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An assessment of the quality and content of information on diverticulitis on the internet
t h e s u r g e o n x x x ( 2 0 1 8 ) 1 e6
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An assessment of the quality and content of information on diverticulitis on the internet* Tara M. Connelly*, Mohammad Shoaib Khan, Liana Victory, Abeera Mehmood, Fiachra Cooke Department of Surgery, University Hospital Waterford, Waterford, Ireland
article info
abstract
Article history:
Aim: Although commonly the first port of call for medical information, the internet pro-
Received 18 December 2017
vides unregulated information of variable quality. We aimed to evaluate commonly
Received in revised form
accessed web-based patient information on diverticulitis using validated and novel scoring
27 March 2018
systems.
Accepted 30 March 2018
Methods: The top internet search engines (Google/Bing/Yahoo) were queried using the
Available online xxx
keyword ‘diverticulitis.’ The first 20 websites from each were graded using the DISCERN and Journal of the American Medical Association (JAMA) benchmark criteria. A novel
Keywords:
diverticulitis-specific score was devised and applied.
Diverticulitis
Results: Thirty-six unique websites were identified. The mean total DISCERN score for all
DISCERN
websites was 39.92 ± 12.44 (range ¼ 18e62). No website achieved the maximum DISCERN
JAMA
score of 75. The mean JAMA and diverticulitis scores were 2.5 ± 1.08 (maximum possible
Internet
score ¼ 4) and 11.08 ± 4.17 (19 points possible) respectively. Fourteen (35.9%) and 20
Patient information
(51.2%) did not provide the date of last update and authorship respectively. Thirty-three (84.6%) mentioned surgery as a treatment option; however, the majority (69.7%) did not describe the surgery or the possibility of a stoma. All except two described disease symptoms. Only ten (25.64%) provided information on when to seek further medical advice or help. Conclusion: Web-based information on diverticulitis is of variable content and quality. The majority of top websites describe disease symptoms and aetiology; however, information to prompt seeking medical attention if required, descriptions of surgical procedures and the possibility of stoma creation are poorly described in the majority of websites. These findings should be highlighted to patients utilising the internet to obtain information on diverticulitis. © 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
*
This paper was presented at the VVXI Waterford Surgical October Meeting, University Hospital, Waterford, Ireland, Oct 1, 2016. * Corresponding author. E-mail addresses: [email protected] (T.M. Connelly), [email protected] (M.S. Khan), [email protected] (L. Victory), [email protected] (A. Mehmood), [email protected] (F. Cooke). https://doi.org/10.1016/j.surge.2018.03.010 1479-666X/© 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Connelly TM, et al., An assessment of the quality and content of information on diverticulitis on the internet, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.03.010
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t h e s u r g e o n x x x ( 2 0 1 8 ) 1 e6
Introduction Commonly the internet is a patient's first port of call for medical information; however, it provides unregulated data of variable quality.1 Inaccurate information can lead to inappropriate and/or late diagnosis and adverse outcomes. Over 75% of patients seeking health related information employ the search engines Google, Yahoo and/or Bing.2 Approximately 7 million Google searches for health related information are performed daily.3 Searching Google using the term ‘diverticulitis’ returns 3,380,000 results in 0.40 s.4 Validated tools created for the evaluation of written health related information have been applied to web based information. In the field of colorectal surgery, previously studied topics include inflammatory bowel disease,5 anal fissures and fistulae6 and colorectal cancer.7 Novel tools for the evaluation of information provided in websites have also been developed. One such tool is the DISCERN tool. This instrument was created by Oxford University and the British Library through a collaboration of healthcare professionals, laypeople and information experts.8 It has been validated and, together with a handbook for its use, is freely available online (www.discern. org.uk).9 The tool contains 15 individual questions and an overall quality rating. Of the 15 questions, 8 assess reliability and 7 focus on the information regarding treatment provided. The majority of studies on the quality of healthcare related information on the internet have utilised the DISCERN tool.5e7 Similarly, the Journal of the American Medical Association (JAMA) benchmark criteria assesses four aspects of health related information: authorship, disclosure, attribution and currency. Disclosure refers to the revelation of sponsorship and/or conflicts of interest. Attribution ensures the content is referenced. Currency is the provision the date content was posted or updated.10 We aimed to evaluate the content and quality of frequently accessed web-based patient information on diverticulitis. The identification of potential gaps in information and misinformation provides the opportunity to highlight and supplement this information to patients.
Methods The top three internet search engines, Google (Mountain View, CA, USA), Yahoo (Sunnyvale, CA, USA) and Bing (Belleview, WA, USA) were queried using the keyword ‘diverticulitis.’ The top 20 websites from each engine were graded using the DISCERN tool (Table 1) and the JAMA benchmark criteria utilising a technique developed by Nassiri et al. to evaluate web-based medical information.11 For the most relevant interpretation of the DISCERN score in relation to the study topic, two categories in the tool were interpreted as follows: In the question ‘Does it refer to areas of uncertainty?,’ ‘uncertainty’ was interpreted to refer to the timing of surgery. The question ‘Does it describe the risks of each treatment?’ was interpreted to include the need for a stoma. The maximum score for each criteria in DISCERN is 6. JAMA criteria are awarded either a 0 or 1 according to absence or presence of the factor absence or presence of the factor evaluated. A novel diverticulitis-specific content score was devised by two of the
Table 1 e DISCERN tool and scores (Maximum of 4 points for each category).
Are the aims clear? Does it achieve its aims? Is it relevant? Is it clear what sources of information were used to compile the publication (other than the author or producer)? Is it clear when the information used or reported in the publication was produced? Is it balanced and unbiased? Does it provide details of additional sources of support and information? Does it refer to areas of uncertainty? (Timing of surgical intervention) Does it describe how each treatment works? Does it describe the benefits of each treatment? Does it describe the risks of each treatment? (including stoma) Does it describe what would happen if no treatment is used? Does it describe how the treatment choices affect overall quality of life? Is it clear that there may be more than one possible treatment choice? Does it provide support for shared decision-making?
Mean
Stand Deviation
3.94 3.81 3.91 2.97
1.39 1.28 1.26 1.80
2.86
1.94
4.03 2.58
1.32 1.46
2.0
1.43
2.39
1.42
2.17
1.18
1.89
1.33
1.33
0.99
1.08
0.28
3.61
1.44
1.36
0.99
authors who are surgeons with an interest in colorectal disease (Table 2). One point was awarded for the mention of each of the predefined terms relating to general aspects of the disease, treatment and complications for a maximum score of 19 points.11,12 The DISCERN and JAMA tools have maximum cumulative attainable scores of 75 and 4 points respectively. All free, English language websites which did not require a password or sign up were included. All paid advertisement websites annotated by the search engine as ‘ad’ were excluded. The websites were evaluated jointly by two authors (TMC and MSK) and a consensus score was attained for each aspect of the DISCERN, JAMA and diverticulitis-specific content tools for each website. Simple descriptive statistics were employed. Standard deviation is provided where appropriate.
Results The top 10 websites for each search engine are listed in Table 3. After the removal of duplicate websites, thirty-six unique websites were identified (Table 4). The mean total DISCERN score for all websites was 39.92 ± 12.44 (range ¼ 16e62). No website achieved the maximum DISCERN score of 75. Wikipedia.org/wiki/Diverticulitis and emedi cine.medscape.com/article/173388-overview had the highest total DISCERN scores with 62 and 61 respectively. The DISCERN categories evaluating clarity of aims, relevancy and lack of bias scored the highest with 20, 19 and 19 of the 36 websites receiving a score of 5 out of a maximum of 6 points for the category. Only 2 categories (providing the date of
Please cite this article in press as: Connelly TM, et al., An assessment of the quality and content of information on diverticulitis on the internet, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.03.010
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Table 2 e Diverticulitis specific score. Disease summary 1 2 3
Gender Age Pathophysiology (diverticulum with infection) Diet Family History or genetics Symptoms Diverticulosis vs divertiulitis When to seek further help Diagnosis
4 5 6 7 8 9 Treatment 1 2 3 4 Complications 1 2 3 4 Other 1 2
Antibiotics Surgery Benefits of treatment options Complications of surgery Abscess Perforation Fistula Recurrence No increased Risk of Cancer Need for colonoscopy after episode of diverticulitis
webpage creation/update and referencing the information sources used) received the maximum score of 6, in one website only respectively. Overall, the websites scored poorly in the categories: 1) referring to areas of uncertainty (interpreted as appropriate timing of surgery for the study aims), 2)
describing the benefits of each treatment and 3) explaining the consequences if no treatment is undertaken. No website scored maximum points in the category focussing on description of how the treatment choices affect overall quality of life. The mean JAMA score for the websites was 2.5 ± 1.08 (maximum possible ¼ 4). Www.webmd.com/digestivedisorders/tc/diverticulitis-topic-overview obtained the highest mean JAMA score (3.93 ± 1.49). Overall, the websites performed well on disclosure with all except three revealing sponsorship or conflicts of interest. Authorship was poorly described with 22 websites failing to reveal the author. Currency and attribution were adequate in 47.2 and 61.1%. Fourteen (35.9%) did not provide the date of last update. Thirty three (84.6%) mentioned surgery as a treatment option; however, the majority of these 23 (69.7%) did not describe the surgery or the possibility of a stoma. The mean diverticulitisspecific score was 11.08 ± 4.17 (19 points possible). All except two described disease symptoms. Only ten (25.64%) provided information on when to seek further medical advice or help (see Fig. 1).
Discussion and conclusions The internet has enabled patients to instantly obtain disease related information at their convenience. We have demonstrated that web-based information on diverticulitis is of variable content and quality. Analysis of the 36 unique
Table 3 e Top 10 diverticulitis websites by search engine. Google
Bing
Yahoo
1
http://www.webmd.com/digestive-disorders/ http://www.webmd.com/digestive-disorders/ http://www.nhs.uk/conditions/Diverticulartc/diverticulitis-topic-overview tc/diverticulitis-topic-overview disease-and-diverticulitis/Pages/ Introduction.aspx 2 http://www.mayoclinic.org/diseaseshttps://www.betterhealth.vic.gov.au/health/ http://www.medicinenet.com/ conditions/diverticulitis/basics/ conditionsandtreatments/diverticulosisdiverticulosis/article.htm definition/con-20033495 and-diverticulitis 3 http://www.healthline.com/health/ http://www.mayoclinic.org/diseaseshttps://en.wikipedia.org/wiki/ diverticulitis conditions/diverticulitis/basics/ Diverticulitis definition/CON-20033495 4 https://www.niddk.nih.gov/healthhttp://www.ncbi.nlm.nih.gov/ http://www.webmd.com/digestiveinformation/health-topics/digestivepubmedhealth/PMHT0022910/ disorders/diverticulitis-diet diseases/diverticulosis-diverticulitis/ Pages/overview.aspx 5 http://www.medicinenet.com/ http://www.medicinenet.com/ http://www.healthline.com/health/ diverticulosis/article.htm diverticulosis/article.htm diverticulitis 6 https://en.wikipedia.org/wiki/Diverticulitis http://www.webmd.com/digestive-disorders/ www.dailymail.co.uk/health/ tc/diverticulitis-symptoms article-156886 7 http://www.hse.ie/eng/health/az/D/ http://www.nhs.uk/conditions/Diverticular- http://www.mayoclinic.org/diseasesDiverticular-disease-and-diverticulitis/ disease-and-diverticulitis/Pages/ conditions/diverticulitis/basics/ Treating-diverticular-disease-andIntroduction.aspx definition/CON-20033495 diverticulitis.html 8 https://medlineplus.gov/ https://medlineplus.gov/ency/article/ https://www.bupa.co.uk/healthdiverticulosisanddiverticulitis.html 000257.htm information/directory/d/diverticulardisease-diverticulitis 9 http://www.merckmanuals.com/home/ https://en.wikipedia.org/wiki/Diverticulitis http://www.nhs.uk/Conditions/Diverticulardigestive-disorders/diverticular-disease/ disease-and-diverticulitis/Pages/ diverticulitis Treatment.aspx 10 http://emedicine.medscape.com/ https://medlineplus.gov/ http://www.webmd.com/digestivearticle/173388-overview diverticulosisanddiverticulitis.html disorders/tc/diverticulitis-topic-overview
Please cite this article in press as: Connelly TM, et al., An assessment of the quality and content of information on diverticulitis on the internet, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.03.010
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Table 4 e Unique diverticulitis websites. 1 2 3 4 5 6 7 8 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
http://www.webmd.com/digestive-disorders/tc/diverticulitis-topic-overview http://www.mayoclinic.org/diseases-conditions/diverticulitis/basics/definition/con-20033495 https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/diverticulosis-and-diverticulitis http://www.healthline.com/health/diverticulitis http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022910/ http://www.webmd.com/digestive-disorders/diverticulitis-diet https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/diverticulosisdiverticulitis/Pages/overview.aspx http://www.medicinenet.com/diverticulosis/article.htm https://en.wikipedia.org/wiki/Diverticulitis www.dailymail.co.uk/health/article-156886 http://www.hse.ie/eng/health/az/D/Diverticular-disease-and-diverticulitis/Treating-diverticular-diseaseand-diverticulitis.html http://www.nhs.uk/conditions/Diverticular-disease-and-diverticulitis/Pages/Introduction.aspx https://medlineplus.gov/diverticulosisanddiverticulitis.html https://medlineplus.gov/ency/article/000257.htm http://www.merckmanuals.com/home/digestive-disorders/diverticular-disease/diverticulitis http://emedicine.medscape.com/article/173388-overview http://www.diverticulitis.org.uk/ http://www.medicalnewstoday.com/articles/152995.php http://www.webmd.boots.com/healthy-eating/guide/diverticulitis-diet http://patients.gi.org/topics/diverticulosis-and-diverticulitis/ https://diverticulitispainfreefoods.com/home http://www.diet-blog.com/16/diverticulitis-diet.php http://www.emedicinehealth.com/diverticulosis_and_diverticulitis/article_em.htm http://patient.info/health/diverticula-including-diverticulosis-diverticular-disease-and-diverticulitis http://www.livescience.com/54884-diverticulitis.html https://www.bupa.co.uk/health-information/directory/d/diverticular-disease-diverticulitis https://draxe.com/diverticulitis-diet/ http://www.lynchspharmacy.com/health/diverticulitis http://www.medicinenet.com/diverticulosis/page2.htm http://iffgd.org/other-disorders/diverticulosis-and-diverticulitis/diverticula-diverticulosis-diverticulitiswhat-s-the-difference.html http://www.activebeat.com/your-health/10-signs-and-symptoms-of-of-diverticulitis/ http://www.webmd.boots.com/digestive-disorders/understanding-diverticulitis-symptoms http://radiopaedia.org/articles/diverticulitis http://www.mydr.com.au/gastrointestinal-health/diverticular-disease-and-diverticulitis http://www.livestrong.com/article/276671-foods-that-aggravate-diverticulitis/
Fig. 1 e Diverticulitis specific content scores. A score or 1 is awarded if the topic of interest is mentioned. Please cite this article in press as: Connelly TM, et al., An assessment of the quality and content of information on diverticulitis on the internet, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.03.010
t h e s u r g e o n x x x ( 2 0 1 8 ) 1 e6
websites compiled by searching the three most commonly utilised search engines provides an important insight into what information patients are encountering when seeking additional assistance to guide medical decision making. We limited our analysis to the top 20 websites from each search engine. The majority of individuals stop viewing their internet search results after the first ten to twenty results. A 2009 Dutch study of 109 individuals asked to perform basic internet searches demonstrated that greater than 91% did not proceed past the first page of the results. Greater than 50% did not read past the first 3 results on the first page.13 In another small study of internet search behaviour specific to health related information by Eysenbach et al., 97.2% of individual's clicks were made on the first ten links provided. 71.3% of clicks were on the first five results.14 The current study was performed using general search engines instead of medical search tools such as UptoDate and PubMed as this more accurately reflects the way the majority of patients search for information online. Interestingly, in Eysenbach et al. study, although the cohort was small, none of the participants utilised medical sites as starting point when searching for medical information. They all used search engines. We chose to use Google, Bing and Yahoo because between March 2017 and 2018, 74.1%, 8.1% and 5.3% of worldwide internet searches were performed using these engines, respectively.15 Upon entering the search term, on the first page of search results, 10 websites and 6 ads (Yahoo), 10 websites (Google) and 8 websites and 2 ads (Bing) were encountered, presenting the first challenge to obtaining objective, quality information. However, websites of good quality were also present. Webmd websites are the first sites listed in two engines and a National Health Service based site is first in the 3rd engine. These websites ranked relatively high with DISCERN scores of 59 and 50 respectively, diverticulitis specific scores of 14 and 17 and JAMA scores of 3 and 2. On one search engine, the poorest overall scoring website in the study was present on the first page. The majority of studied websites describe the symptoms and aetiology of diverticulitis well; however, only a quarter provide information to prompt seeking further medical attention if required. Thus these signs and symptoms should be highlighted to patients. The overall mean DISCERN score for the 36 websites is 39.2. This is just above a 50% quality rating given the maximum possible score of 75. No websites scored a maximum score on providing information on quality of life. The following DISCERN categories had the most websites with the lowest possible score: ‘Does the website describe the benefits of each treatment?’ (n ¼ 33), ‘Does the website describe what would happen if no treatment is used?’ (n ¼ 32). This information is key to decision making regarding surgical treatment, particularly in the elective setting and should also be highlighted to patients. Necessity and timing of elective resection a current topic of debate in colorectal surgery.16,17 Specific information on elective resection was only provided in 3 websites and is conflicting. The three websites state “Three or more attacks of mild diverticulitis (or one attack in someone younger than 50) is an indication,” “Elective resection of the involved bowel segment after 3 episodes of uncomplicated diverticulitis to prevent further attacks is generally recommended by consensus guidelines. In addition, earlier resection for younger patients with diverticulitis as
5
well as for patients who are immunocompromised has been proposed” and “Patients who have at least two diverticulitis episodes may benefit from surgery. Studies indicate that such patients are significantly more likely to have subsequent episodes, as well as complications if they do not have surgery.” No references, study details or links to evidence based guidelines are provided. Another current hot topic in colorectal surgery is washout versus resection for perforated diverticulitis. This is only mentioned in 3 of the 36 websites. Only one mentions that the use of oral antibiotics in mild diverticulitis is debated.18,19 The novel concept of a genetic component of disease pathophysiology was also underaddressed in the websites with family history mentioned in 6 websites. The need for colonoscopy after an episode of diverticulitis, which is being reviewed but is currently gold standard, is also only mentioned in 6 websites. Our results are comparable to other studies on content and quality of colorectal disease based internet information. The mean overall DISCERN score for inflammatory bowel disease websites was higher than ours.5 Similar to our study, the authors found the lowest-scoring items to be quality of life, source information and the option of ‘no treatment.’ Scott et al. found used the DISCERN score to categorise websites on anal fistulas and fissures. For fistulae 44%, 38% and 18% were rated high, moderate or poor. Anal fissures sites were 21%, 35% and 44%.6 The diverticulitis websites scored poorly in more categories than the anal fistulae and fissures, namely in the categories ‘Does it refer to areas of uncertainty?’ (mean score ¼ 2), ‘Does it provide support for shared decision-making?’ (mean score ¼ 1.36), ‘Does it describe how the treatment choices affect overall quality of life?’ (mean ¼ 1.1), and ‘Does it describe what would happen if no treatment is used?’ (mean 1.3).
Limitations The study is limited by including only websites in the English language. Good quality information may be available on non-English language websites. Also, there may be regional variation in websites returned in a search. This is reflected in a UK NHS website being found at the top of one search engine's results. Additionally, although designed and known for objectivity, the JAMA and DISCERN tools are subject to human error. In attempt to minimalise this, 2 authors carefully evaluated each website and reached a consensus on each. The topic of medical information provided within the rapidly expanding arenas of social media including Twitter, Youtube, Facebook and subscription internet channels is timely and interesting. Social media platforms have revolutionalised the way medical information is shared and disseminated. This is demonstrated with the creation of the Twitter campaign #colorectal surgery. Within 180 days of creation, 15 708 tweets using #colorectal were recorded demonstrating both the acceptability and reach of this platform.20 Additionally, views of medical videos on Youtube have increased 4 fold between 2016 and 2017.21 These videos are free, readily available and, similar to our analysis of websites, unregulated and of varying quality.22 The current manuscript does not address these other sources of information as we aimed to focus solely on websites.
Please cite this article in press as: Connelly TM, et al., An assessment of the quality and content of information on diverticulitis on the internet, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.03.010
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t h e s u r g e o n x x x ( 2 0 1 8 ) 1 e6
Information for healthcare providers provided by social media platforms is also a topic of debate and study. However, we focus on information found on the internet created for an intended audience of patients and non-medical professionals. When studying the general population, Google, Bing and Yahoo are reflective of the majority of search engines. When internet search activity of medical professionals is studied, several websites are commonly used in addition to these search engines. In Celentano et al.'s study of colorectal surgery videos, thirty-one relevant websites were used by healthcare professionals to find the videos evaluated. The content of these videos showed a marked variation in quality and content. Similar to our websites, only 18% had undergone a peer review process prior to online publishing.23 Peer support via social media is also a timely topic. This is evident in Zhang et al.'s study of members of a Facebook diabetes community. This study highlighted an international patient group, overcoming language barriers and providing and providing peer support.24
Conclusion These findings should be highlighted to patients utilising the internet to obtain diverticulitis information. Advice on when to seek further medical attention should be provided as this is concerningly lacking in the top searched websites. Patients should be directed to the objectively higher quality websites identified here.
Conflicts of interest All authors have no disclosures and no conflicts of interest.
references
1. Diaz J, Griffith R, Ng J, Reinert S, Friedmann P, Moulton A. Patients' use of the Internet for medical information. J Gen Intern Med 2002;17:180e5. 2. http://www.pewresearch.org/fact-tank/2013/02/01/majorityof-adults-look-online-for-health-information/ [Accessed 30 September 2017]. 3. Eysenbach G, Kohler C. What is the prevalence of healthrelated searches on the World Wide Web? Qualitative and quantitative analysis of search engine queries on the internet. AMIA Annu Symp Proc 2003:225e9. 4. www.google.com. [Accessed 30 September 2017]. 5. Van der Marel S, Duijvestein M, Hardwick J, van den Brink G, Veenendaal R, Hommes D, et al. Quality of web-based information on inflammatory bowel diseases. Inflamm Bowel Dis 2009;15:1891e6. 6. Scott F, Sehgal A, Joshi H, Yeung T, Gosselink M. Quality of patient information on the internet for the treatment of anal fistula and anal fissure. Tech Coloproctol 2014;12:1181e3.
7. Grewal P, Alagaratnam S. The quality and readability of colorectal cancer information on the internet. Int J Surg 2013;11:410e3. 8. 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;53:105e11. 9. www.discern.org.uk [Accessed 30 September 2017]. 10. Silberg W, Lundberg G, Musacchio R. Assessing, controlling, and assuring the quality of medical information on the Internet: Caveant lector et viewor e let the reader and viewer beware. J Am Med Assoc 1997;277:1244e5. 11. Nassiri M, Bruce-Brand R, O'Neill F, Chenouri S, Curtin P. Surfing for hip replacements: has the “internet tidal wave” led to better quality information. J Arthroplasty 2014;29:1339e44. 12. Nassiri M, Bruce-Brand R, O'Neill F, Chenouri S, Curtin P. Perthes disease: the quality and reliability of information on the internet. J Pediatr Orthop 2015;35:530e5. 13. van Deursen AJAM, van Dijk JAGM. Using the internet: skill related problems in users' online behavior 2009;21(5e6):393e402. 14. Eysenbach G, Kohler C. How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and indepth interviews. BMJ 2002;324:573e7. 15. https://netmarketshare.com/search-engine-market-share. aspx [Accessed 24 March 2018]. 16. Lamb M, Kaiser A. Elective resection versus observation after nonoperative management of complicated diverticulitis with abscess: a systematic review and meta-analysis. Dis Colon Rectum 2014;57:1430e40. 17. Khan R, Hajibandeh S, Hajibandeh S. Early elective versus delayed elective surgery in acute recurrent diverticulitis: a systematic review and meta-analysis. Int J Surg 2017;46:92e101. 18. Vennix S, Musters G, Mulder I, Swank H, Consten E, Belgers E, et al. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet 2015;386:1269e77. 19. Garfinkle R, Kugler A, Pelsser V, Vasilevsky CA, Morin N, Gordon P, et al. Diverticular abscess managed with long-term definitive nonoperative intent is safe. Dis Colon Rectum 2016;59:648e55. 20. Brady RRW, Chapman SJ, Atallah S, Chand M, Mayol J, Lacy AM, et al. #colorectalsurgery. BJS 2017;104:1470e6. 21. Tackett S, Slinn K, Tanner M, Gaglani S, Waldman V, Desai R. Medical education videos for the world: an analysis of viewing patterns for a YouTube channel. Acad Med January 2, 2018 [EPub ahead of Print]. 22. Topps D, Helmer J, Ellaway R. YouTube as a platform for publishing clinical skills training videos. Acad Med 2013;88:192e7. 23. Celentano V, Browning M, Hitchins C. Training value of laparoscopic colorectal videos on the World Wide Web: a pilot study on the educational quality of laparoscopic right hemicolectomy videos. Surg Endosc 2017;31:4496e504. 24. Zhang Y, He D, Sang Y. Facebook as a platform for health information and communication: a case study of a diabetes group. J Med Syst 2013 Jun;37(3):9942.
Please cite this article in press as: Connelly TM, et al., An assessment of the quality and content of information on diverticulitis on the internet, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.03.010
Available online at www.sciencedirect.com
ScienceDirect The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
An assessment of the quality and content of information on diverticulitis on the internet* Tara M. Connelly*, Mohammad Shoaib Khan, Liana Victory, Abeera Mehmood, Fiachra Cooke Department of Surgery, University Hospital Waterford, Waterford, Ireland
article info
abstract
Article history:
Aim: Although commonly the first port of call for medical information, the internet pro-
Received 18 December 2017
vides unregulated information of variable quality. We aimed to evaluate commonly
Received in revised form
accessed web-based patient information on diverticulitis using validated and novel scoring
27 March 2018
systems.
Accepted 30 March 2018
Methods: The top internet search engines (Google/Bing/Yahoo) were queried using the
Available online xxx
keyword ‘diverticulitis.’ The first 20 websites from each were graded using the DISCERN and Journal of the American Medical Association (JAMA) benchmark criteria. A novel
Keywords:
diverticulitis-specific score was devised and applied.
Diverticulitis
Results: Thirty-six unique websites were identified. The mean total DISCERN score for all
DISCERN
websites was 39.92 ± 12.44 (range ¼ 18e62). No website achieved the maximum DISCERN
JAMA
score of 75. The mean JAMA and diverticulitis scores were 2.5 ± 1.08 (maximum possible
Internet
score ¼ 4) and 11.08 ± 4.17 (19 points possible) respectively. Fourteen (35.9%) and 20
Patient information
(51.2%) did not provide the date of last update and authorship respectively. Thirty-three (84.6%) mentioned surgery as a treatment option; however, the majority (69.7%) did not describe the surgery or the possibility of a stoma. All except two described disease symptoms. Only ten (25.64%) provided information on when to seek further medical advice or help. Conclusion: Web-based information on diverticulitis is of variable content and quality. The majority of top websites describe disease symptoms and aetiology; however, information to prompt seeking medical attention if required, descriptions of surgical procedures and the possibility of stoma creation are poorly described in the majority of websites. These findings should be highlighted to patients utilising the internet to obtain information on diverticulitis. © 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
*
This paper was presented at the VVXI Waterford Surgical October Meeting, University Hospital, Waterford, Ireland, Oct 1, 2016. * Corresponding author. E-mail addresses: [email protected] (T.M. Connelly), [email protected] (M.S. Khan), [email protected] (L. Victory), [email protected] (A. Mehmood), [email protected] (F. Cooke). https://doi.org/10.1016/j.surge.2018.03.010 1479-666X/© 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Connelly TM, et al., An assessment of the quality and content of information on diverticulitis on the internet, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.03.010
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Introduction Commonly the internet is a patient's first port of call for medical information; however, it provides unregulated data of variable quality.1 Inaccurate information can lead to inappropriate and/or late diagnosis and adverse outcomes. Over 75% of patients seeking health related information employ the search engines Google, Yahoo and/or Bing.2 Approximately 7 million Google searches for health related information are performed daily.3 Searching Google using the term ‘diverticulitis’ returns 3,380,000 results in 0.40 s.4 Validated tools created for the evaluation of written health related information have been applied to web based information. In the field of colorectal surgery, previously studied topics include inflammatory bowel disease,5 anal fissures and fistulae6 and colorectal cancer.7 Novel tools for the evaluation of information provided in websites have also been developed. One such tool is the DISCERN tool. This instrument was created by Oxford University and the British Library through a collaboration of healthcare professionals, laypeople and information experts.8 It has been validated and, together with a handbook for its use, is freely available online (www.discern. org.uk).9 The tool contains 15 individual questions and an overall quality rating. Of the 15 questions, 8 assess reliability and 7 focus on the information regarding treatment provided. The majority of studies on the quality of healthcare related information on the internet have utilised the DISCERN tool.5e7 Similarly, the Journal of the American Medical Association (JAMA) benchmark criteria assesses four aspects of health related information: authorship, disclosure, attribution and currency. Disclosure refers to the revelation of sponsorship and/or conflicts of interest. Attribution ensures the content is referenced. Currency is the provision the date content was posted or updated.10 We aimed to evaluate the content and quality of frequently accessed web-based patient information on diverticulitis. The identification of potential gaps in information and misinformation provides the opportunity to highlight and supplement this information to patients.
Methods The top three internet search engines, Google (Mountain View, CA, USA), Yahoo (Sunnyvale, CA, USA) and Bing (Belleview, WA, USA) were queried using the keyword ‘diverticulitis.’ The top 20 websites from each engine were graded using the DISCERN tool (Table 1) and the JAMA benchmark criteria utilising a technique developed by Nassiri et al. to evaluate web-based medical information.11 For the most relevant interpretation of the DISCERN score in relation to the study topic, two categories in the tool were interpreted as follows: In the question ‘Does it refer to areas of uncertainty?,’ ‘uncertainty’ was interpreted to refer to the timing of surgery. The question ‘Does it describe the risks of each treatment?’ was interpreted to include the need for a stoma. The maximum score for each criteria in DISCERN is 6. JAMA criteria are awarded either a 0 or 1 according to absence or presence of the factor absence or presence of the factor evaluated. A novel diverticulitis-specific content score was devised by two of the
Table 1 e DISCERN tool and scores (Maximum of 4 points for each category).
Are the aims clear? Does it achieve its aims? Is it relevant? Is it clear what sources of information were used to compile the publication (other than the author or producer)? Is it clear when the information used or reported in the publication was produced? Is it balanced and unbiased? Does it provide details of additional sources of support and information? Does it refer to areas of uncertainty? (Timing of surgical intervention) Does it describe how each treatment works? Does it describe the benefits of each treatment? Does it describe the risks of each treatment? (including stoma) Does it describe what would happen if no treatment is used? Does it describe how the treatment choices affect overall quality of life? Is it clear that there may be more than one possible treatment choice? Does it provide support for shared decision-making?
Mean
Stand Deviation
3.94 3.81 3.91 2.97
1.39 1.28 1.26 1.80
2.86
1.94
4.03 2.58
1.32 1.46
2.0
1.43
2.39
1.42
2.17
1.18
1.89
1.33
1.33
0.99
1.08
0.28
3.61
1.44
1.36
0.99
authors who are surgeons with an interest in colorectal disease (Table 2). One point was awarded for the mention of each of the predefined terms relating to general aspects of the disease, treatment and complications for a maximum score of 19 points.11,12 The DISCERN and JAMA tools have maximum cumulative attainable scores of 75 and 4 points respectively. All free, English language websites which did not require a password or sign up were included. All paid advertisement websites annotated by the search engine as ‘ad’ were excluded. The websites were evaluated jointly by two authors (TMC and MSK) and a consensus score was attained for each aspect of the DISCERN, JAMA and diverticulitis-specific content tools for each website. Simple descriptive statistics were employed. Standard deviation is provided where appropriate.
Results The top 10 websites for each search engine are listed in Table 3. After the removal of duplicate websites, thirty-six unique websites were identified (Table 4). The mean total DISCERN score for all websites was 39.92 ± 12.44 (range ¼ 16e62). No website achieved the maximum DISCERN score of 75. Wikipedia.org/wiki/Diverticulitis and emedi cine.medscape.com/article/173388-overview had the highest total DISCERN scores with 62 and 61 respectively. The DISCERN categories evaluating clarity of aims, relevancy and lack of bias scored the highest with 20, 19 and 19 of the 36 websites receiving a score of 5 out of a maximum of 6 points for the category. Only 2 categories (providing the date of
Please cite this article in press as: Connelly TM, et al., An assessment of the quality and content of information on diverticulitis on the internet, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.03.010
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Table 2 e Diverticulitis specific score. Disease summary 1 2 3
Gender Age Pathophysiology (diverticulum with infection) Diet Family History or genetics Symptoms Diverticulosis vs divertiulitis When to seek further help Diagnosis
4 5 6 7 8 9 Treatment 1 2 3 4 Complications 1 2 3 4 Other 1 2
Antibiotics Surgery Benefits of treatment options Complications of surgery Abscess Perforation Fistula Recurrence No increased Risk of Cancer Need for colonoscopy after episode of diverticulitis
webpage creation/update and referencing the information sources used) received the maximum score of 6, in one website only respectively. Overall, the websites scored poorly in the categories: 1) referring to areas of uncertainty (interpreted as appropriate timing of surgery for the study aims), 2)
describing the benefits of each treatment and 3) explaining the consequences if no treatment is undertaken. No website scored maximum points in the category focussing on description of how the treatment choices affect overall quality of life. The mean JAMA score for the websites was 2.5 ± 1.08 (maximum possible ¼ 4). Www.webmd.com/digestivedisorders/tc/diverticulitis-topic-overview obtained the highest mean JAMA score (3.93 ± 1.49). Overall, the websites performed well on disclosure with all except three revealing sponsorship or conflicts of interest. Authorship was poorly described with 22 websites failing to reveal the author. Currency and attribution were adequate in 47.2 and 61.1%. Fourteen (35.9%) did not provide the date of last update. Thirty three (84.6%) mentioned surgery as a treatment option; however, the majority of these 23 (69.7%) did not describe the surgery or the possibility of a stoma. The mean diverticulitisspecific score was 11.08 ± 4.17 (19 points possible). All except two described disease symptoms. Only ten (25.64%) provided information on when to seek further medical advice or help (see Fig. 1).
Discussion and conclusions The internet has enabled patients to instantly obtain disease related information at their convenience. We have demonstrated that web-based information on diverticulitis is of variable content and quality. Analysis of the 36 unique
Table 3 e Top 10 diverticulitis websites by search engine. Google
Bing
Yahoo
1
http://www.webmd.com/digestive-disorders/ http://www.webmd.com/digestive-disorders/ http://www.nhs.uk/conditions/Diverticulartc/diverticulitis-topic-overview tc/diverticulitis-topic-overview disease-and-diverticulitis/Pages/ Introduction.aspx 2 http://www.mayoclinic.org/diseaseshttps://www.betterhealth.vic.gov.au/health/ http://www.medicinenet.com/ conditions/diverticulitis/basics/ conditionsandtreatments/diverticulosisdiverticulosis/article.htm definition/con-20033495 and-diverticulitis 3 http://www.healthline.com/health/ http://www.mayoclinic.org/diseaseshttps://en.wikipedia.org/wiki/ diverticulitis conditions/diverticulitis/basics/ Diverticulitis definition/CON-20033495 4 https://www.niddk.nih.gov/healthhttp://www.ncbi.nlm.nih.gov/ http://www.webmd.com/digestiveinformation/health-topics/digestivepubmedhealth/PMHT0022910/ disorders/diverticulitis-diet diseases/diverticulosis-diverticulitis/ Pages/overview.aspx 5 http://www.medicinenet.com/ http://www.medicinenet.com/ http://www.healthline.com/health/ diverticulosis/article.htm diverticulosis/article.htm diverticulitis 6 https://en.wikipedia.org/wiki/Diverticulitis http://www.webmd.com/digestive-disorders/ www.dailymail.co.uk/health/ tc/diverticulitis-symptoms article-156886 7 http://www.hse.ie/eng/health/az/D/ http://www.nhs.uk/conditions/Diverticular- http://www.mayoclinic.org/diseasesDiverticular-disease-and-diverticulitis/ disease-and-diverticulitis/Pages/ conditions/diverticulitis/basics/ Treating-diverticular-disease-andIntroduction.aspx definition/CON-20033495 diverticulitis.html 8 https://medlineplus.gov/ https://medlineplus.gov/ency/article/ https://www.bupa.co.uk/healthdiverticulosisanddiverticulitis.html 000257.htm information/directory/d/diverticulardisease-diverticulitis 9 http://www.merckmanuals.com/home/ https://en.wikipedia.org/wiki/Diverticulitis http://www.nhs.uk/Conditions/Diverticulardigestive-disorders/diverticular-disease/ disease-and-diverticulitis/Pages/ diverticulitis Treatment.aspx 10 http://emedicine.medscape.com/ https://medlineplus.gov/ http://www.webmd.com/digestivearticle/173388-overview diverticulosisanddiverticulitis.html disorders/tc/diverticulitis-topic-overview
Please cite this article in press as: Connelly TM, et al., An assessment of the quality and content of information on diverticulitis on the internet, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.03.010
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Table 4 e Unique diverticulitis websites. 1 2 3 4 5 6 7 8 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
http://www.webmd.com/digestive-disorders/tc/diverticulitis-topic-overview http://www.mayoclinic.org/diseases-conditions/diverticulitis/basics/definition/con-20033495 https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/diverticulosis-and-diverticulitis http://www.healthline.com/health/diverticulitis http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022910/ http://www.webmd.com/digestive-disorders/diverticulitis-diet https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/diverticulosisdiverticulitis/Pages/overview.aspx http://www.medicinenet.com/diverticulosis/article.htm https://en.wikipedia.org/wiki/Diverticulitis www.dailymail.co.uk/health/article-156886 http://www.hse.ie/eng/health/az/D/Diverticular-disease-and-diverticulitis/Treating-diverticular-diseaseand-diverticulitis.html http://www.nhs.uk/conditions/Diverticular-disease-and-diverticulitis/Pages/Introduction.aspx https://medlineplus.gov/diverticulosisanddiverticulitis.html https://medlineplus.gov/ency/article/000257.htm http://www.merckmanuals.com/home/digestive-disorders/diverticular-disease/diverticulitis http://emedicine.medscape.com/article/173388-overview http://www.diverticulitis.org.uk/ http://www.medicalnewstoday.com/articles/152995.php http://www.webmd.boots.com/healthy-eating/guide/diverticulitis-diet http://patients.gi.org/topics/diverticulosis-and-diverticulitis/ https://diverticulitispainfreefoods.com/home http://www.diet-blog.com/16/diverticulitis-diet.php http://www.emedicinehealth.com/diverticulosis_and_diverticulitis/article_em.htm http://patient.info/health/diverticula-including-diverticulosis-diverticular-disease-and-diverticulitis http://www.livescience.com/54884-diverticulitis.html https://www.bupa.co.uk/health-information/directory/d/diverticular-disease-diverticulitis https://draxe.com/diverticulitis-diet/ http://www.lynchspharmacy.com/health/diverticulitis http://www.medicinenet.com/diverticulosis/page2.htm http://iffgd.org/other-disorders/diverticulosis-and-diverticulitis/diverticula-diverticulosis-diverticulitiswhat-s-the-difference.html http://www.activebeat.com/your-health/10-signs-and-symptoms-of-of-diverticulitis/ http://www.webmd.boots.com/digestive-disorders/understanding-diverticulitis-symptoms http://radiopaedia.org/articles/diverticulitis http://www.mydr.com.au/gastrointestinal-health/diverticular-disease-and-diverticulitis http://www.livestrong.com/article/276671-foods-that-aggravate-diverticulitis/
Fig. 1 e Diverticulitis specific content scores. A score or 1 is awarded if the topic of interest is mentioned. Please cite this article in press as: Connelly TM, et al., An assessment of the quality and content of information on diverticulitis on the internet, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.03.010
t h e s u r g e o n x x x ( 2 0 1 8 ) 1 e6
websites compiled by searching the three most commonly utilised search engines provides an important insight into what information patients are encountering when seeking additional assistance to guide medical decision making. We limited our analysis to the top 20 websites from each search engine. The majority of individuals stop viewing their internet search results after the first ten to twenty results. A 2009 Dutch study of 109 individuals asked to perform basic internet searches demonstrated that greater than 91% did not proceed past the first page of the results. Greater than 50% did not read past the first 3 results on the first page.13 In another small study of internet search behaviour specific to health related information by Eysenbach et al., 97.2% of individual's clicks were made on the first ten links provided. 71.3% of clicks were on the first five results.14 The current study was performed using general search engines instead of medical search tools such as UptoDate and PubMed as this more accurately reflects the way the majority of patients search for information online. Interestingly, in Eysenbach et al. study, although the cohort was small, none of the participants utilised medical sites as starting point when searching for medical information. They all used search engines. We chose to use Google, Bing and Yahoo because between March 2017 and 2018, 74.1%, 8.1% and 5.3% of worldwide internet searches were performed using these engines, respectively.15 Upon entering the search term, on the first page of search results, 10 websites and 6 ads (Yahoo), 10 websites (Google) and 8 websites and 2 ads (Bing) were encountered, presenting the first challenge to obtaining objective, quality information. However, websites of good quality were also present. Webmd websites are the first sites listed in two engines and a National Health Service based site is first in the 3rd engine. These websites ranked relatively high with DISCERN scores of 59 and 50 respectively, diverticulitis specific scores of 14 and 17 and JAMA scores of 3 and 2. On one search engine, the poorest overall scoring website in the study was present on the first page. The majority of studied websites describe the symptoms and aetiology of diverticulitis well; however, only a quarter provide information to prompt seeking further medical attention if required. Thus these signs and symptoms should be highlighted to patients. The overall mean DISCERN score for the 36 websites is 39.2. This is just above a 50% quality rating given the maximum possible score of 75. No websites scored a maximum score on providing information on quality of life. The following DISCERN categories had the most websites with the lowest possible score: ‘Does the website describe the benefits of each treatment?’ (n ¼ 33), ‘Does the website describe what would happen if no treatment is used?’ (n ¼ 32). This information is key to decision making regarding surgical treatment, particularly in the elective setting and should also be highlighted to patients. Necessity and timing of elective resection a current topic of debate in colorectal surgery.16,17 Specific information on elective resection was only provided in 3 websites and is conflicting. The three websites state “Three or more attacks of mild diverticulitis (or one attack in someone younger than 50) is an indication,” “Elective resection of the involved bowel segment after 3 episodes of uncomplicated diverticulitis to prevent further attacks is generally recommended by consensus guidelines. In addition, earlier resection for younger patients with diverticulitis as
5
well as for patients who are immunocompromised has been proposed” and “Patients who have at least two diverticulitis episodes may benefit from surgery. Studies indicate that such patients are significantly more likely to have subsequent episodes, as well as complications if they do not have surgery.” No references, study details or links to evidence based guidelines are provided. Another current hot topic in colorectal surgery is washout versus resection for perforated diverticulitis. This is only mentioned in 3 of the 36 websites. Only one mentions that the use of oral antibiotics in mild diverticulitis is debated.18,19 The novel concept of a genetic component of disease pathophysiology was also underaddressed in the websites with family history mentioned in 6 websites. The need for colonoscopy after an episode of diverticulitis, which is being reviewed but is currently gold standard, is also only mentioned in 6 websites. Our results are comparable to other studies on content and quality of colorectal disease based internet information. The mean overall DISCERN score for inflammatory bowel disease websites was higher than ours.5 Similar to our study, the authors found the lowest-scoring items to be quality of life, source information and the option of ‘no treatment.’ Scott et al. found used the DISCERN score to categorise websites on anal fistulas and fissures. For fistulae 44%, 38% and 18% were rated high, moderate or poor. Anal fissures sites were 21%, 35% and 44%.6 The diverticulitis websites scored poorly in more categories than the anal fistulae and fissures, namely in the categories ‘Does it refer to areas of uncertainty?’ (mean score ¼ 2), ‘Does it provide support for shared decision-making?’ (mean score ¼ 1.36), ‘Does it describe how the treatment choices affect overall quality of life?’ (mean ¼ 1.1), and ‘Does it describe what would happen if no treatment is used?’ (mean 1.3).
Limitations The study is limited by including only websites in the English language. Good quality information may be available on non-English language websites. Also, there may be regional variation in websites returned in a search. This is reflected in a UK NHS website being found at the top of one search engine's results. Additionally, although designed and known for objectivity, the JAMA and DISCERN tools are subject to human error. In attempt to minimalise this, 2 authors carefully evaluated each website and reached a consensus on each. The topic of medical information provided within the rapidly expanding arenas of social media including Twitter, Youtube, Facebook and subscription internet channels is timely and interesting. Social media platforms have revolutionalised the way medical information is shared and disseminated. This is demonstrated with the creation of the Twitter campaign #colorectal surgery. Within 180 days of creation, 15 708 tweets using #colorectal were recorded demonstrating both the acceptability and reach of this platform.20 Additionally, views of medical videos on Youtube have increased 4 fold between 2016 and 2017.21 These videos are free, readily available and, similar to our analysis of websites, unregulated and of varying quality.22 The current manuscript does not address these other sources of information as we aimed to focus solely on websites.
Please cite this article in press as: Connelly TM, et al., An assessment of the quality and content of information on diverticulitis on the internet, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.03.010
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Information for healthcare providers provided by social media platforms is also a topic of debate and study. However, we focus on information found on the internet created for an intended audience of patients and non-medical professionals. When studying the general population, Google, Bing and Yahoo are reflective of the majority of search engines. When internet search activity of medical professionals is studied, several websites are commonly used in addition to these search engines. In Celentano et al.'s study of colorectal surgery videos, thirty-one relevant websites were used by healthcare professionals to find the videos evaluated. The content of these videos showed a marked variation in quality and content. Similar to our websites, only 18% had undergone a peer review process prior to online publishing.23 Peer support via social media is also a timely topic. This is evident in Zhang et al.'s study of members of a Facebook diabetes community. This study highlighted an international patient group, overcoming language barriers and providing and providing peer support.24
Conclusion These findings should be highlighted to patients utilising the internet to obtain diverticulitis information. Advice on when to seek further medical attention should be provided as this is concerningly lacking in the top searched websites. Patients should be directed to the objectively higher quality websites identified here.
Conflicts of interest All authors have no disclosures and no conflicts of interest.
references
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7. Grewal P, Alagaratnam S. The quality and readability of colorectal cancer information on the internet. Int J Surg 2013;11:410e3. 8. 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;53:105e11. 9. www.discern.org.uk [Accessed 30 September 2017]. 10. Silberg W, Lundberg G, Musacchio R. Assessing, controlling, and assuring the quality of medical information on the Internet: Caveant lector et viewor e let the reader and viewer beware. J Am Med Assoc 1997;277:1244e5. 11. Nassiri M, Bruce-Brand R, O'Neill F, Chenouri S, Curtin P. Surfing for hip replacements: has the “internet tidal wave” led to better quality information. J Arthroplasty 2014;29:1339e44. 12. Nassiri M, Bruce-Brand R, O'Neill F, Chenouri S, Curtin P. Perthes disease: the quality and reliability of information on the internet. J Pediatr Orthop 2015;35:530e5. 13. van Deursen AJAM, van Dijk JAGM. Using the internet: skill related problems in users' online behavior 2009;21(5e6):393e402. 14. Eysenbach G, Kohler C. How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and indepth interviews. BMJ 2002;324:573e7. 15. https://netmarketshare.com/search-engine-market-share. aspx [Accessed 24 March 2018]. 16. Lamb M, Kaiser A. Elective resection versus observation after nonoperative management of complicated diverticulitis with abscess: a systematic review and meta-analysis. Dis Colon Rectum 2014;57:1430e40. 17. Khan R, Hajibandeh S, Hajibandeh S. Early elective versus delayed elective surgery in acute recurrent diverticulitis: a systematic review and meta-analysis. Int J Surg 2017;46:92e101. 18. Vennix S, Musters G, Mulder I, Swank H, Consten E, Belgers E, et al. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial. Lancet 2015;386:1269e77. 19. Garfinkle R, Kugler A, Pelsser V, Vasilevsky CA, Morin N, Gordon P, et al. Diverticular abscess managed with long-term definitive nonoperative intent is safe. Dis Colon Rectum 2016;59:648e55. 20. Brady RRW, Chapman SJ, Atallah S, Chand M, Mayol J, Lacy AM, et al. #colorectalsurgery. BJS 2017;104:1470e6. 21. Tackett S, Slinn K, Tanner M, Gaglani S, Waldman V, Desai R. Medical education videos for the world: an analysis of viewing patterns for a YouTube channel. Acad Med January 2, 2018 [EPub ahead of Print]. 22. Topps D, Helmer J, Ellaway R. YouTube as a platform for publishing clinical skills training videos. Acad Med 2013;88:192e7. 23. Celentano V, Browning M, Hitchins C. Training value of laparoscopic colorectal videos on the World Wide Web: a pilot study on the educational quality of laparoscopic right hemicolectomy videos. Surg Endosc 2017;31:4496e504. 24. Zhang Y, He D, Sang Y. Facebook as a platform for health information and communication: a case study of a diabetes group. J Med Syst 2013 Jun;37(3):9942.
Please cite this article in press as: Connelly TM, et al., An assessment of the quality and content of information on diverticulitis on the internet, The Surgeon (2018), https://doi.org/10.1016/j.surge.2018.03.010