- Email: [email protected]
Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears
J Shoulder Elbow Surg (2015) 24, e135-e140
www.elsevier.com/locate/ymse
Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears David M. Dalton, MB MCh BAO, MRCS*, Enda G. Kelly, MB MCh BAO, MRCS, Diarmuid C. Molony, MB MCh BAO, FRCS (Tr&Orth) Department of Orthopaedic Surgery, Waterford University Hospital, Ardkeen, Waterford, Ireland Background: In the era of informed patient decision-making, educated patients are vital contributors. The Internet provides a vast information source that patients will access. It is imperative that this information be relevant and understandable. Various treatments, each with advantages and disadvantages, are available. We sought to examine the standard of information about the diagnosis and management of rotator cuff tears available to patients on the Internet. Methods: We identified 125 websites from searching ‘‘rotator cuff tear’’ in the 5 most popular Internet search engines. The websites were examined for readability by measuring the Flesch Reading Ease Score, the Flesch-Kincaid Grade Level, and the Gunning Fog Index. The quality of the websites was measured by the DISCERN instrument, the Journal of the American Medical Association benchmark criteria, and Health on the Net Foundation certification. Results: There were 59 individual URLs analyzed. Overall, the quality was poor, with the average DISCERN score being only 39.47. Furthermore, the mean reading grade level was above 9 (recommended level, 6). Health on the Net Foundation certification did correspond to significantly worse readability scores (P ¼ .004) but did not correlate with improved DISCERN scores. Those that satisfied more of the Journal of the American Medical Association benchmark criteria had significantly better DISCERN scores (P <.001). Conclusion: Information about rotator cuff tears is of a low standard and is in many cases written at too high a level for the general population. There are instruments of which we, as surgeons, must be aware to evaluate the resources available and to recommend them to patients to ensure that they understand their condition and treatment options. Level of evidence: Education Methodology Study, Survey of MaterialsdInternet. Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Rotator cuff; patient information; education; DISCERN; Internet; readability; JAMA; HONcode
IRB approval was not required as no patient records, information, or hospital resources were used during the study.
*Reprint requests: David M. Dalton, MB MCh BAO, MRCS, Department of Orthopaedic Surgery, Waterford Regional Hospital, Ardkeen, Waterford, Ireland. E-mail address: [email protected] (D.M. Dalton).
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.09.036
e136 Shoulder diseases, and specifically rotator cuff tears, require appropriate and individualized investigation and treatment as decided by the patient and the patient’s physician. In the past, the decision would be led by the expertise of the physician, but we are entering an era of joint decision-making and the educated patient. Much of this education will come from the Internet. The Internet has revolutionized society. In particular, it has revolutionized knowledge acquisition. In 2012, 81% of the population were regular Internet users compared with just 48% in 2000.22 Furthermore, in a large survey, 72% of respondents had used the Internet to research a health-related issue in the previous 12 months.23 The quality of information available in these studies is variable and can often be biased24 or misleading. It is frequently beyond the technical expertise of the patient, leading to confusion.2,15 As the Internet is a nonregulated resource, it is difficult to control what information people access. Search engines remain a popular means of gathering information from the Internet, and 91% of Internet users regularly use search engines.22 Shoulder pain is a common cause of presentation to medical services, with more than 4.5 million patient visits per year in the United States.17 Cadaveric studies have demonstrated that 39% of the population older than 60 years have full-thickness rotator cuff tears.3 Risk factors for the development of rotator cuff tears are repetitive overhead activity (usually occupational or sports related), aging, and the poor blood supply to the cuff insertion, making healing unusual.16,25,31 Treatment must be tailored to the patient and the specific injury. The optimal treatment is still debatable, and a Cochrane review on the topic did not come to any definitive conclusions regarding optimal treatment.7 In the case of large acute traumatic tears in young people, the literature favors early surgical treatment, ideally within the first 3 weeks.1 Lag time between tear and surgery can result in muscle atrophy, fatty necrosis, tendon retraction, increase in the size of the tear, and poor operative outcomes.19 In cases of chronic tears, there does not appear to be a clear consensus on how to manage these patients. In symptomatic atraumatic tears, a 6-week to 3-month trial of conservative treatment is reasonable before surgical intervention. Treatment plans tailored to physiologic age, acromiohumeral distance, and muscle strength may lead to improved outcomes.13,28,31 Preoperatively, those who are in employment, older, and married and those who have higher expectations were more likely to be satisfied with their surgical outcome. Postoperatively, decreased pain, improved function, quality of life, shoulder outcome score, and Simple Shoulder Test scores correlate with improved overall patient satisfaction. The size of tear and duration of symptoms have no relationship with patient satisfaction.29 Whereas the literature would suggest improvement in most parameters with cuff repair, this does not always correlate with patient expectation. Our study investigates the quality of information available to patients with rotator
D.M. Dalton et al. cuff tears. We seek to evaluate this information to determine whether patients are receiving accurate and unbiased information. We also seek to identify those characteristics of websites that may signal that they are of high quality.
Materials and methods The top 5 Internet search engines were identified.22 Google is the dominant search engine, with 83% of Internet users surveyed listing it as their most frequently used search engine. Yahoo!, BING, AOL, and Ask are distant followers. The term ‘‘rotator cuff tear’’ was searched; in each case, the top 25 results were included in line with previous similar studies.8,21 All unique URLs were analyzed, and inaccessible websites, those that were primarily nonreadable (e.g., YouTube), and URLs that were subsections of previously analyzed websites were excluded. The authorship of the article was judged by 2 authors (D.D. and E.K). It was classified as physician, academic, commercial, medicolegal, allied health professional, or forum/social media. The readability scores recorded were the Flesch Reading Ease Score (FRES), the Flesch-Kincaid Grade Level (FKGL), and the Gunning Fog Index (GFI). They were calculated with an online tool, read-able.com, that automatically calculates these scores after inputting the website’s URL. The FRES score is 0 (easiest) to 100 (most difficult) and is calculated by the following formula: 206.8351.015 (total words/total sentences)84.6 (total syllables/ total words).14 The FKGL is used as a marker of the U.S. reading grade level and is calculated by the following formula: 0.39 (total words/total sentences) þ 11.8 (total syllables/total words)15.59.9 The GFI estimates the number of years of formal education required to read a passage of text and is calculated by the following formula: 0.4 [(words/sentences) þ 100 (complex words/words)].10 The DISCERN instrument was funded by The British Library and the National Health Service (NHS) Research and Development Programme and produced by an expert panel in the United Kingdom consisting of clinical specialists (physicians), self-help groups, general practitioners, a consumer health expert, a lay medical publisher, a health journalist, a health consumer, a Community Health Council representative, a Plain English Campaign representative, and an NHS Centre for Reviews and Dissemination representative. The aim of the instrument was to help health consumers and information providers assess the quality of written information about treatment choices for a health problem.6 It consists of 15 questions and an overall quality rating. The overall score is 16 to 80, with higher scores representing a higher quality site. The DISCERN instrument includes sections assessing website bias, benefits of each treatment, risks of each treatment, information on alternative treatments, relevance, areas of uncertainty, and overall quality.6 This instrument allowed us to use specialist knowledge in assessing the quality of the websites while simultaneously remaining objective. The Journal of the American Medical Association (JAMA) benchmark criteria award a point for clear presentation of 4 elements on the sitedauthorship, source, date of last update, and disclosures of ownership/sponsorship/conflicts of interest.26 The JAMA benchmark criteria and authorship were established by the authors D.D. and E.K. The Health on the Net Foundation (HON) is a nonprofit organization accredited to the United Nations established to protect
Internet information regarding rotator cuff tears the public from misleading medical information.4 It awards websites that meet their standard of quality HONcode certification. All URLs were entered on their website to establish whether they were HONcode certified. Statistics were calculated on Minitab 17 (Minitab Inc., State College, PA, USA). Significance was established as a P value < .05. Two-sample t test and Pearson correlation value were used to establish relationships.
Results The term ‘‘rotator cuff tear’’ returned 1,010,000 results in 0.22 second on Google. We excluded sponsored/advertised links. There were 66 unique URLs identified; 59 websites were individually analyzed. Two websites were excluded for requiring registration as a member. Two websites were purely indexes and links to papers/other sites. Two websites were purely video based, and one individual URL was inaccessible. There were 21 websites that had a physician/surgeon as the primary author. Other authors included allied health professionals (physiotherapists/physical therapists, osteopaths; n ¼ 7) and insurance providers (n ¼ 2). The author was not clearly stated in 31 websites. Fifteen websites were HONcode certified. The readability average U.S. equivalent grade level was 9.19. The average FRES, FKGL, and GFI scores were 51.24 (11.42), 8.10 (1.74), and 9.02 (2.34), respectively. The average DISCERN score was 39.47 (11.39), and the average JAMA benchmark criteria score was 1.72. There was no significant difference in the DISCERN score between websites written by physicians and those produced by nonphysicians/those in which the author was not stated (P ¼ .576) (Fig. 1). Similarly, HON certification did not result in better DISCERN scores (P ¼ .791). There was no significant difference in the FRES between websites written by physicians and those produced by nonphysicians/those in which the author was not stated (P ¼ .839) (Fig. 2). HON-certified websites were significantly more difficult to read (P ¼ .004). The DISCERN score was only weakly correlated with the FRES, FKGL, and GFI (Pearson correlation values of 0.177, 0.166, and 0.027, respectively) (Fig. 3) but did correlate with JAMA criteria (Pearson value, 0.483; P < .001).
Discussion As we enter an era of shared decision-making in medicine, it is vital that patients be well informed to ensure that they are fully aware of the available treatments and the associated risks and benefits. Misunderstandings between patients and physicians on invasive treatments have been well documented.12,20 This is hardly surprising, given that patients about to undergo a procedure or who have received a new diagnosis would be under considerable stress. Improving patient resources implicitly improves patient
e137 knowledge. This has been done with pamphlets and other communication resources in the past with moderate success.18,27 The Internet is a cornucopia of patient information; the problem lies in the heterogeneity and sometimes questionable reliability of this information. Unfortunately, the quality of these websites is such that they may give misleading, biased, or incomprehensible information to patients, increasing the risk of their choosing incorrect treatment advice for their particular needs. Communicating with patients who have come across incorrect information can be difficult. Patients may not see why they should trust you over whatever advice they received on the Internet. We use objective evidence to demonstrate the facts to the patients and to guide them to what we consider to be the correct choice of treatment based on available data. Biased and incorrect information could also lead patients to believe that they were somehow treated incorrectly and may fracture the physician-patient relationship. The readability scores are calculated on the basis of word count, sentence length, and number of syllables. The scientific nature of medical content means that it may be difficult to rank the readability accurately. The fact that readability did not correlate closely with the DISCERN score demonstrates that the complexity of information does not necessarily have to be reproduced in a manner that is difficult to read. Unfortunately, the websites that were HON certified were significantly more difficult to read. This is something that must be addressed for the HON initiative to be effective and useful for patients. There is an obvious need for improvement in the quality of the information the patients are accessing. Because of the very nature of the Internet, we cannot control what is published, but we can direct patients to the best sources. Because of biases, financial or preferential, we need a system of customer guarantee. The HON initiative is certainly a positive development, but not enough physicians, patients, or web designers are aware of it for it to be effective. Physicians, allied health professionals, and government departments of health should be directing patients toward these type of resources. Our study contradicts other studies that have found significant relationships between the HON certification and authorship of the website and the DISCERN score.5,21 O’Neill et al21 studied the information available to patients about cauda equina on the Internet. They found that websites with a physician as author had significantly better DISCERN and JAMA benchmark criteria and were more likely to be HON certified compared with websites with other authors. The DISCERN scores of the websites included in this study were much higher than in a study done on websites recommended by U.K. NHS consultants that provide information on adolescent idiopathic scoliosis. In that particular study, only 7 websites were analyzed, with the maximum DISCERN score being a meager 49, and only 1
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D.M. Dalton et al.
Figure 1
Figure 2
Distribution of DISCERN score by authorship.
Distribution of Flesch Reading Ease Score by authorship.
website was HON certified.30 This emphasizes the point that clinicians should objectively analyze sources of information before recommending them to patients. Our data support studies showing that most information collected on the Internet is pitched above the recommended sixth-grade level.32 The principles to which websites should adhere to gain HON certification are stated as Authoritative, Complementarity, Privacy, Attribution, Justifiability, Transparency, Financial Disclosure, and Advertising Policy.11 In our study, the websites that have HON certification did not have
significantly higher DISCERN scores. The reason for this is not clear, and although the DISCERN scores are somewhat subjective, there is a transparency lacking in the HON certification system. To have effective and unbiased quality control, all HON evaluations should be published. It is possible that some high-quality websites are not submitted for evaluation. Our study has limitations. Nonreadable information was not included in the study, and more and more patients are going to be using these multimedia instruments to educate themselves on medical matters. Also, there are many
Internet information regarding rotator cuff tears
Figure 3
e139
Correlation of DISCERN score to Flesch Reading Ease Score.
websites that have interactive or multimedia components to them. These may be educational to the patients but do not come under the remit of the DISCERN instrument and so may underscore on it.
Conclusion The quality of available information on rotator cuff tears is poor. The readability of information on rotator cuff disease is inappropriately high. We recommend that physicians take a more active role in creating and assessing patient information websites. This could lead to improved patient satisfaction and more effective physician-patient interactions. We also suggest that the assessing tools should have a readability element included in them.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Acknowledgment Of Aileen O’Shea for her editing of our text.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jse.2014.09.036
References 1. Bassett RW, Cofield RH. Acute tears of the rotator cuff. The timing of surgical repair. Clin Orthop Relat Res 1983:18-24. 2. Beredjiklian PK, Bozentka DJ, Steinberg DR, Bernstein J. Evaluating the source and content of orthopaedic information on the Internet. The case of carpal tunnel syndrome. J Bone Joint Surg Am 2000;82:1540-3. 3. Bigliani LU, Morrison DS, April EW. The morphology of the acromion and its relationship to rotator cuff tears. Orthop Trans 1986;10:288. 4. Boyer C, Selby M, Appel RD. The Health On the Net Code of Conduct for medical and health web sites. Stud Health Technol Inform 1998;52(Pt 2):1163-6. 5. 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: 1095-100. http://dx.doi.org/10.1016/j.arthro.2013.02.007 6. Charnock D, Shepperd S, Needham G, Gann R. DISCERN: an instrument for judging the quality of written consumer health information on treatment choices. J Epidemiol Community Health 1999;53:105-11. 7. Ejnisman B, Andreoli CV, Soares BGO, Fallopa F, Peccin MS, Abdalla RJ, et al. Interventions for tears of the rotator cuff in adults. Cochrane Database Syst Rev 2004;1:CD002758. http://dx.doi.org/10. 1002/14651858.CD002758.pub2 8. Fast AM, Deibert CM, Hruby GW, Glassberg KI. Evaluating the quality of Internet health resources in pediatric urology. J Pediatr Urol 2013;9:151-6. http://dx.doi.org/10.1016/j.jpurol.2012.01.004 9. Flesch R. A new readability yardstick. J Appl Psychol 1948;32:221-33. 10. Gunning R. Technique of clear writing. New York: McGraw-Hill; 1952. p. 36-7. 11. Health On the Net Foundation. HONcode: principlesdquality and trustworthy health information [Internet]. Available at: http://www. hon.ch/HONcode/Pro/Conduct.html. Accessed March 28, 2014.
e140 12. Kadakia RJ, Tsahakis JM, Issar NM, Archer KR, Jahangir AA, Sethi MK, et al. Health literacy in an orthopedic trauma patient population: a cross-sectional survey of patient comprehension. J Orthop Trauma 2013;27:467-71. http://dx.doi.org/10.1097/BOT. 0b013e3182793338 13. Kijima H, Minagawa H, Nishi T, Kikuchi K, Shimada Y. Long-term follow-up of cases of rotator cuff tear treated conservatively. J Shoulder Elbow Surg 2012;21:491-4. http://dx.doi.org/10.1016/j.jse. 2011.10.012 14. Kincaid JP, Fishburne RP Jr, Rogers RL, Chissom BS. Derivation of new readability formulas (Automated Readability Index, Fog Count and Flesch Reading Ease Formula) for Navy enlisted personnel. Available at: http://oai.dtic.mil/oai/oai?verb¼getRecord&metadataPrefix¼html& identifier¼ADA006655; February 1975 Accessed March 28, 2014. 15. Kumar VS, Subramani S, Veerapan S, Khan SA. Evaluation of online health information on clubfoot using the DISCERN tool. J Pediatr Orthop B 2014;23:135-8. http://dx.doi.org/10.1097/BPB. 0000000000000000 16. Matava MJ, Purcell DB, Rudzki JR. Partial-thickness rotator cuff tears. Am J Sports Med 2005;33:1405-17. http://dx.doi.org/10.1177/ 0363546505280213 17. Mather RC, Koenig L, Acevedo D, Dall TM, Gallo P, Romeo A, et al. The societal and economic value of rotator cuff repair. J Bone Joint Surg Am 2013;95:1993-2000. http://dx.doi.org/10.2106/JBJS.L.01495 18. Mayich DJ, Tieszer C, Lawendy A, McCormick W, Sanders D. Role of patient information handouts following operative treatment of ankle fractures: a prospective randomized study. Foot Ankle Int 2013;34:2-7. http://dx.doi.org/10.1177/1071100712460229 19. MOON Shoulder Group, Unruh KP, Kuhn JE, Sanders R, An Q, Baumgarten KM, et al. The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a crosssectional study of patients with atraumatic, full-thickness rotator cuff tears. J Shoulder Elbow Surg 2014;23:1052-8. http://dx.doi.org/10. 1016/j.jse.2013.10.001 20. Murphy SM, Donnelly M, Fitzgerald T, Tanner WA, Keane FB, Tierney S. Patients’ recall of clinical information following laparoscopy for acute abdominal pain. Br J Surg 2004;91:485-8. http://dx.doi. org/10.1002/bjs.4460 21. O’Neill SC, Baker JF, Fitzgerald C, Fleming C, Rowan F, Byrne D, et al. Cauda equina syndrome: assessing the readability and quality of patient information on the internet. Spine (Phila Pa 1976) 2014;39: E645-9. http://dx.doi.org/10.1097/BRS.0000000000000282
D.M. Dalton et al. 22. Pew Research Center. Search engine use 2012 j Pew Research Center’s Internet & American Life Project [Internet]. Available at: http://www.pewinternet.org/files/old-media/Files/Reports/2012/PIP_ Search_Engine_Use_2012.pdf. Accessed March 28, 2014. 23. Pew Research Center. Pew Research Internet Project: health fact sheet [Internet]. 2014. Available at: http://www.pewinternet.org/fact-sheets/ health-fact-sheet/. Accessed March 28, 2014. 24. Sadowski DJ, Ellimoottil CS, Tejwani A, Gorbonos A. Proton therapy for prostate cancer online: patient education or marketing? Can J Urol 2013;20:7015-20. 25. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10-5. 26. Silberg WM, Lundberg GD, Musacchio RA. Assessing, controlling, and assuring the quality of medical information on the Internet: caveant lector et viewordlet the reader and viewer beware. JAMA 1997; 277:1244-5. 27. Simmons SA, Sharp B, Fowler J, Singal B. Implementation of a novel communication tool and its effect on patient comprehension of care and satisfaction. Emerg Med J 2013;30:363-70. http://dx.doi.org/10. 1136/emermed-2011-200907 28. Slabaugh MA, Nho SJ, Grumet RC, Wilson JB, Seroyer ST, Frank RM, et al. Does the literature confirm superior clinical results in radiographically healed rotator cuffs after rotator cuff repair? Arthroscopy 2010;26:393-403. http://dx.doi.org/10.1016/j.arthro. 2009.07.023 29. Tashjian RZ, Bradley MP, Tocci S, Rey J, Henn RF, Green A. Factors influencing patient satisfaction after rotator cuff repair. J Shoulder Elbow Surg 2007;16:752-8. http://dx.doi.org/10.1016/j.jse.2007.02.136 30. Wellburn S, Bettany-Saltikov J, van Schaik P. An evaluation of web sites recommended by UK NHS consultants to patients with adolescent idiopathic scoliosis at the first point of diagnosis. Spine (Phila Pa 1976) 2013;38:1590-4. http://dx.doi.org/10.1097/BRS. 0b013e31829965bc 31. Wolf BR, Dunn WR, Wright RW. Indications for repair of fullthickness rotator cuff tears. Am J Sports Med 2007;35:1007-16. http://dx.doi.org/10.1177/0363546506295079 32. Yi PH, Ganta A, Hussein KI, Frank RM, Jawa A. Readability of arthroscopy-related patient education materials from the American Academy of Orthopaedic Surgeons and Arthroscopy Association of North America Web sites. Arthroscopy 2013;29:1108-12. http://dx. doi.org/10.1016/j.arthro.2013.03.003
www.elsevier.com/locate/ymse
Availability of accessible and high-quality information on the Internet for patients regarding the diagnosis and management of rotator cuff tears David M. Dalton, MB MCh BAO, MRCS*, Enda G. Kelly, MB MCh BAO, MRCS, Diarmuid C. Molony, MB MCh BAO, FRCS (Tr&Orth) Department of Orthopaedic Surgery, Waterford University Hospital, Ardkeen, Waterford, Ireland Background: In the era of informed patient decision-making, educated patients are vital contributors. The Internet provides a vast information source that patients will access. It is imperative that this information be relevant and understandable. Various treatments, each with advantages and disadvantages, are available. We sought to examine the standard of information about the diagnosis and management of rotator cuff tears available to patients on the Internet. Methods: We identified 125 websites from searching ‘‘rotator cuff tear’’ in the 5 most popular Internet search engines. The websites were examined for readability by measuring the Flesch Reading Ease Score, the Flesch-Kincaid Grade Level, and the Gunning Fog Index. The quality of the websites was measured by the DISCERN instrument, the Journal of the American Medical Association benchmark criteria, and Health on the Net Foundation certification. Results: There were 59 individual URLs analyzed. Overall, the quality was poor, with the average DISCERN score being only 39.47. Furthermore, the mean reading grade level was above 9 (recommended level, 6). Health on the Net Foundation certification did correspond to significantly worse readability scores (P ¼ .004) but did not correlate with improved DISCERN scores. Those that satisfied more of the Journal of the American Medical Association benchmark criteria had significantly better DISCERN scores (P <.001). Conclusion: Information about rotator cuff tears is of a low standard and is in many cases written at too high a level for the general population. There are instruments of which we, as surgeons, must be aware to evaluate the resources available and to recommend them to patients to ensure that they understand their condition and treatment options. Level of evidence: Education Methodology Study, Survey of MaterialsdInternet. Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Rotator cuff; patient information; education; DISCERN; Internet; readability; JAMA; HONcode
IRB approval was not required as no patient records, information, or hospital resources were used during the study.
*Reprint requests: David M. Dalton, MB MCh BAO, MRCS, Department of Orthopaedic Surgery, Waterford Regional Hospital, Ardkeen, Waterford, Ireland. E-mail address: [email protected] (D.M. Dalton).
1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.09.036
e136 Shoulder diseases, and specifically rotator cuff tears, require appropriate and individualized investigation and treatment as decided by the patient and the patient’s physician. In the past, the decision would be led by the expertise of the physician, but we are entering an era of joint decision-making and the educated patient. Much of this education will come from the Internet. The Internet has revolutionized society. In particular, it has revolutionized knowledge acquisition. In 2012, 81% of the population were regular Internet users compared with just 48% in 2000.22 Furthermore, in a large survey, 72% of respondents had used the Internet to research a health-related issue in the previous 12 months.23 The quality of information available in these studies is variable and can often be biased24 or misleading. It is frequently beyond the technical expertise of the patient, leading to confusion.2,15 As the Internet is a nonregulated resource, it is difficult to control what information people access. Search engines remain a popular means of gathering information from the Internet, and 91% of Internet users regularly use search engines.22 Shoulder pain is a common cause of presentation to medical services, with more than 4.5 million patient visits per year in the United States.17 Cadaveric studies have demonstrated that 39% of the population older than 60 years have full-thickness rotator cuff tears.3 Risk factors for the development of rotator cuff tears are repetitive overhead activity (usually occupational or sports related), aging, and the poor blood supply to the cuff insertion, making healing unusual.16,25,31 Treatment must be tailored to the patient and the specific injury. The optimal treatment is still debatable, and a Cochrane review on the topic did not come to any definitive conclusions regarding optimal treatment.7 In the case of large acute traumatic tears in young people, the literature favors early surgical treatment, ideally within the first 3 weeks.1 Lag time between tear and surgery can result in muscle atrophy, fatty necrosis, tendon retraction, increase in the size of the tear, and poor operative outcomes.19 In cases of chronic tears, there does not appear to be a clear consensus on how to manage these patients. In symptomatic atraumatic tears, a 6-week to 3-month trial of conservative treatment is reasonable before surgical intervention. Treatment plans tailored to physiologic age, acromiohumeral distance, and muscle strength may lead to improved outcomes.13,28,31 Preoperatively, those who are in employment, older, and married and those who have higher expectations were more likely to be satisfied with their surgical outcome. Postoperatively, decreased pain, improved function, quality of life, shoulder outcome score, and Simple Shoulder Test scores correlate with improved overall patient satisfaction. The size of tear and duration of symptoms have no relationship with patient satisfaction.29 Whereas the literature would suggest improvement in most parameters with cuff repair, this does not always correlate with patient expectation. Our study investigates the quality of information available to patients with rotator
D.M. Dalton et al. cuff tears. We seek to evaluate this information to determine whether patients are receiving accurate and unbiased information. We also seek to identify those characteristics of websites that may signal that they are of high quality.
Materials and methods The top 5 Internet search engines were identified.22 Google is the dominant search engine, with 83% of Internet users surveyed listing it as their most frequently used search engine. Yahoo!, BING, AOL, and Ask are distant followers. The term ‘‘rotator cuff tear’’ was searched; in each case, the top 25 results were included in line with previous similar studies.8,21 All unique URLs were analyzed, and inaccessible websites, those that were primarily nonreadable (e.g., YouTube), and URLs that were subsections of previously analyzed websites were excluded. The authorship of the article was judged by 2 authors (D.D. and E.K). It was classified as physician, academic, commercial, medicolegal, allied health professional, or forum/social media. The readability scores recorded were the Flesch Reading Ease Score (FRES), the Flesch-Kincaid Grade Level (FKGL), and the Gunning Fog Index (GFI). They were calculated with an online tool, read-able.com, that automatically calculates these scores after inputting the website’s URL. The FRES score is 0 (easiest) to 100 (most difficult) and is calculated by the following formula: 206.8351.015 (total words/total sentences)84.6 (total syllables/ total words).14 The FKGL is used as a marker of the U.S. reading grade level and is calculated by the following formula: 0.39 (total words/total sentences) þ 11.8 (total syllables/total words)15.59.9 The GFI estimates the number of years of formal education required to read a passage of text and is calculated by the following formula: 0.4 [(words/sentences) þ 100 (complex words/words)].10 The DISCERN instrument was funded by The British Library and the National Health Service (NHS) Research and Development Programme and produced by an expert panel in the United Kingdom consisting of clinical specialists (physicians), self-help groups, general practitioners, a consumer health expert, a lay medical publisher, a health journalist, a health consumer, a Community Health Council representative, a Plain English Campaign representative, and an NHS Centre for Reviews and Dissemination representative. The aim of the instrument was to help health consumers and information providers assess the quality of written information about treatment choices for a health problem.6 It consists of 15 questions and an overall quality rating. The overall score is 16 to 80, with higher scores representing a higher quality site. The DISCERN instrument includes sections assessing website bias, benefits of each treatment, risks of each treatment, information on alternative treatments, relevance, areas of uncertainty, and overall quality.6 This instrument allowed us to use specialist knowledge in assessing the quality of the websites while simultaneously remaining objective. The Journal of the American Medical Association (JAMA) benchmark criteria award a point for clear presentation of 4 elements on the sitedauthorship, source, date of last update, and disclosures of ownership/sponsorship/conflicts of interest.26 The JAMA benchmark criteria and authorship were established by the authors D.D. and E.K. The Health on the Net Foundation (HON) is a nonprofit organization accredited to the United Nations established to protect
Internet information regarding rotator cuff tears the public from misleading medical information.4 It awards websites that meet their standard of quality HONcode certification. All URLs were entered on their website to establish whether they were HONcode certified. Statistics were calculated on Minitab 17 (Minitab Inc., State College, PA, USA). Significance was established as a P value < .05. Two-sample t test and Pearson correlation value were used to establish relationships.
Results The term ‘‘rotator cuff tear’’ returned 1,010,000 results in 0.22 second on Google. We excluded sponsored/advertised links. There were 66 unique URLs identified; 59 websites were individually analyzed. Two websites were excluded for requiring registration as a member. Two websites were purely indexes and links to papers/other sites. Two websites were purely video based, and one individual URL was inaccessible. There were 21 websites that had a physician/surgeon as the primary author. Other authors included allied health professionals (physiotherapists/physical therapists, osteopaths; n ¼ 7) and insurance providers (n ¼ 2). The author was not clearly stated in 31 websites. Fifteen websites were HONcode certified. The readability average U.S. equivalent grade level was 9.19. The average FRES, FKGL, and GFI scores were 51.24 (11.42), 8.10 (1.74), and 9.02 (2.34), respectively. The average DISCERN score was 39.47 (11.39), and the average JAMA benchmark criteria score was 1.72. There was no significant difference in the DISCERN score between websites written by physicians and those produced by nonphysicians/those in which the author was not stated (P ¼ .576) (Fig. 1). Similarly, HON certification did not result in better DISCERN scores (P ¼ .791). There was no significant difference in the FRES between websites written by physicians and those produced by nonphysicians/those in which the author was not stated (P ¼ .839) (Fig. 2). HON-certified websites were significantly more difficult to read (P ¼ .004). The DISCERN score was only weakly correlated with the FRES, FKGL, and GFI (Pearson correlation values of 0.177, 0.166, and 0.027, respectively) (Fig. 3) but did correlate with JAMA criteria (Pearson value, 0.483; P < .001).
Discussion As we enter an era of shared decision-making in medicine, it is vital that patients be well informed to ensure that they are fully aware of the available treatments and the associated risks and benefits. Misunderstandings between patients and physicians on invasive treatments have been well documented.12,20 This is hardly surprising, given that patients about to undergo a procedure or who have received a new diagnosis would be under considerable stress. Improving patient resources implicitly improves patient
e137 knowledge. This has been done with pamphlets and other communication resources in the past with moderate success.18,27 The Internet is a cornucopia of patient information; the problem lies in the heterogeneity and sometimes questionable reliability of this information. Unfortunately, the quality of these websites is such that they may give misleading, biased, or incomprehensible information to patients, increasing the risk of their choosing incorrect treatment advice for their particular needs. Communicating with patients who have come across incorrect information can be difficult. Patients may not see why they should trust you over whatever advice they received on the Internet. We use objective evidence to demonstrate the facts to the patients and to guide them to what we consider to be the correct choice of treatment based on available data. Biased and incorrect information could also lead patients to believe that they were somehow treated incorrectly and may fracture the physician-patient relationship. The readability scores are calculated on the basis of word count, sentence length, and number of syllables. The scientific nature of medical content means that it may be difficult to rank the readability accurately. The fact that readability did not correlate closely with the DISCERN score demonstrates that the complexity of information does not necessarily have to be reproduced in a manner that is difficult to read. Unfortunately, the websites that were HON certified were significantly more difficult to read. This is something that must be addressed for the HON initiative to be effective and useful for patients. There is an obvious need for improvement in the quality of the information the patients are accessing. Because of the very nature of the Internet, we cannot control what is published, but we can direct patients to the best sources. Because of biases, financial or preferential, we need a system of customer guarantee. The HON initiative is certainly a positive development, but not enough physicians, patients, or web designers are aware of it for it to be effective. Physicians, allied health professionals, and government departments of health should be directing patients toward these type of resources. Our study contradicts other studies that have found significant relationships between the HON certification and authorship of the website and the DISCERN score.5,21 O’Neill et al21 studied the information available to patients about cauda equina on the Internet. They found that websites with a physician as author had significantly better DISCERN and JAMA benchmark criteria and were more likely to be HON certified compared with websites with other authors. The DISCERN scores of the websites included in this study were much higher than in a study done on websites recommended by U.K. NHS consultants that provide information on adolescent idiopathic scoliosis. In that particular study, only 7 websites were analyzed, with the maximum DISCERN score being a meager 49, and only 1
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Figure 1
Figure 2
Distribution of DISCERN score by authorship.
Distribution of Flesch Reading Ease Score by authorship.
website was HON certified.30 This emphasizes the point that clinicians should objectively analyze sources of information before recommending them to patients. Our data support studies showing that most information collected on the Internet is pitched above the recommended sixth-grade level.32 The principles to which websites should adhere to gain HON certification are stated as Authoritative, Complementarity, Privacy, Attribution, Justifiability, Transparency, Financial Disclosure, and Advertising Policy.11 In our study, the websites that have HON certification did not have
significantly higher DISCERN scores. The reason for this is not clear, and although the DISCERN scores are somewhat subjective, there is a transparency lacking in the HON certification system. To have effective and unbiased quality control, all HON evaluations should be published. It is possible that some high-quality websites are not submitted for evaluation. Our study has limitations. Nonreadable information was not included in the study, and more and more patients are going to be using these multimedia instruments to educate themselves on medical matters. Also, there are many
Internet information regarding rotator cuff tears
Figure 3
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Correlation of DISCERN score to Flesch Reading Ease Score.
websites that have interactive or multimedia components to them. These may be educational to the patients but do not come under the remit of the DISCERN instrument and so may underscore on it.
Conclusion The quality of available information on rotator cuff tears is poor. The readability of information on rotator cuff disease is inappropriately high. We recommend that physicians take a more active role in creating and assessing patient information websites. This could lead to improved patient satisfaction and more effective physician-patient interactions. We also suggest that the assessing tools should have a readability element included in them.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Acknowledgment Of Aileen O’Shea for her editing of our text.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jse.2014.09.036
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