Current Concepts
Evaluating the Quality of Internet Information for Femoroacetabular Impingement Simon Lee, M.P.H., Jason J. Shin, M.D., Marc S. Haro, M.D., M.S.P.T., Sang H. Song, B.S., and Shane J. Nho, M.D., M.S.
Purpose: The Internet has become a ubiquitous source of medical information for both the patient and the physician. However, the quality of this information is highly variable. We evaluated the quality of Internet information available for femoroacetabular impingement (FAI). Methods: Four popular search engines were used to collect 100 Web sites containing information on FAI. Web sites were evaluated based on authorship, various content criteria, and the presence of Health On the Net Code of Conduct (HONcode) certification. By use of a novel evaluation system for quality, Web sites were also classified as excellent, high, moderate, poor, or inadequate and were subsequently analyzed. Web sites were evaluated as a group, followed by authorship type, by HONcode certification, and by quality level. Results: Of the Web sites, 73 offered the ability to contact the author, 91 offered a considerable explanation of FAI, 54 provided surgical treatment options, 58 offered nonsurgical treatment options, 27 discussed possible complications, 11 discussed eligibility criteria, 31 discussed rehabilitation, 67 discussed a differential diagnosis, and 48 included peer-reviewed citations. We categorized 40 Web sites as academic, 33 as private, 9 as industry, 9 as public education, and 9 as blogs. Our novel quality evaluation system classified 16 Web sites as excellent, 18 as high, 17 as moderate, 18 as poor, and 31 as inadequate. Only 8% of all evaluated Web sites contained HONcode certification. Conclusions: We found that the quality of information available on the Internet about FAI was dramatically variable. A significantly large proportion of Web sites were from academic sources, but this did not necessarily indicate higher quality. Sites with HONcode certification showed as much variability in quality as noncertified sites. Clinical Relevance: This study increases clinician competence in the available Internet information about FAI and helps them to confidently guide patients to formulate appropriate medical decisions based on high-quality information.
F
emoroacetabular impingement (FAI) only relatively recently has been recognized as an orthopaedic pathology, but growing awareness and new management techniques are increasing the rate of its diagnosis. Ganz et al.1-3 have characterized the complex morphology of the hip joint and elucidated various biomechanical pathways in which abnormal anatomy of the region may produce symptomatic pathology. FAI is perhaps the most
From the Hip Preservation Center, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, Chicago, Illinois, U.S.A. The authors report the following potential conflict of interest or source of funding: S.J.N. receives support from Stryker, Pivot Medical, Ossur, Arthrex, Linvatec, Smith & Nephew, DJ Orthopaedics, Miomed, Athletico, Allosource. Received February 20, 2014; accepted April 22, 2014. Address correspondence to Shane J. Nho, M.D., M.S., Hip Preservation Center, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, 1611 W Harrison St, Ste 300, Chicago, IL 60612, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/14147/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.04.102
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common cause of these symptoms and typically leads the patient to seek medical attention for labral tears, hip pain, and even early osteoarthritis.4-10 The most common anatomic lesions found in association with FAI are abnormalities in the head-neck offset in the proximal femur (cam) and overcoverage of the acetabular edge (pincer).11 Dynamic hip motion in the setting of cam and pincer lesions leads to bony impingement and consequently applies abnormally high loading forces onto the surrounding soft tissue. This may result in chondral delamination, labral injury, and altered mechanics, leading to other nonspecific intra-articular damage.12-15 The diagnosis and treatment of symptomatic FAI in the United States have grown exponentially in recent years.16-22 Arthroscopic management of FAI to address these morphologic abnormalities and their subsequent pathologic sequelae is becoming a common, effective, and safe method of treating hip pain.16-23 Matsuda et al.24 performed a comparative systematic review of open dislocation, mini-open, and arthroscopic surgeries for FAI, concluding that arthroscopic management achieved equal or superior outcomes as compared with
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 30, No 10 (October), 2014: pp 1372-1379
FEMOROACETABULAR IMPINGEMENT AND THE INTERNET
the other methods and produced fewer complications. Byrd and Jones25 have shown excellent outcomes at 2-year follow-up in an arthroscopically managed FAI cohort with a mean age of 34 years. In addition, Philippon et al.26,27 have recently shown safe and effective outcomes in hip arthroscopy for FAI in patients aged older than 50 years, as well as adolescent patients aged 11 to 16 years. Given that FAI is quickly becoming a publicly recognizable orthopaedic condition, the availability of high-quality informational material for patient education becomes significant in its management. The Internet has become an important and ubiquitous source of medical information for both the patient and the physician. Searching the Internet is often the first resource patients use, allowing them a level of access to medical material not previously available.28 The Internet has therefore become a popular tool of self-education and self-empowerment for patients; however, several studies have shown that the quality of medical information published online varies drastically.29-33 For many patients, the material presented may significantly influence their health care decisions, often without discussion with a physician’s guidance.34,35 The predominant issue is that although academic sources may frequently exhibit a rigorous evaluation process in maintaining the validity of the information they convey, other unregulated Web sites have the freedom to convey material on the same topic without the same level of scrutiny.35 A considerable number of Web sites also combine health information with commercial motives, potentially biasing the information consumed by the patient.29 Studies on a variety of health care topics have shown that the source of authorship dramatically affects the quality of information presented.36 Lubowitz and Poehling34 argue that in the midst of the current explosion in available health care information available for consumption due to the advent of the Internet and electronic media, preserving a high standard of quality in that information is paramount for both clinicians and patients. Previous analyses of orthopaedic health information available on the Internet have been reported, but few have explored sports medicine topics.29-33,37-43 In addition, to our knowledge, this is the first and only study addressing these topics in relation to FAI. Therefore the purpose of this study was to evaluate the quality of available information on the Internet regarding FAI. Specifically, the objectives of our study were 3-fold: (1) to evaluate the authorship and content of the most easily accessible Web sites to the general patient population, (2) to determine whether sites associated with academic institutions offered superiorquality information, and (3) to determine whether sites approved by a verified certification body affected the quality of information presented.
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Methods The approach implemented in the Web site selection and evaluation process of this study was adapted from previously published orthopaedic studies.38 We used the 4 most popular search engines available to simulate the patient experience: Google, Yahoo, Bing, and Ask.com. These search engines represented the vast majority of search utilization by Internet users as of August 2013, with Google predominating the market share (83.07%), followed by Yahoo (8.08%), Bing (5.37%), and Ask.com (
Evaluating the Quality of Internet Information for Femoroacetabular Impingement Simon Lee, M.P.H., Jason J. Shin, M.D., Marc S. Haro, M.D., M.S.P.T., Sang H. Song, B.S., and Shane J. Nho, M.D., M.S.
Purpose: The Internet has become a ubiquitous source of medical information for both the patient and the physician. However, the quality of this information is highly variable. We evaluated the quality of Internet information available for femoroacetabular impingement (FAI). Methods: Four popular search engines were used to collect 100 Web sites containing information on FAI. Web sites were evaluated based on authorship, various content criteria, and the presence of Health On the Net Code of Conduct (HONcode) certification. By use of a novel evaluation system for quality, Web sites were also classified as excellent, high, moderate, poor, or inadequate and were subsequently analyzed. Web sites were evaluated as a group, followed by authorship type, by HONcode certification, and by quality level. Results: Of the Web sites, 73 offered the ability to contact the author, 91 offered a considerable explanation of FAI, 54 provided surgical treatment options, 58 offered nonsurgical treatment options, 27 discussed possible complications, 11 discussed eligibility criteria, 31 discussed rehabilitation, 67 discussed a differential diagnosis, and 48 included peer-reviewed citations. We categorized 40 Web sites as academic, 33 as private, 9 as industry, 9 as public education, and 9 as blogs. Our novel quality evaluation system classified 16 Web sites as excellent, 18 as high, 17 as moderate, 18 as poor, and 31 as inadequate. Only 8% of all evaluated Web sites contained HONcode certification. Conclusions: We found that the quality of information available on the Internet about FAI was dramatically variable. A significantly large proportion of Web sites were from academic sources, but this did not necessarily indicate higher quality. Sites with HONcode certification showed as much variability in quality as noncertified sites. Clinical Relevance: This study increases clinician competence in the available Internet information about FAI and helps them to confidently guide patients to formulate appropriate medical decisions based on high-quality information.
F
emoroacetabular impingement (FAI) only relatively recently has been recognized as an orthopaedic pathology, but growing awareness and new management techniques are increasing the rate of its diagnosis. Ganz et al.1-3 have characterized the complex morphology of the hip joint and elucidated various biomechanical pathways in which abnormal anatomy of the region may produce symptomatic pathology. FAI is perhaps the most
From the Hip Preservation Center, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, Chicago, Illinois, U.S.A. The authors report the following potential conflict of interest or source of funding: S.J.N. receives support from Stryker, Pivot Medical, Ossur, Arthrex, Linvatec, Smith & Nephew, DJ Orthopaedics, Miomed, Athletico, Allosource. Received February 20, 2014; accepted April 22, 2014. Address correspondence to Shane J. Nho, M.D., M.S., Hip Preservation Center, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Rush Medical College of Rush University, 1611 W Harrison St, Ste 300, Chicago, IL 60612, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/14147/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.04.102
1372
common cause of these symptoms and typically leads the patient to seek medical attention for labral tears, hip pain, and even early osteoarthritis.4-10 The most common anatomic lesions found in association with FAI are abnormalities in the head-neck offset in the proximal femur (cam) and overcoverage of the acetabular edge (pincer).11 Dynamic hip motion in the setting of cam and pincer lesions leads to bony impingement and consequently applies abnormally high loading forces onto the surrounding soft tissue. This may result in chondral delamination, labral injury, and altered mechanics, leading to other nonspecific intra-articular damage.12-15 The diagnosis and treatment of symptomatic FAI in the United States have grown exponentially in recent years.16-22 Arthroscopic management of FAI to address these morphologic abnormalities and their subsequent pathologic sequelae is becoming a common, effective, and safe method of treating hip pain.16-23 Matsuda et al.24 performed a comparative systematic review of open dislocation, mini-open, and arthroscopic surgeries for FAI, concluding that arthroscopic management achieved equal or superior outcomes as compared with
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 30, No 10 (October), 2014: pp 1372-1379
FEMOROACETABULAR IMPINGEMENT AND THE INTERNET
the other methods and produced fewer complications. Byrd and Jones25 have shown excellent outcomes at 2-year follow-up in an arthroscopically managed FAI cohort with a mean age of 34 years. In addition, Philippon et al.26,27 have recently shown safe and effective outcomes in hip arthroscopy for FAI in patients aged older than 50 years, as well as adolescent patients aged 11 to 16 years. Given that FAI is quickly becoming a publicly recognizable orthopaedic condition, the availability of high-quality informational material for patient education becomes significant in its management. The Internet has become an important and ubiquitous source of medical information for both the patient and the physician. Searching the Internet is often the first resource patients use, allowing them a level of access to medical material not previously available.28 The Internet has therefore become a popular tool of self-education and self-empowerment for patients; however, several studies have shown that the quality of medical information published online varies drastically.29-33 For many patients, the material presented may significantly influence their health care decisions, often without discussion with a physician’s guidance.34,35 The predominant issue is that although academic sources may frequently exhibit a rigorous evaluation process in maintaining the validity of the information they convey, other unregulated Web sites have the freedom to convey material on the same topic without the same level of scrutiny.35 A considerable number of Web sites also combine health information with commercial motives, potentially biasing the information consumed by the patient.29 Studies on a variety of health care topics have shown that the source of authorship dramatically affects the quality of information presented.36 Lubowitz and Poehling34 argue that in the midst of the current explosion in available health care information available for consumption due to the advent of the Internet and electronic media, preserving a high standard of quality in that information is paramount for both clinicians and patients. Previous analyses of orthopaedic health information available on the Internet have been reported, but few have explored sports medicine topics.29-33,37-43 In addition, to our knowledge, this is the first and only study addressing these topics in relation to FAI. Therefore the purpose of this study was to evaluate the quality of available information on the Internet regarding FAI. Specifically, the objectives of our study were 3-fold: (1) to evaluate the authorship and content of the most easily accessible Web sites to the general patient population, (2) to determine whether sites associated with academic institutions offered superiorquality information, and (3) to determine whether sites approved by a verified certification body affected the quality of information presented.
1373
Methods The approach implemented in the Web site selection and evaluation process of this study was adapted from previously published orthopaedic studies.38 We used the 4 most popular search engines available to simulate the patient experience: Google, Yahoo, Bing, and Ask.com. These search engines represented the vast majority of search utilization by Internet users as of August 2013, with Google predominating the market share (83.07%), followed by Yahoo (8.08%), Bing (5.37%), and Ask.com (
