10% of all sites identified in our study and had mean DISCERN and JAMA score of 46.9 ⫾ 14.2 and .2 ⫾ .4, respectively. Another study by Maher et al. [21] systematically reviewed the effectiveness and quality of online social network health behavior interventions. The studies involved a total of 113,988 participants and concluded that there was only modest quality evidence on social network websites. Contrary to that, other researchers have shown efficacious websites and programs through social media platforms [22]. Makar et al. [23] prospectively evaluated the role of the Internet in 100 patients undergoing bariatric surgery. For this study, patients that were scheduled for surgery filled out a 10 question survey about bariatric surgery information available on the Internet. Forty-two percent of patients obtained their bariatric surgery information from the Internet initially and 58% of the websites utilized did not
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provide technical details (laparoscopic option, for instance); 25% of visited websites had confusing information. Studies investigating the quality of information on other healthcare topics available on the Internet suggest that the HONcode seal certification is associated with the highest quality websites [5,24]. The HONcode seal certification was observed in 4% (n ¼ 2) of the websites analyzed in our study (both were in the academic group and had the highest scores). The scarcity of HONcode seals further indicates suboptimal quality of information available about SG. Conclusion Our study indicates that the most common available internet information on a “laparoscopic sleeve gastrectomy” search is poor. Patients seeking information on this bariatric approach (and others) should be directed to sites provided by academic institutions with HONcode certification seals whenever possible. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Internet World Stats [homepage on the Internet]. Usage and population statistics. [cited 2012 June 30]. Available from: http://www. internetworldstats.com/. [2] Pew Research Internet Project [homepage on the Internet]. Health fact sheet. Available from: http://www.pewinternet.org. [3] Murray E, Lo B, Pollack L, et al. The impact of health information on the internet on health care and the physician-patient relationship: National U.S. survey among 1,050 U.S. physicians. J Med Internet Res 2003;5:e17. [4] Reid P, Borycki EM. Emergence of a new consumer health informatics framework: Introducing the healthcare organization. Stud Health Technol Inform 2011;164:353–7. [5] Kaicker J, Debono VB, Dang W, Buckley N, Thabane L. Assessment of the quality and variability of health information on chronic pain websites using the DISCERN instrument. BMC Med. Epub 2010 Oct 12. [6] Meric F, Bernstam EV, Mirza NQ, et al. Breast cancer on the World Wide Web: Cross sectional survey of quality of information and popularity of websites. BMJ 2002;324:577–81. [7] Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the internet: Caveant lector et viewor–let the reader and viewer beware. JAMA 1997;277:1244–5. [8] Fox S, Rainie L, Horrigan J, et al. The online health care revolution: how the web helps Americans take better care of themselves. Pew Internet and American Life Project [cited 2006 March 3]. Available from: http://www.pewinternet.org/pdfs/PIP_Health_Report.pdf. [9] Diamantis T, Apostolou KG, Alexandrou A, Griniatsos J, Felekouras E, Tsigris C. Review of long-term weight loss results after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2014;10:177–83. [10] Rosenthal RJ. International Sleeve Gastrectomy Expert Panel, Diaz AA, et al. International sleeve gastrectomy expert panel consensus statement: best practice guidelines based on experience of 412,000 cases. Surg Obes Relat Dis 2012;8:8–19.
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R. Corcelles et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
[11] Charnock D, Shepperd S, Needham G, Gann R. DISCERN: An instrument for judging the quality of written consumer health information on treatment choices. J Epidemiol Community Health 1999;53:105–11. [12] Boyer C, Baujard V, Geissbuhler A. Evolution of health web certification through the HONcode experience. Stud Health Technol Inform 2011;169:53–7. [13] Hesse BW, Nelson DE, Kreps GL, et al. Trust and sources of health information: the impact of the internet and its implications for health care providers: findings from the first health information national trends survey. Arch Intern Med 2005;165:2618–24. [14] Nguyen NT, Nguyen B, Gebhart A, Hohmann S. Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy. J Am Coll Surg 2013;216:252–7. [15] O’Neill SC, Baker JF, Fitzgerald C, et al. Cauda equina syndrome: assessing the readability & quality of patient information on the internet. Spine (Phila Pa 1976). Epub 2014 May 1. [16] Grewal P, Alagaratnam S. The quality and readability of colorectal cancer information on the internet. Int J Surg 2013;11:410–3. [17] Bruce-Brand RA, Baker JF, Byrne DP, Hogan NA, McCarthy T. Assessment of the quality and content of information on anterior
[18]
[19] [20]
[21]
[22] [23] [24]
cruciate ligament reconstruction on the internet. Arthroscopy 2013;29:1095–100. Hanif F, Abayasekara K, Willcocks L, et al. The quality of information about kidney transplantation on the World Wide Web. Clin Transplant 2007;21:371–6. Fraquelli M, Conte D, Camma C, et al. Quality-related variables at hepatological websites. Dig Liver Dis 2004;36:533–8. Khazaal Y, Chatton A, Zullino D, Khan R. HON label and DISCERN as content quality indicators of health-related websites. Psychiatr Q 2012;83:15–27. Maher CA, Lewis LK, Ferrar K, Marshall S, De Bourdeaudhuij I, Vandelanotte C. Are health behavior change interventions that use online social networks effective? A systematic review. J Med Internet Res 2014;16:e40. Saperstein SL, Atkinson NL, Gold RS. The impact of internet use for weight loss. Obes Rev 2007;8:459–65. Makar B, Quilliot D, Zarnegar R, et al. What is the quality of information about bariatric surgery on the internet? Obes Surg 2008;18:1455–9. Tavare AN, Alsafi A, Hamady MS. Analysis of the quality of information obtained about uterine artery embolization from the internet. Cardiovasc Intervent Radiol 2012;35:1355–62.