- Email: [email protected]
Assessment of Quality and Content of Online Information About Hip Arthroscopy
Assessment of Quality and Content of Online Information About Hip Arthroscopy Bridget Ellsworth, B.A., Hiren Patel, B.A., and Atul F. Kamath, M.D.
Purpose: The purpose of this study was to assess the quality of information available to patients on the Internet when using popular search engines to search the term “hip arthroscopy.” Methods: We analyzed the quality and content of information about hip arthroscopy (HA) on the first 50 websites returned by the search engines Google and Bing for the search term “hip arthroscopy.” The sites were categorized by type, and quality and content were measured using the DISCERN score, along with an HA-specific content score. The HA-specific content score was used to assess each website for the presence or absence of 19 topics about HA determined to be important for a patient seeking information about the procedure. The Health on the Net Code (HONcode) status of each website was also noted. Results: The mean DISCERN score for all websites analyzed was 39.5, considered “poor,” while only 44.6% of sites were considered “fair” or “good.” Governmental and nonprofit organization (NPO) websites had the highest average DISCERN score. The mean HA-specific content score was 8.6 (range, 2 to 16). The commercial website category had the highest average HA-specific content score, followed by the governmental and NPO category. Sites that bore the HONcode certification obtained significantly higher DISCERN scores than those without the certification (P ¼ .0032) but did not obtain significantly higher HA-specific content scores. Conclusions: “Hip arthroscopy” is a fairly general term, and there is significant variability in the quality of HA information available online. The HONcode is useful to identify quality patient information websites; however, it is not commonly used in HA-specific websites and does not encompass all quality websites about HA. Clinical Relevance: This study increases awareness of the quality of information on HA available online.
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he Internet is a popular source for individuals to get health information. A staggering 86.9% of the U.S. population currently uses the Internet.1 Moreover, a telephone interview conducted in 2010 found that 80% of American Internet users have searched for health information online.2 Given the already huge number of people who obtain health information online, and the fact that this number will likely continue to grow, it is imperative that patients have access to high-quality and accurate health information online. This is especially important as shared decision-making between physicians and patients becomes more common3 in a consumer-oriented health care environment.
From the Perelman School of Medicine (B.E., H.P.) and the Department of Orthopaedic Surgery (A.F.K.), Center for Hip Preservation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 21, 2015; accepted March 11, 2016. Address correspondence to Atul F. Kamath, M.D., Department of Orthopaedic Surgery, University of Pennsylvania Hospital, 8th Floor Preston, Philadelphia, PA 19107, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 0749-8063/15977/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.03.019
While it is empowering for patients to have the ability to access an abundance of health information online, several studies have shown that the quality of health information available online is at best variable.4-6 The Internet is largely unregulated, and there is potential for patients to find inaccurate or misleading information about their health condition or treatment options. The first step to improving online health information is to determine the quality of the websites currently available. Hip arthroscopy (HA) is a minimally invasive procedure that has increased in popularity over the past decade.7-9 HA was first described by Burman in 1931 but did not become popular in the United States until recently owing to anatomical constraints of the hip that make arthroscopy more challenging than in the shoulder or knee.10 Additionally, the current indications for HA, including femoroacetabular impingement, have historically gone unrecognized until recently.10 As HA continues to grow in popularity, more patients may turn to the Internet for information about the indications, benefits, recovery, prognosis, and complications of HA. It is important that the information they find be both accurate and complete as the decision to
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Fig 1. Internet search flow diagram. The search term “hip arthroscopy” was entered into Google and Bing. The first 50 sites returned by both the Google and Bing queries were analyzed. News sites, blogs/forums, websites containing solely video, unrelated websites, and inaccessible, modular, or duplicate websites were excluded, leaving 56 unique sites for analysis.
proceed with an HA procedure is ultimately a shared one between the patient and the physician. The purpose of this study was to assess the quality of information available to patients on the Internet when using popular search engines to search the term “hip arthroscopy.” Our hypothesis was that heterogeneity exists with respect to the quality of information available to patients on the Internet about HA.
Methods
We used the search term “hip arthroscopy” in the 2 most popular global search engines as of August 2015: Google and Bing.11 All searches were performed on August 8, 2015. We analyzed the first 50 sites returned by both the Google and Bing queries. News sites, blogs/ forums, websites containing solely video, unrelated websites, inaccessible websites, and duplicate websites were excluded from analysis (Fig 1). Additionally, modular-type websites in which information about HA was contained in multiple different web pages, such as sites in which the indications for HA were described on a different page than the risks of the procedure, were excluded. First, websites were categorized by type, namely, academic, commercial, governmental and nonprofit organization (NPO), physician, and unspecified. These categories were based on those described in previous
works.6,12 Academic websites included those affiliated with a university or medical society. Websites were classified as commercial if they displayed advertisements or sold products. Governmental and NPO websites included those operating from government funding or donations only. Physician websites included both individual physician websites and physician groups not affiliated with an academic institution. Unspecified websites were those that did not fit into a preceding category, such as the Wikipedia page about HA. Websites were assessed for quality and content using the DISCERN instrument,13 as well as an HA-specific content score (Table 1). All websites were assessed within 1 month of the original search. The independent reviewers were medical students with familiarity in web search engines and trained in the above methodology. All results, including search term identification and tabulation of scores, were verified by an attending orthopaedic surgeon experienced in HA. A separate DISCERN score was determined by 2 independent reviewers for each website owing to the more subjective nature of the DISCERN score compared with the HAspecific content score. The scores were then averaged to determine the particular website’s final DISCERN score. DISCERN is a 16-question survey designed to assist health care professionals and patients in assessing the quality of information about treatment choices for a given health problem. DISCERN was created as part of a British national project to establish quality thresholds for consumer health information.13 It is simple to use, Table 1. Hip ArthroscopyeSpecific Content Score Components Does the Site Contain Information About? General aspects: Indications for hip arthroscopy What is hip arthroscopy? Benefits of hip arthroscopy Preoperative assessment Anesthesia Outpatient procedure Expected activities postoperatively Rehabilitation Potential need for total hip replacement in future Management Surgical alternatives: observation and analgesia Surgical alternative: physical therapy Surgical technique (approach) Complications Blood clot/venous thromboembolic disease Infection Nerve palsy Traction-related changes Chronic pain Avascular necrosis of the femoral head Fracture, intraoperative or postoperative Total score (out of 19)
Points 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
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QUALITY OF HIP ARTHROSCOPY ONLINE MATERIAL
and it has been shown to have high interobserver reliability and construct validity when used by either medical professionals or patients.14,15 The DISCERN instrument is summarized in Table 2. The maximum DISCERN score for a given publication is 80, as each question is rated on a 5-point scale. Websites are then classified by their total score as “excellent” (68 to 80), “good” (55 to 67), “fair” (42 to 54), “poor” (29 to 41), or “very poor” (16 to 28), as described elsewhere.16 An HA-specific content score was created in consultation with an orthopaedic surgeon trained in HA and after referencing peer-reviewed literature on HA.10,17,18 This score consists of 19 topics about HA determined to be important for a patient seeking information about the procedure. These topics fall into the categories of general aspects about the procedure, management, and complications. One point was allocated by a single independent reviewer for each of the predefined topics (Table 1), with a maximum score of 19 and a minimum score of 0. A site in which none of the predefined topics were discussed received a score of zero, while a site in which each of the predefined topics were discussed received a score of 19. Websites that discussed some, but not all, of the predefined topics received an intermediary score between 0 and 19 based on the number of topics that were discussed. The websites were also assessed for the Health on the Net Code (HONcode) certification. The Health on the Net (HON) Foundation was established in 1995 as a nonprofit, nongovernmental organization with a mission of improving the quality of online patient health information.19 The HON Foundation accredits
websites based on 8 ethical principles. Certified websites must agree to HON standards and are subject to random audits for compliance. The HONcode status was assessed by downloading a free HONcode plug-in that displays accreditation status for each website visited in the browser toolbar.20 The mean scores and standard error of the mean (SEM) for the quality and content scores were calculated for each website category. Statistical analysis was performed using Microsoft Excel (Microsoft Corp., Redmond, WA, U.S.A.). Regression analysis was performed to determine whether website type and HONcode certification predicted higher DISCERN and HA-specific content scores. Statistical significance was set at P < .05.
Results A total of 56 unique websites were included in the study and analyzed (Table 3). Figure 2 shows the breakdown of website by type of organization sponsoring the online material. The majority (53.6%) of websites were physician sponsored. Only 5 of the websites were HONcode certified (8.9%). Figure 3 illustrates the mean overall scores by website type, and Table 4 lists the values. The mean DISCERN score of 39.5 for all websites analyzed was “poor” but was highly variable (SEM ¼ 1.36; range, 21.5 to 59). The majority (55.4%) of websites were categorized as being of “poor” or “very poor” quality, while only 44.6% earned scores high enough to be considered “fair” or “good.” The 2 highest scoring websites were governmental and NPO sites, and both were HONcode certified. The 5 websites that were HONcode certified obtained significantly higher
Table 2. DISCERN Instrument Score Section 1: Is the publication reliable? 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? Section 2: How good is the quality of information on treatment choices? Does it describe how each treatment works? Does it describe the benefits of each treatment? Does it describe the risks of each treatment? 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? Section 3: Overall rating of the publication. Based on the answers to all of the above questions, rate the overall quality of the publication as a source of information about treatment choices Total score (out of 80)
1 (no)-5 (yes)
1 (low)-5 (high)
NOTE. General instructions for the use of the DISCERN Instrument are available at http://www.discern.org.uk/general_instructions.php.
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Table 3. List of Unique Websites Analyzed Through Search Criteria Search Engine Google
Result Number 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
Bing
29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56
NOTE. Date of search: August 8, 2015.
Website http://orthoinfo.aaos.org/topic.cfm?topic¼A00572 https://en.wikipedia.org/wiki/Hip_arthroscopy http://www.nlm.nih.gov/medlineplus/ency/article/007500.htm http://www.cfosm.com/services-specialties/hip-arthroscopy-falls-church-virginia-va.php http://www.uwhealth.org/files/uwhealth/docs/pdf2/Rehab_Hip_Arthroscopy.pdf http://www.yoummd.com/hip-arthroscopy-thomas-youm.html http://www.nirschl.com/questions-to-ask-prior-to-hip-arthroscopic-surgery.asp http://www.emoryhealthcare.org/orthopaedics/procedures/hip-care/hip-arthroscopy.html http://orthopedics.about.com/od/hipinjuries/a/hiparthroscopy.htm http://www.advancedortho.net/pages/procedures/hipscope.htm http://www.rothmaninstitute.com/specialties/treatments/hip-arthroscopy http://www.bjr.boneandjoint.org.uk/content/1/7/131.full http://www.thecoreinstitute.com/patient-and-visitor-information/core-patient-education/ hip/hip-arthroscopy.html http://www.mainlineorthopaedics.com/files/hip-arthroscopy-instructions.pdf http://www.portlandhiparthroscopy.com/ http://www.hiparthroscopy-ireland.com/ http://www.arthroscopichipsurgeon.com/hip-arthroscopy.html http://www.em-consulte.com/en/article/272073 http://columbushiparthroscopy.com/ http://www.rushortho.com/hip-arthroscopy.cfm http://www.sciencedirect.com/science/article/pii/S2255497114000998 http://www.hiparthroscopyaustralia.com.au/ http://www.hiparthroscopydoctor.com/ https://patienteducation.osumc.edu/Documents/PTHipPh1-2.pdf http://www.orthosports.com.au/content_common/pg-hip-arthroscopy.seo http://www.clohisyhipsurgeon.com/treatment-options/hip-arthroscopy http://www.southcountyhealth.org/Services/OrthopedicsCenter/HipSurgery/ HipArthroscopy.aspx http://www.ohsu.edu/xd/health/services/ortho/getting-treatment/services/hip-services/ treatment/hip-arthroscopy.cfm http://www.hiparthroscopyutah.com/ http://www.osaliortho.com/hip.php http://www.northtownsorthopedics.com/arthroscopic-hip-surgery/ http://www.oregonortho.com/hip-arthroscopy.php http://www.villarbajwa.com/hip-arthroscopy.shtml http://www.hss.edu/conditions_femoroacetabular-impingement-a-patient-guide-to-hipmobility-and-hip-arthroscopy.asp http://bonesmart.org/hip/hip-arthroscopy/ http://www.chop.edu/treatments/hip-arthroscopy#.VcZ7vPm-1cY http://www.hiphelp.com/pages/arthro.html http://www.aaos.org/news/aaosnow/aug11/clinical5.asp https://xnet.kp.org/misg/procedures/arth_hip.html http://www.bch.org/hip-orthopedic-treatment/hip-arthroscopy-surgery.aspx http://advancedorthosports.com/hip-arthroscopy/ http://www.nhs.uk/Conditions/Arthroscopy/Pages/Introduction.aspx http://www.orthobullets.com/sports/3100/hip-arthroscopy http://www.wakehealth.edu/Orthopaedic-Services/Hip-Arthroscopy.htm http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3293959/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3353094/ http://www.ohsu.edu/xd/health/services/ortho/getting-treatment/services/sportsmedicine-clinic/treatment/hip-arthroscopy.cfm http://www.browardhealth.org/hiparthroscopy http://www.johnodonnell.com.au/FAQ.pdf http://phoenixhiparthroscopy.com/ http://umm.edu/health/medical/ency/articles/hip-arthroscopy http://www.sharp.com/ortho/minimally-invasive-hip-surgery.cfm http://www.spirehealthcare.com/our-treatments/body-map-and-a-z/a-z-treatments/hiparthroscopy-/ http://www.aaos.org/news/aaosnow/aug13/clinical4.asp http://www.hiparthroscopy-ireland.com/hiparthroscopy.html http://www.tulsaorthopaedicsurgeon.com/hip-arthroscopy.html
QUALITY OF HIP ARTHROSCOPY ONLINE MATERIAL
2 Academic
17
Commercial Government & NPO 30
2 5
Physician Unspecified
Fig 2. Distribution of websites by type of organization sponsoring the online material. A total of 56 unique websites were included in the study and analyzed. The majority of websites were physician sponsored (53.6%), followed by academic (30.4%), government and nonprofit organization (NPO) (8.9%), commercial (3.6%), and unspecified (3.6%).
DISCERN scores than those that were not certified (53.6 v 38.1; P ¼ .0032). The physician website category had the lowest mean DISCERN score of 36.3, which was significantly lower than both the government and NPO (51.5; P ¼ .004) and commercial categories (44.75; P ¼ .033). The academic category had a mean DISCERN score of 40.6, which was significantly lower than the government and NPO category (P ¼ .023). The mean HA-specific content score was 8.6 (SEM ¼ 0.55; range, 2 to 16). The highest score was an academic website that was not HONcode certified. The HONcode-certified websites did not obtain significantly higher HA-specific content scores than those that were not certified (8.8 v 8.5; P ¼ .79). Twenty-nine websites (51.7%) scored 9 or lower points, while 27 websites (48.2%) scored 10 or higher points. The commercial website category had the highest mean HA-specific content score of 11.5, but this value was not significantly higher than any of the other categories. The governmental and NPO category had the second highest mean HA-specific content score of 10.4, which was significantly higher than that of the academic category (7.5; P ¼ .028).
Discussion There is significant variability in the quality of HA information available online, with 55.4% being of “poor” or “very poor” quality; however, there are also several sources of high-quality information. The Internet has evolved into a major source of patient health information, as both the number of Internet users and percentage of those users searching for health information online has increased in the last decade.1,2 While the increase in availability of information is important for patients to make informed decisions regarding their health, the unregulated nature of the
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Internet raises concerns about the quality and content of information obtained online. According to a systematic review, information quality was an issue in 70% of studies assessing the quality of online health information.21 Within the orthopaedic literature, the quality of online information has also been shown to be variable.22-24 It is important that patients have access to high-quality and complete information to make well-informed health care decisions. Our findings indicate that the quality of online information regarding HA is highly variable. The mean DISCERN score for the websites analyzed was “poor.” In examining the DISCERN question-specific responses, we found that several questions consistently scored poorly. First, websites often did not specify the aim of the online content or the intended reader. Only 1 physician website included an introductory paragraph specifying the intended audience, purpose, and limits of the content material. Second, the majority of websites did not cite sources or offer unaffiliated reference materials to direct the patient to additional information. Lastly, websites often did not display the date of publication or date of last content update. The mean HA-specific content score for the websites analyzed was 8.6 (SEM ¼ 0.55). Like the DISCERN question-specific responses, we found that websites commonly missed several predefined points. First, only 61% of websites mentioned at least 1 complication of HA. Additionally, websites did not commonly mention alternative or nonoperative management, including observation, oral and/or injection analgesia, and physical therapy. The omission of these important points represents serious shortcomings in website quality and completeness and may introduce bias in the patientphysician interaction. Our study findings differed from previous studies examining the quality of online arthroscopic materials in several ways. First, unlike previous studies, we did not find that academic institution-created websites provided better information quality.25 Moreover, we found that commercial websites obtained the highest, albeit nonsignificant, HA-specific content scores. This may be a result of the small number of commercial sites identified in the search engine queries. Additionally, we found that physician and physician group websites predominated the HA literature, whereas other studies of knee-specific content have found that commercial websites predominated.6,26 This finding represents a unique opportunity for individual physicians to improve their web pages and thereby improve the quality of patient information. Another difference between this study and others of its kind is the usefulness of the HONcode.6,26 While HONcode-certified websites did obtain significantly higher DISCERN scores when compared with
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Fig 3. Quality and content scores of websites by organizational type. The physician website category had the lowest mean DISCERN score of 36.3, which was significantly lower than both the government and NPO (51.5; P ¼ .004) and commercial categories (44.75; P ¼ .033). The academic category had a mean DISCERN score of 40.6, which was significantly lower than the government and NPO category (P ¼ .023). The commercial website category had the highest mean HA-specific content score of 11.5, but this value was not significantly higher than any of the other categories. The governmental and NPO category had the second highest mean HA-specific content score of 10.4, which was significantly higher than that of the academic category (7.5; P ¼ .028). (HA, hip arthroscopy; NPO, nonprofit organization.)
nonaccredited websites in our study, these accredited sites did not obtain significantly higher HA-specific content scores. Additionally, only 5 websites (8.9%) were HONcode accredited, and of those, none displayed the HONcode seal on their website. Therefore, in order to determine a website’s HONcode accreditation status, a patient (or provider) would need to
download a special toolbar plug-in from the HON Foundation website. While this is not unreasonable, the average patient is unlikely to download this plugin. Moreover, some high-quality websites were not HONcode certified, which may limit the usefulness of the HONcode accreditation status in HA-specific literature.
Table 4. Summary of Website Scores DISCERN Score Site Type Overall HONcode (present) HONcode (absent) Academic Commercial Governmental and nonprofit organization Physician Unspecified
n 56 5 51 17 2 5 30 2
Mean 39.5 53.6 38.1 40.6 44.8 51.5 36.3 43.0
HONcode, Health On the Net Code; SEM, standard error of the mean.
SEM 1.36 2.91 1.32 2.74 1.77 3.09 1.57 8.98
Hip Arthroscopy Content Score Mean 8.6 8.8 8.5 7.5 11.5 10.4 8.6 8.5
SEM 0.55 0.80 0.59 1.04 2.47 0.58 0.79 2.47
QUALITY OF HIP ARTHROSCOPY ONLINE MATERIAL
Limitations This study has several limitations. A single reviewer assessed the HA-specific content score for each website, and 2 independent reviewers assessed the DISCERN score for each website. While there is subjectivity to these scoring systems, DISCERN has very high interoperator reliability, with a weighted kappa of 0.53 (95% confidence interval, 0.48 to 0.59).14 The 2 independent reviewers in this study confirmed this high interoperator reliability, with an average difference in DISCERN score of 3.64 (P ¼ .46). We also made assumptions that the best available information was included in the results of the popular search engines. While patients may generally review the first few sites after searching a given topic, we acknowledge that some high-quality websites may have been missed.27 Another limitation is that this study was done using the general search term “hip arthroscopy.” While many patients may use this general search term, others may use a more focused search term for their diagnosis such as “hip arthroscopy for labrum tear.” Additionally, the geographical location from which the search was conducted (Philadelphia, PA, U.S.A.) can affect results. Another limitation is the measurement of website quality using the HA-specific content score because it has not been validated for this purpose and scores sites only by the presence or absence of predetermined topics without verification of accuracy of the information provided. Additionally, this analysis was performed on one topic at one point in time and provides just a snapshot of the dynamic information available about HA on the Internet. It would be valuable to repeat the study in the future to assess trends in the quality of online patient information regarding HA.
Conclusions
Even though “hip arthroscopy” is a fairly general term, there is significant variability in the quality of HA information available online. Ideally, patients should be directed to websites that present well-balanced literature regarding arthroscopy of the hip. Although the HONcode seal indicates high-quality HA-specific websites, the code use is not common in HA literature and does not encompass all high-quality websites, thereby limiting its usefulness. While physician websites predominate the search results, governmental and NPO websites provide higher quality information. This has important implications as physicians may be more likely to direct patients to their own websites for information.
References 1. Internet usage statistics for all the Americas. Internet World Stats website. http://www.internetworldstats.com/ stats2.htm. Accessed September 27, 2015.
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2. Fox S. The social life of health information, 2011. http:// www.pewinternet.org/files/old-media//Files/Reports/2011/ PIP_Social_Life_of_Health_Info.pdf. Published May 12, 2011. Accessed September 27, 2015. 3. Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med 1999;49: 651-661. 4. Lee S, Shin JJ, Haro MS, Song SH, Nho SJ. Evaluating the quality of Internet information for femoroacetabular impingement. Arthroscopy 2014;30:1372-1379. 5. Duncan IC, Kane PW, Lawson KA, Cohen SB, Ciccotti MG, Dodson CC. Evaluation of information available on the Internet regarding anterior cruciate ligament reconstruction. Arthroscopy 2013;29:1101-1107. 6. Bruce-Brand RA, Baker JF, Byrne DP, Hogan NA, McCarthy T. Assessment of the quality and content of information on anterior cruciate ligament reconstruction on the Internet. Arthroscopy 2013;29:1095-1100. 7. Bozic KJ, Chan V, Valone FH, Feeley BT, Vail TP. Trends in hip arthroscopy utilization in the United States. J Arthroplasty 2013;28:140-143(8 Suppl). 8. Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy 2013;29:661-665. 9. Colvin AC, Harrast J, Harner C. Trends in hip arthroscopy. J Bone Joint Surg Am 2012;94:e23. 10. Kelly BT, Williams RJ, Philippon MJ. Hip arthroscopy: current indications, treatment options, and management issues. Am J Sports Med 2003;31:1020-1037. 11. Search engine market share. NetMarketShare website. https://www.netmarketshare.com/search-engine-marketshare.aspx?qprid¼4&qpcustomd¼0. Accessed September 25, 2015. 12. Starman JS, Gettys FK, Capo JA, Fleischli JE, Norton HJ, Karunakar MA. Quality and content of Internet-based information for ten common orthopaedic sports medicine diagnoses. J Bone Joint Surg Am 2010;92:1612-1618. 13. The DISCERN Instrument. http://www.discern.org.uk/ discern_instrument.php. Accessed September 28, 2015. 14. 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 Commun Health 1999;53:105-111. 15. Ademiluyi G, Rees CE, Sheard CE. Evaluating the reliability and validity of three tools to assess the quality of health information on the Internet. Patient Educ Couns 2003;50:151-155. 16. Goslin RA, Elhassan HA. Evaluating Internet health resources in ear, nose, and throat surgery. Laryngoscope 2013;123:1626-1631. 17. McCarthy JC, Lee J. Hip arthroscopy: indications, outcomes, and complications. Instr Course Lect 2006;55:301-308. 18. Kowalczuk M, Bhandari M, Farrokhyar F, et al. Complications following hip arthroscopy: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc Off J ESSKA 2013;21:1669-1675. 19. Our commitment to reliable health and medical information. Health On the Net Foundation website. http://www. hon.ch/HONcode/Patients/Visitor/visitor.html. Accessed September 26, 2015.
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20. Health information you can trust. Health On the Net Foundation website. http://www.hon.ch/HONtools/ Patients/Plugin/Plugins.html. Accessed September 27, 2015. 21. Eysenbach G, Powell J, Kuss O, Sa E-R. Empirical studies assessing the quality of health information for consumers on the World Wide Web: a systematic review. JAMA 2002;287:2691-2700. 22. Butler L, Foster NE. Back pain online: a cross-sectional survey of the quality of web-based information on low back pain. Spine 2003;28:395-401. 23. Fabricant PD, Dy CJ, Patel RM, Blanco JS, Doyle SM. Internet search term affects the quality and accuracy of online information about developmental hip dysplasia. J Pediatr Orthop 2013;33:361-365.
24. Rose S, Bruce J, Maffulli N. Accessing the Internet for patient information about orthopedics. JAMA 1998;280: 1309. 25. Nason GJ, Baker JF, Byrne DP, Noel J, Moore D, Kiely PJ. Scoliosis-specific information on the Internet: has the “information highway” led to better information provision? Spine 2012;37:E1364-E1369. 26. Nassiri M, Bruce-Brand RA, O’Neill F, Chenouri S, Curtin PT. Surfing for hip replacements: has the “Internet tidal wave” led to better quality information. J Arthroplasty 2014;29:1339-1344. 27. Eysenbach G, Köhler C. How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and in-depth interviews. BMJ 2002;324:573-577.
Purpose: The purpose of this study was to assess the quality of information available to patients on the Internet when using popular search engines to search the term “hip arthroscopy.” Methods: We analyzed the quality and content of information about hip arthroscopy (HA) on the first 50 websites returned by the search engines Google and Bing for the search term “hip arthroscopy.” The sites were categorized by type, and quality and content were measured using the DISCERN score, along with an HA-specific content score. The HA-specific content score was used to assess each website for the presence or absence of 19 topics about HA determined to be important for a patient seeking information about the procedure. The Health on the Net Code (HONcode) status of each website was also noted. Results: The mean DISCERN score for all websites analyzed was 39.5, considered “poor,” while only 44.6% of sites were considered “fair” or “good.” Governmental and nonprofit organization (NPO) websites had the highest average DISCERN score. The mean HA-specific content score was 8.6 (range, 2 to 16). The commercial website category had the highest average HA-specific content score, followed by the governmental and NPO category. Sites that bore the HONcode certification obtained significantly higher DISCERN scores than those without the certification (P ¼ .0032) but did not obtain significantly higher HA-specific content scores. Conclusions: “Hip arthroscopy” is a fairly general term, and there is significant variability in the quality of HA information available online. The HONcode is useful to identify quality patient information websites; however, it is not commonly used in HA-specific websites and does not encompass all quality websites about HA. Clinical Relevance: This study increases awareness of the quality of information on HA available online.
T
he Internet is a popular source for individuals to get health information. A staggering 86.9% of the U.S. population currently uses the Internet.1 Moreover, a telephone interview conducted in 2010 found that 80% of American Internet users have searched for health information online.2 Given the already huge number of people who obtain health information online, and the fact that this number will likely continue to grow, it is imperative that patients have access to high-quality and accurate health information online. This is especially important as shared decision-making between physicians and patients becomes more common3 in a consumer-oriented health care environment.
From the Perelman School of Medicine (B.E., H.P.) and the Department of Orthopaedic Surgery (A.F.K.), Center for Hip Preservation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 21, 2015; accepted March 11, 2016. Address correspondence to Atul F. Kamath, M.D., Department of Orthopaedic Surgery, University of Pennsylvania Hospital, 8th Floor Preston, Philadelphia, PA 19107, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 0749-8063/15977/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.03.019
While it is empowering for patients to have the ability to access an abundance of health information online, several studies have shown that the quality of health information available online is at best variable.4-6 The Internet is largely unregulated, and there is potential for patients to find inaccurate or misleading information about their health condition or treatment options. The first step to improving online health information is to determine the quality of the websites currently available. Hip arthroscopy (HA) is a minimally invasive procedure that has increased in popularity over the past decade.7-9 HA was first described by Burman in 1931 but did not become popular in the United States until recently owing to anatomical constraints of the hip that make arthroscopy more challenging than in the shoulder or knee.10 Additionally, the current indications for HA, including femoroacetabular impingement, have historically gone unrecognized until recently.10 As HA continues to grow in popularity, more patients may turn to the Internet for information about the indications, benefits, recovery, prognosis, and complications of HA. It is important that the information they find be both accurate and complete as the decision to
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Fig 1. Internet search flow diagram. The search term “hip arthroscopy” was entered into Google and Bing. The first 50 sites returned by both the Google and Bing queries were analyzed. News sites, blogs/forums, websites containing solely video, unrelated websites, and inaccessible, modular, or duplicate websites were excluded, leaving 56 unique sites for analysis.
proceed with an HA procedure is ultimately a shared one between the patient and the physician. The purpose of this study was to assess the quality of information available to patients on the Internet when using popular search engines to search the term “hip arthroscopy.” Our hypothesis was that heterogeneity exists with respect to the quality of information available to patients on the Internet about HA.
Methods
We used the search term “hip arthroscopy” in the 2 most popular global search engines as of August 2015: Google and Bing.11 All searches were performed on August 8, 2015. We analyzed the first 50 sites returned by both the Google and Bing queries. News sites, blogs/ forums, websites containing solely video, unrelated websites, inaccessible websites, and duplicate websites were excluded from analysis (Fig 1). Additionally, modular-type websites in which information about HA was contained in multiple different web pages, such as sites in which the indications for HA were described on a different page than the risks of the procedure, were excluded. First, websites were categorized by type, namely, academic, commercial, governmental and nonprofit organization (NPO), physician, and unspecified. These categories were based on those described in previous
works.6,12 Academic websites included those affiliated with a university or medical society. Websites were classified as commercial if they displayed advertisements or sold products. Governmental and NPO websites included those operating from government funding or donations only. Physician websites included both individual physician websites and physician groups not affiliated with an academic institution. Unspecified websites were those that did not fit into a preceding category, such as the Wikipedia page about HA. Websites were assessed for quality and content using the DISCERN instrument,13 as well as an HA-specific content score (Table 1). All websites were assessed within 1 month of the original search. The independent reviewers were medical students with familiarity in web search engines and trained in the above methodology. All results, including search term identification and tabulation of scores, were verified by an attending orthopaedic surgeon experienced in HA. A separate DISCERN score was determined by 2 independent reviewers for each website owing to the more subjective nature of the DISCERN score compared with the HAspecific content score. The scores were then averaged to determine the particular website’s final DISCERN score. DISCERN is a 16-question survey designed to assist health care professionals and patients in assessing the quality of information about treatment choices for a given health problem. DISCERN was created as part of a British national project to establish quality thresholds for consumer health information.13 It is simple to use, Table 1. Hip ArthroscopyeSpecific Content Score Components Does the Site Contain Information About? General aspects: Indications for hip arthroscopy What is hip arthroscopy? Benefits of hip arthroscopy Preoperative assessment Anesthesia Outpatient procedure Expected activities postoperatively Rehabilitation Potential need for total hip replacement in future Management Surgical alternatives: observation and analgesia Surgical alternative: physical therapy Surgical technique (approach) Complications Blood clot/venous thromboembolic disease Infection Nerve palsy Traction-related changes Chronic pain Avascular necrosis of the femoral head Fracture, intraoperative or postoperative Total score (out of 19)
Points 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
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QUALITY OF HIP ARTHROSCOPY ONLINE MATERIAL
and it has been shown to have high interobserver reliability and construct validity when used by either medical professionals or patients.14,15 The DISCERN instrument is summarized in Table 2. The maximum DISCERN score for a given publication is 80, as each question is rated on a 5-point scale. Websites are then classified by their total score as “excellent” (68 to 80), “good” (55 to 67), “fair” (42 to 54), “poor” (29 to 41), or “very poor” (16 to 28), as described elsewhere.16 An HA-specific content score was created in consultation with an orthopaedic surgeon trained in HA and after referencing peer-reviewed literature on HA.10,17,18 This score consists of 19 topics about HA determined to be important for a patient seeking information about the procedure. These topics fall into the categories of general aspects about the procedure, management, and complications. One point was allocated by a single independent reviewer for each of the predefined topics (Table 1), with a maximum score of 19 and a minimum score of 0. A site in which none of the predefined topics were discussed received a score of zero, while a site in which each of the predefined topics were discussed received a score of 19. Websites that discussed some, but not all, of the predefined topics received an intermediary score between 0 and 19 based on the number of topics that were discussed. The websites were also assessed for the Health on the Net Code (HONcode) certification. The Health on the Net (HON) Foundation was established in 1995 as a nonprofit, nongovernmental organization with a mission of improving the quality of online patient health information.19 The HON Foundation accredits
websites based on 8 ethical principles. Certified websites must agree to HON standards and are subject to random audits for compliance. The HONcode status was assessed by downloading a free HONcode plug-in that displays accreditation status for each website visited in the browser toolbar.20 The mean scores and standard error of the mean (SEM) for the quality and content scores were calculated for each website category. Statistical analysis was performed using Microsoft Excel (Microsoft Corp., Redmond, WA, U.S.A.). Regression analysis was performed to determine whether website type and HONcode certification predicted higher DISCERN and HA-specific content scores. Statistical significance was set at P < .05.
Results A total of 56 unique websites were included in the study and analyzed (Table 3). Figure 2 shows the breakdown of website by type of organization sponsoring the online material. The majority (53.6%) of websites were physician sponsored. Only 5 of the websites were HONcode certified (8.9%). Figure 3 illustrates the mean overall scores by website type, and Table 4 lists the values. The mean DISCERN score of 39.5 for all websites analyzed was “poor” but was highly variable (SEM ¼ 1.36; range, 21.5 to 59). The majority (55.4%) of websites were categorized as being of “poor” or “very poor” quality, while only 44.6% earned scores high enough to be considered “fair” or “good.” The 2 highest scoring websites were governmental and NPO sites, and both were HONcode certified. The 5 websites that were HONcode certified obtained significantly higher
Table 2. DISCERN Instrument Score Section 1: Is the publication reliable? 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? Section 2: How good is the quality of information on treatment choices? Does it describe how each treatment works? Does it describe the benefits of each treatment? Does it describe the risks of each treatment? 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? Section 3: Overall rating of the publication. Based on the answers to all of the above questions, rate the overall quality of the publication as a source of information about treatment choices Total score (out of 80)
1 (no)-5 (yes)
1 (low)-5 (high)
NOTE. General instructions for the use of the DISCERN Instrument are available at http://www.discern.org.uk/general_instructions.php.
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Table 3. List of Unique Websites Analyzed Through Search Criteria Search Engine Google
Result Number 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
Bing
29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56
NOTE. Date of search: August 8, 2015.
Website http://orthoinfo.aaos.org/topic.cfm?topic¼A00572 https://en.wikipedia.org/wiki/Hip_arthroscopy http://www.nlm.nih.gov/medlineplus/ency/article/007500.htm http://www.cfosm.com/services-specialties/hip-arthroscopy-falls-church-virginia-va.php http://www.uwhealth.org/files/uwhealth/docs/pdf2/Rehab_Hip_Arthroscopy.pdf http://www.yoummd.com/hip-arthroscopy-thomas-youm.html http://www.nirschl.com/questions-to-ask-prior-to-hip-arthroscopic-surgery.asp http://www.emoryhealthcare.org/orthopaedics/procedures/hip-care/hip-arthroscopy.html http://orthopedics.about.com/od/hipinjuries/a/hiparthroscopy.htm http://www.advancedortho.net/pages/procedures/hipscope.htm http://www.rothmaninstitute.com/specialties/treatments/hip-arthroscopy http://www.bjr.boneandjoint.org.uk/content/1/7/131.full http://www.thecoreinstitute.com/patient-and-visitor-information/core-patient-education/ hip/hip-arthroscopy.html http://www.mainlineorthopaedics.com/files/hip-arthroscopy-instructions.pdf http://www.portlandhiparthroscopy.com/ http://www.hiparthroscopy-ireland.com/ http://www.arthroscopichipsurgeon.com/hip-arthroscopy.html http://www.em-consulte.com/en/article/272073 http://columbushiparthroscopy.com/ http://www.rushortho.com/hip-arthroscopy.cfm http://www.sciencedirect.com/science/article/pii/S2255497114000998 http://www.hiparthroscopyaustralia.com.au/ http://www.hiparthroscopydoctor.com/ https://patienteducation.osumc.edu/Documents/PTHipPh1-2.pdf http://www.orthosports.com.au/content_common/pg-hip-arthroscopy.seo http://www.clohisyhipsurgeon.com/treatment-options/hip-arthroscopy http://www.southcountyhealth.org/Services/OrthopedicsCenter/HipSurgery/ HipArthroscopy.aspx http://www.ohsu.edu/xd/health/services/ortho/getting-treatment/services/hip-services/ treatment/hip-arthroscopy.cfm http://www.hiparthroscopyutah.com/ http://www.osaliortho.com/hip.php http://www.northtownsorthopedics.com/arthroscopic-hip-surgery/ http://www.oregonortho.com/hip-arthroscopy.php http://www.villarbajwa.com/hip-arthroscopy.shtml http://www.hss.edu/conditions_femoroacetabular-impingement-a-patient-guide-to-hipmobility-and-hip-arthroscopy.asp http://bonesmart.org/hip/hip-arthroscopy/ http://www.chop.edu/treatments/hip-arthroscopy#.VcZ7vPm-1cY http://www.hiphelp.com/pages/arthro.html http://www.aaos.org/news/aaosnow/aug11/clinical5.asp https://xnet.kp.org/misg/procedures/arth_hip.html http://www.bch.org/hip-orthopedic-treatment/hip-arthroscopy-surgery.aspx http://advancedorthosports.com/hip-arthroscopy/ http://www.nhs.uk/Conditions/Arthroscopy/Pages/Introduction.aspx http://www.orthobullets.com/sports/3100/hip-arthroscopy http://www.wakehealth.edu/Orthopaedic-Services/Hip-Arthroscopy.htm http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3293959/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3353094/ http://www.ohsu.edu/xd/health/services/ortho/getting-treatment/services/sportsmedicine-clinic/treatment/hip-arthroscopy.cfm http://www.browardhealth.org/hiparthroscopy http://www.johnodonnell.com.au/FAQ.pdf http://phoenixhiparthroscopy.com/ http://umm.edu/health/medical/ency/articles/hip-arthroscopy http://www.sharp.com/ortho/minimally-invasive-hip-surgery.cfm http://www.spirehealthcare.com/our-treatments/body-map-and-a-z/a-z-treatments/hiparthroscopy-/ http://www.aaos.org/news/aaosnow/aug13/clinical4.asp http://www.hiparthroscopy-ireland.com/hiparthroscopy.html http://www.tulsaorthopaedicsurgeon.com/hip-arthroscopy.html
QUALITY OF HIP ARTHROSCOPY ONLINE MATERIAL
2 Academic
17
Commercial Government & NPO 30
2 5
Physician Unspecified
Fig 2. Distribution of websites by type of organization sponsoring the online material. A total of 56 unique websites were included in the study and analyzed. The majority of websites were physician sponsored (53.6%), followed by academic (30.4%), government and nonprofit organization (NPO) (8.9%), commercial (3.6%), and unspecified (3.6%).
DISCERN scores than those that were not certified (53.6 v 38.1; P ¼ .0032). The physician website category had the lowest mean DISCERN score of 36.3, which was significantly lower than both the government and NPO (51.5; P ¼ .004) and commercial categories (44.75; P ¼ .033). The academic category had a mean DISCERN score of 40.6, which was significantly lower than the government and NPO category (P ¼ .023). The mean HA-specific content score was 8.6 (SEM ¼ 0.55; range, 2 to 16). The highest score was an academic website that was not HONcode certified. The HONcode-certified websites did not obtain significantly higher HA-specific content scores than those that were not certified (8.8 v 8.5; P ¼ .79). Twenty-nine websites (51.7%) scored 9 or lower points, while 27 websites (48.2%) scored 10 or higher points. The commercial website category had the highest mean HA-specific content score of 11.5, but this value was not significantly higher than any of the other categories. The governmental and NPO category had the second highest mean HA-specific content score of 10.4, which was significantly higher than that of the academic category (7.5; P ¼ .028).
Discussion There is significant variability in the quality of HA information available online, with 55.4% being of “poor” or “very poor” quality; however, there are also several sources of high-quality information. The Internet has evolved into a major source of patient health information, as both the number of Internet users and percentage of those users searching for health information online has increased in the last decade.1,2 While the increase in availability of information is important for patients to make informed decisions regarding their health, the unregulated nature of the
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Internet raises concerns about the quality and content of information obtained online. According to a systematic review, information quality was an issue in 70% of studies assessing the quality of online health information.21 Within the orthopaedic literature, the quality of online information has also been shown to be variable.22-24 It is important that patients have access to high-quality and complete information to make well-informed health care decisions. Our findings indicate that the quality of online information regarding HA is highly variable. The mean DISCERN score for the websites analyzed was “poor.” In examining the DISCERN question-specific responses, we found that several questions consistently scored poorly. First, websites often did not specify the aim of the online content or the intended reader. Only 1 physician website included an introductory paragraph specifying the intended audience, purpose, and limits of the content material. Second, the majority of websites did not cite sources or offer unaffiliated reference materials to direct the patient to additional information. Lastly, websites often did not display the date of publication or date of last content update. The mean HA-specific content score for the websites analyzed was 8.6 (SEM ¼ 0.55). Like the DISCERN question-specific responses, we found that websites commonly missed several predefined points. First, only 61% of websites mentioned at least 1 complication of HA. Additionally, websites did not commonly mention alternative or nonoperative management, including observation, oral and/or injection analgesia, and physical therapy. The omission of these important points represents serious shortcomings in website quality and completeness and may introduce bias in the patientphysician interaction. Our study findings differed from previous studies examining the quality of online arthroscopic materials in several ways. First, unlike previous studies, we did not find that academic institution-created websites provided better information quality.25 Moreover, we found that commercial websites obtained the highest, albeit nonsignificant, HA-specific content scores. This may be a result of the small number of commercial sites identified in the search engine queries. Additionally, we found that physician and physician group websites predominated the HA literature, whereas other studies of knee-specific content have found that commercial websites predominated.6,26 This finding represents a unique opportunity for individual physicians to improve their web pages and thereby improve the quality of patient information. Another difference between this study and others of its kind is the usefulness of the HONcode.6,26 While HONcode-certified websites did obtain significantly higher DISCERN scores when compared with
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Fig 3. Quality and content scores of websites by organizational type. The physician website category had the lowest mean DISCERN score of 36.3, which was significantly lower than both the government and NPO (51.5; P ¼ .004) and commercial categories (44.75; P ¼ .033). The academic category had a mean DISCERN score of 40.6, which was significantly lower than the government and NPO category (P ¼ .023). The commercial website category had the highest mean HA-specific content score of 11.5, but this value was not significantly higher than any of the other categories. The governmental and NPO category had the second highest mean HA-specific content score of 10.4, which was significantly higher than that of the academic category (7.5; P ¼ .028). (HA, hip arthroscopy; NPO, nonprofit organization.)
nonaccredited websites in our study, these accredited sites did not obtain significantly higher HA-specific content scores. Additionally, only 5 websites (8.9%) were HONcode accredited, and of those, none displayed the HONcode seal on their website. Therefore, in order to determine a website’s HONcode accreditation status, a patient (or provider) would need to
download a special toolbar plug-in from the HON Foundation website. While this is not unreasonable, the average patient is unlikely to download this plugin. Moreover, some high-quality websites were not HONcode certified, which may limit the usefulness of the HONcode accreditation status in HA-specific literature.
Table 4. Summary of Website Scores DISCERN Score Site Type Overall HONcode (present) HONcode (absent) Academic Commercial Governmental and nonprofit organization Physician Unspecified
n 56 5 51 17 2 5 30 2
Mean 39.5 53.6 38.1 40.6 44.8 51.5 36.3 43.0
HONcode, Health On the Net Code; SEM, standard error of the mean.
SEM 1.36 2.91 1.32 2.74 1.77 3.09 1.57 8.98
Hip Arthroscopy Content Score Mean 8.6 8.8 8.5 7.5 11.5 10.4 8.6 8.5
SEM 0.55 0.80 0.59 1.04 2.47 0.58 0.79 2.47
QUALITY OF HIP ARTHROSCOPY ONLINE MATERIAL
Limitations This study has several limitations. A single reviewer assessed the HA-specific content score for each website, and 2 independent reviewers assessed the DISCERN score for each website. While there is subjectivity to these scoring systems, DISCERN has very high interoperator reliability, with a weighted kappa of 0.53 (95% confidence interval, 0.48 to 0.59).14 The 2 independent reviewers in this study confirmed this high interoperator reliability, with an average difference in DISCERN score of 3.64 (P ¼ .46). We also made assumptions that the best available information was included in the results of the popular search engines. While patients may generally review the first few sites after searching a given topic, we acknowledge that some high-quality websites may have been missed.27 Another limitation is that this study was done using the general search term “hip arthroscopy.” While many patients may use this general search term, others may use a more focused search term for their diagnosis such as “hip arthroscopy for labrum tear.” Additionally, the geographical location from which the search was conducted (Philadelphia, PA, U.S.A.) can affect results. Another limitation is the measurement of website quality using the HA-specific content score because it has not been validated for this purpose and scores sites only by the presence or absence of predetermined topics without verification of accuracy of the information provided. Additionally, this analysis was performed on one topic at one point in time and provides just a snapshot of the dynamic information available about HA on the Internet. It would be valuable to repeat the study in the future to assess trends in the quality of online patient information regarding HA.
Conclusions
Even though “hip arthroscopy” is a fairly general term, there is significant variability in the quality of HA information available online. Ideally, patients should be directed to websites that present well-balanced literature regarding arthroscopy of the hip. Although the HONcode seal indicates high-quality HA-specific websites, the code use is not common in HA literature and does not encompass all high-quality websites, thereby limiting its usefulness. While physician websites predominate the search results, governmental and NPO websites provide higher quality information. This has important implications as physicians may be more likely to direct patients to their own websites for information.
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