Ondansetron

Researchers say they have discovered the source of a bloodstream infection observed in more than 50 South American cancer patients.

Using whole-genome sequence typing (WGST), the team was able to link infection with the fungus Sarocladium kiliense to a tainted antinausea medication, ondansetron, that was given to cancer patients in Chile and Colombia.

This work is described in Emerging Infectious Diseases.

“Contamination of medical products, particularly with environmental fungi, poses growing concern and a public health threat, especially in vulnerable populations such as cancer patients,” said study author David Engelthaler, PhD, of The Translational Genomics Research Institute in Flagstaff, Arizona.

“Increased vigilance and the use of advanced technologies are needed to rapidly identify the likely sources of infection to efficiently guide epidemiologic investigations and initiate appropriate control measures.”

The S kiliense bloodstream-infection outbreak, which occurred from June 2013 through January 2014, included a cluster of cases at 8 hospitals in Santiago, Chile.

All of the patients received the same 4 intravenous medications. But only the antinausea medication ondansetron was given exclusively to cancer patients.

All of the patients infected with S kiliense received ondansetron from the same source, a pharmaceutical company called Vitrofarma SA (specifically, Plant No. 8 in Bogotá, Colombia). The drug was imported by LabVitales Chile SA and distributed by Pharma Isa Ltda.

Two of 3 lots of unopened ondansetron, tested by the Chilean Ministry of Health, yielded vials contaminated with S kiliense, forcing a recall of all ondansetron in Chile that was made by Vitrofarma SA.

Subsequently, Colombian officials discovered 14 other cases in which patients who were given ondansetron from Vitrofarma SA were infected with S kiliense.

S kiliense has been implicated in healthcare-related infections before, but the lack of available typing methods has precluded the ability to substantiate sources.

“The use of WGST to investigate fungal outbreaks has become integral to epidemiologic investigations,” Dr Engelthaler said. “Our WGST analysis demonstrated that the patient isolates from Chile and Colombia were nearly genetically indistinguishable from those recovered from the unopened medication vials, indicating the likely presence of a single-source infection.”

Ondansetron

Researchers say they have discovered the source of a bloodstream infection observed in more than 50 South American cancer patients.

Using whole-genome sequence typing (WGST), the team was able to link infection with the fungus Sarocladium kiliense to a tainted antinausea medication, ondansetron, that was given to cancer patients in Chile and Colombia.

This work is described in Emerging Infectious Diseases.

“Contamination of medical products, particularly with environmental fungi, poses growing concern and a public health threat, especially in vulnerable populations such as cancer patients,” said study author David Engelthaler, PhD, of The Translational Genomics Research Institute in Flagstaff, Arizona.

“Increased vigilance and the use of advanced technologies are needed to rapidly identify the likely sources of infection to efficiently guide epidemiologic investigations and initiate appropriate control measures.”

The S kiliense bloodstream-infection outbreak, which occurred from June 2013 through January 2014, included a cluster of cases at 8 hospitals in Santiago, Chile.

All of the patients received the same 4 intravenous medications. But only the antinausea medication ondansetron was given exclusively to cancer patients.

All of the patients infected with S kiliense received ondansetron from the same source, a pharmaceutical company called Vitrofarma SA (specifically, Plant No. 8 in Bogotá, Colombia). The drug was imported by LabVitales Chile SA and distributed by Pharma Isa Ltda.

Two of 3 lots of unopened ondansetron, tested by the Chilean Ministry of Health, yielded vials contaminated with S kiliense, forcing a recall of all ondansetron in Chile that was made by Vitrofarma SA.

Subsequently, Colombian officials discovered 14 other cases in which patients who were given ondansetron from Vitrofarma SA were infected with S kiliense.

S kiliense has been implicated in healthcare-related infections before, but the lack of available typing methods has precluded the ability to substantiate sources.

“The use of WGST to investigate fungal outbreaks has become integral to epidemiologic investigations,” Dr Engelthaler said. “Our WGST analysis demonstrated that the patient isolates from Chile and Colombia were nearly genetically indistinguishable from those recovered from the unopened medication vials, indicating the likely presence of a single-source infection.”

Ondansetron

Researchers say they have discovered the source of a bloodstream infection observed in more than 50 South American cancer patients.

Using whole-genome sequence typing (WGST), the team was able to link infection with the fungus Sarocladium kiliense to a tainted antinausea medication, ondansetron, that was given to cancer patients in Chile and Colombia.

This work is described in Emerging Infectious Diseases.

“Contamination of medical products, particularly with environmental fungi, poses growing concern and a public health threat, especially in vulnerable populations such as cancer patients,” said study author David Engelthaler, PhD, of The Translational Genomics Research Institute in Flagstaff, Arizona.

“Increased vigilance and the use of advanced technologies are needed to rapidly identify the likely sources of infection to efficiently guide epidemiologic investigations and initiate appropriate control measures.”

The S kiliense bloodstream-infection outbreak, which occurred from June 2013 through January 2014, included a cluster of cases at 8 hospitals in Santiago, Chile.

All of the patients received the same 4 intravenous medications. But only the antinausea medication ondansetron was given exclusively to cancer patients.

All of the patients infected with S kiliense received ondansetron from the same source, a pharmaceutical company called Vitrofarma SA (specifically, Plant No. 8 in Bogotá, Colombia). The drug was imported by LabVitales Chile SA and distributed by Pharma Isa Ltda.

Two of 3 lots of unopened ondansetron, tested by the Chilean Ministry of Health, yielded vials contaminated with S kiliense, forcing a recall of all ondansetron in Chile that was made by Vitrofarma SA.

Subsequently, Colombian officials discovered 14 other cases in which patients who were given ondansetron from Vitrofarma SA were infected with S kiliense.

S kiliense has been implicated in healthcare-related infections before, but the lack of available typing methods has precluded the ability to substantiate sources.

“The use of WGST to investigate fungal outbreaks has become integral to epidemiologic investigations,” Dr Engelthaler said. “Our WGST analysis demonstrated that the patient isolates from Chile and Colombia were nearly genetically indistinguishable from those recovered from the unopened medication vials, indicating the likely presence of a single-source infection.”

The widely used painkiller acetaminophen has little effect on osteoarthritic pain even at high doses, according to results from a new meta-analysis, while several other agents, including diclofenac, improve pain more robustly.

The study, published online March 17 in The Lancet (doi: 10.1016/S0140-6736(16)30002-2), reviewed results from 74 randomized trials enrolling nearly 60,000 patients with knee or hip osteoarthritis.

©Ingram Publishing/thinkstockphotos.com

Patients were assigned different single-agent treatment regimens, comprising various dosages of seven nonsteroidal anti-inflammatory drugs (rofecoxib, lumiracoxib, etoricoxib, diclofenac, celecoxib, naproxen, and ibuprofen) or acetaminophen; in the included trials some treatments were compared head to head, and others to placebo.

First author Bruno R. da Costa, Ph.D., of the University of Bern (Switzerland) and his colleagues found to their surprise that acetaminophen had a nearly null effect on pain symptoms at doses ranging from under 2,000 mg a day to as much as 4,000 mg.

The study’s preestablished cutoff for clinically important pain reduction was an effect size of –0.37. While the most effective regimens in the study had effect sizes approaching –0.6, compared with placebo, acetaminophen’s effect size was only –0.17 across the doses studied.

Acetaminophen “is clinically ineffective and should not be recommended for the symptomatic treatment of osteoarthritis, irrespective of the dose,” the researchers concluded.

Diclofenac, meanwhile, had one of the greatest effect sizes at the maximum dose of 150 mg per day (–0.57), and etoricoxib 60 mg and rofecoxib 25 mg were comparably effective. All three agents at these maximum daily doses had 100% probability to reach the minimum clinically important difference established in the study when used to reduce osteoarthritic pain.

By comparison, maximum daily doses of ibuprofen (2,400 mg) and naproxen (1,000 mg) had 83% and 78% probability, respectively, of achieving clinically important reductions. Treatment effects increased with dosage, but reached statistical significance only for celecoxib, diclofenac, and naproxen.

“Although our findings suggest that some NSAIDs have a clinically relevant treatment effect on osteoarthritis pain,” the investigators wrote, their benefit has to be weighed against their potential harmful effects, which include cardiovascular risk associated with diclofenac and gastrointestinal complications linked to naproxen.

“Appropriate drug selection is a major challenge in patients with osteoarthritis, who are often elderly with polypharmacy. Our study will help to put the available safety data into perspective,” they wrote.

The agents were used short-term, reflecting real-life practice, with average follow-up in the study less than 3 months. However, trials with longer-term follow-up may be needed to compare effectiveness of regimens “on a continuous fixed-dose versus NSAIDs on an as-needed basis,” the researchers acknowledged.

The Swiss National Science Foundation and the Arco Foundation of Switzerland sponsored the study. One investigator disclosed institutional research support from AstraZeneca, Biotronik, Biosensors International, Eli Lilly, and the Medicines Company, while another is currently employed by Novartis and holds shares in Cogitars.

The widely used painkiller acetaminophen has little effect on osteoarthritic pain even at high doses, according to results from a new meta-analysis, while several other agents, including diclofenac, improve pain more robustly.

The study, published online March 17 in The Lancet (doi: 10.1016/S0140-6736(16)30002-2), reviewed results from 74 randomized trials enrolling nearly 60,000 patients with knee or hip osteoarthritis.

©Ingram Publishing/thinkstockphotos.com

Patients were assigned different single-agent treatment regimens, comprising various dosages of seven nonsteroidal anti-inflammatory drugs (rofecoxib, lumiracoxib, etoricoxib, diclofenac, celecoxib, naproxen, and ibuprofen) or acetaminophen; in the included trials some treatments were compared head to head, and others to placebo.

First author Bruno R. da Costa, Ph.D., of the University of Bern (Switzerland) and his colleagues found to their surprise that acetaminophen had a nearly null effect on pain symptoms at doses ranging from under 2,000 mg a day to as much as 4,000 mg.

The study’s preestablished cutoff for clinically important pain reduction was an effect size of –0.37. While the most effective regimens in the study had effect sizes approaching –0.6, compared with placebo, acetaminophen’s effect size was only –0.17 across the doses studied.

Acetaminophen “is clinically ineffective and should not be recommended for the symptomatic treatment of osteoarthritis, irrespective of the dose,” the researchers concluded.

Diclofenac, meanwhile, had one of the greatest effect sizes at the maximum dose of 150 mg per day (–0.57), and etoricoxib 60 mg and rofecoxib 25 mg were comparably effective. All three agents at these maximum daily doses had 100% probability to reach the minimum clinically important difference established in the study when used to reduce osteoarthritic pain.

By comparison, maximum daily doses of ibuprofen (2,400 mg) and naproxen (1,000 mg) had 83% and 78% probability, respectively, of achieving clinically important reductions. Treatment effects increased with dosage, but reached statistical significance only for celecoxib, diclofenac, and naproxen.

“Although our findings suggest that some NSAIDs have a clinically relevant treatment effect on osteoarthritis pain,” the investigators wrote, their benefit has to be weighed against their potential harmful effects, which include cardiovascular risk associated with diclofenac and gastrointestinal complications linked to naproxen.

“Appropriate drug selection is a major challenge in patients with osteoarthritis, who are often elderly with polypharmacy. Our study will help to put the available safety data into perspective,” they wrote.

The agents were used short-term, reflecting real-life practice, with average follow-up in the study less than 3 months. However, trials with longer-term follow-up may be needed to compare effectiveness of regimens “on a continuous fixed-dose versus NSAIDs on an as-needed basis,” the researchers acknowledged.

The Swiss National Science Foundation and the Arco Foundation of Switzerland sponsored the study. One investigator disclosed institutional research support from AstraZeneca, Biotronik, Biosensors International, Eli Lilly, and the Medicines Company, while another is currently employed by Novartis and holds shares in Cogitars.

The widely used painkiller acetaminophen has little effect on osteoarthritic pain even at high doses, according to results from a new meta-analysis, while several other agents, including diclofenac, improve pain more robustly.

The study, published online March 17 in The Lancet (doi: 10.1016/S0140-6736(16)30002-2), reviewed results from 74 randomized trials enrolling nearly 60,000 patients with knee or hip osteoarthritis.

©Ingram Publishing/thinkstockphotos.com

Patients were assigned different single-agent treatment regimens, comprising various dosages of seven nonsteroidal anti-inflammatory drugs (rofecoxib, lumiracoxib, etoricoxib, diclofenac, celecoxib, naproxen, and ibuprofen) or acetaminophen; in the included trials some treatments were compared head to head, and others to placebo.

First author Bruno R. da Costa, Ph.D., of the University of Bern (Switzerland) and his colleagues found to their surprise that acetaminophen had a nearly null effect on pain symptoms at doses ranging from under 2,000 mg a day to as much as 4,000 mg.

The study’s preestablished cutoff for clinically important pain reduction was an effect size of –0.37. While the most effective regimens in the study had effect sizes approaching –0.6, compared with placebo, acetaminophen’s effect size was only –0.17 across the doses studied.

Acetaminophen “is clinically ineffective and should not be recommended for the symptomatic treatment of osteoarthritis, irrespective of the dose,” the researchers concluded.

Diclofenac, meanwhile, had one of the greatest effect sizes at the maximum dose of 150 mg per day (–0.57), and etoricoxib 60 mg and rofecoxib 25 mg were comparably effective. All three agents at these maximum daily doses had 100% probability to reach the minimum clinically important difference established in the study when used to reduce osteoarthritic pain.

By comparison, maximum daily doses of ibuprofen (2,400 mg) and naproxen (1,000 mg) had 83% and 78% probability, respectively, of achieving clinically important reductions. Treatment effects increased with dosage, but reached statistical significance only for celecoxib, diclofenac, and naproxen.

“Although our findings suggest that some NSAIDs have a clinically relevant treatment effect on osteoarthritis pain,” the investigators wrote, their benefit has to be weighed against their potential harmful effects, which include cardiovascular risk associated with diclofenac and gastrointestinal complications linked to naproxen.

“Appropriate drug selection is a major challenge in patients with osteoarthritis, who are often elderly with polypharmacy. Our study will help to put the available safety data into perspective,” they wrote.

The agents were used short-term, reflecting real-life practice, with average follow-up in the study less than 3 months. However, trials with longer-term follow-up may be needed to compare effectiveness of regimens “on a continuous fixed-dose versus NSAIDs on an as-needed basis,” the researchers acknowledged.

The Swiss National Science Foundation and the Arco Foundation of Switzerland sponsored the study. One investigator disclosed institutional research support from AstraZeneca, Biotronik, Biosensors International, Eli Lilly, and the Medicines Company, while another is currently employed by Novartis and holds shares in Cogitars.

The Food and Drug Administration has approved Idelvion, the first hemophilia B therapy with up to 14-day dosing intervals, and Kovaltry, an unmodified, full-length factor VIII compound for the treatment of hemophilia A.

Idelvion is a novel long-acting recombinant albumin fusion protein administered intravenously. In clinical trials from the PROLONG-9FP clinical development program – including phase I through III open-label, multicenter studies – the biotherapeutic agent maintained factor IX activity levels above 5% over 14 days at a dose of 75 IU/kg, resulting in a median annualized spontaneous bleeding rate of zero in patients, according to a statement by Idelvion’s manufacturer, CSL Behring. That “reduces the monthly number of units needed for prophylaxis therapy,” the company noted.

Idelvion is indicated in children and adults with hemophilia B for routine prophylaxis, as well as for on-demand control and prevention of bleeding episodes. It is also indicated for the perioperative management of bleeding. With on-demand treatment, 94% of bleeds were controlled with one infusion, and 99% were controlled with one or two infusions.

Appropriate patients 12 years and older can go up to 14 days between infusions, according to CSL Behring. The most common adverse reaction in the clinical trials was headache.

Idelvion is expected to be available later this month.

“The approval of this long-acting recombinant factor IX therapy for hemophilia B is vital, as physicians need more options to help their patients effectively and safely manage their bleeding disorder,” said Elena Santagostino, M.D., Ph.D., of the University of Milan/IRCCS Maggiore Hospital, and lead investigator of PROLONG-9FP, in a statement. “This provides them with greater freedom from frequent infusions.”

The FDA approved Kovaltry for children and adults with hemophilia A based on the results of the LEOPOLD (Long-Term Efficacy Open-Label Program in Severe Hemophilia A Disease) clinical trials. Kovaltry received approval in Europe and Canada earlier this year.

The LEOPOLD findings supported the approval for routine prophylaxis to reduce the frequency of bleeding episodes.

“In the LEOPOLD trials, Kovaltry reduced bleeding episodes in patients with hemophilia A when infused twice to three times per week with routine prophylaxis,” said Dr. Sanjay P. Ahuja, LEOPOLD investigator and director of the hemostasis and thrombosis center at University Hospitals Rainbow Babies & Children’s Hospital, Cleveland, in a statement by Kovaltry manufacturer Bayer. “Kovaltry may offer appropriate patients a twice-weekly prophylaxis dosing option.”

Dosing is 20-40 IU/kg of body weight 2-3 times per week in adolescents and adults, and 25-50 IU/kg of body weight 2-3 times per week or every other day in children aged 12 years or younger.

The most common adverse events associated with Kovaltry in the clinical trials were headache, fever, and pruritus.

[email protected]

The Food and Drug Administration has approved Idelvion, the first hemophilia B therapy with up to 14-day dosing intervals, and Kovaltry, an unmodified, full-length factor VIII compound for the treatment of hemophilia A.

Idelvion is a novel long-acting recombinant albumin fusion protein administered intravenously. In clinical trials from the PROLONG-9FP clinical development program – including phase I through III open-label, multicenter studies – the biotherapeutic agent maintained factor IX activity levels above 5% over 14 days at a dose of 75 IU/kg, resulting in a median annualized spontaneous bleeding rate of zero in patients, according to a statement by Idelvion’s manufacturer, CSL Behring. That “reduces the monthly number of units needed for prophylaxis therapy,” the company noted.

Idelvion is indicated in children and adults with hemophilia B for routine prophylaxis, as well as for on-demand control and prevention of bleeding episodes. It is also indicated for the perioperative management of bleeding. With on-demand treatment, 94% of bleeds were controlled with one infusion, and 99% were controlled with one or two infusions.

Appropriate patients 12 years and older can go up to 14 days between infusions, according to CSL Behring. The most common adverse reaction in the clinical trials was headache.

Idelvion is expected to be available later this month.

“The approval of this long-acting recombinant factor IX therapy for hemophilia B is vital, as physicians need more options to help their patients effectively and safely manage their bleeding disorder,” said Elena Santagostino, M.D., Ph.D., of the University of Milan/IRCCS Maggiore Hospital, and lead investigator of PROLONG-9FP, in a statement. “This provides them with greater freedom from frequent infusions.”

The FDA approved Kovaltry for children and adults with hemophilia A based on the results of the LEOPOLD (Long-Term Efficacy Open-Label Program in Severe Hemophilia A Disease) clinical trials. Kovaltry received approval in Europe and Canada earlier this year.

The LEOPOLD findings supported the approval for routine prophylaxis to reduce the frequency of bleeding episodes.

“In the LEOPOLD trials, Kovaltry reduced bleeding episodes in patients with hemophilia A when infused twice to three times per week with routine prophylaxis,” said Dr. Sanjay P. Ahuja, LEOPOLD investigator and director of the hemostasis and thrombosis center at University Hospitals Rainbow Babies & Children’s Hospital, Cleveland, in a statement by Kovaltry manufacturer Bayer. “Kovaltry may offer appropriate patients a twice-weekly prophylaxis dosing option.”

Dosing is 20-40 IU/kg of body weight 2-3 times per week in adolescents and adults, and 25-50 IU/kg of body weight 2-3 times per week or every other day in children aged 12 years or younger.

The most common adverse events associated with Kovaltry in the clinical trials were headache, fever, and pruritus.

[email protected]

The Food and Drug Administration has approved Idelvion, the first hemophilia B therapy with up to 14-day dosing intervals, and Kovaltry, an unmodified, full-length factor VIII compound for the treatment of hemophilia A.

Idelvion is a novel long-acting recombinant albumin fusion protein administered intravenously. In clinical trials from the PROLONG-9FP clinical development program – including phase I through III open-label, multicenter studies – the biotherapeutic agent maintained factor IX activity levels above 5% over 14 days at a dose of 75 IU/kg, resulting in a median annualized spontaneous bleeding rate of zero in patients, according to a statement by Idelvion’s manufacturer, CSL Behring. That “reduces the monthly number of units needed for prophylaxis therapy,” the company noted.

Idelvion is indicated in children and adults with hemophilia B for routine prophylaxis, as well as for on-demand control and prevention of bleeding episodes. It is also indicated for the perioperative management of bleeding. With on-demand treatment, 94% of bleeds were controlled with one infusion, and 99% were controlled with one or two infusions.

Appropriate patients 12 years and older can go up to 14 days between infusions, according to CSL Behring. The most common adverse reaction in the clinical trials was headache.

Idelvion is expected to be available later this month.

“The approval of this long-acting recombinant factor IX therapy for hemophilia B is vital, as physicians need more options to help their patients effectively and safely manage their bleeding disorder,” said Elena Santagostino, M.D., Ph.D., of the University of Milan/IRCCS Maggiore Hospital, and lead investigator of PROLONG-9FP, in a statement. “This provides them with greater freedom from frequent infusions.”

The FDA approved Kovaltry for children and adults with hemophilia A based on the results of the LEOPOLD (Long-Term Efficacy Open-Label Program in Severe Hemophilia A Disease) clinical trials. Kovaltry received approval in Europe and Canada earlier this year.

The LEOPOLD findings supported the approval for routine prophylaxis to reduce the frequency of bleeding episodes.

“In the LEOPOLD trials, Kovaltry reduced bleeding episodes in patients with hemophilia A when infused twice to three times per week with routine prophylaxis,” said Dr. Sanjay P. Ahuja, LEOPOLD investigator and director of the hemostasis and thrombosis center at University Hospitals Rainbow Babies & Children’s Hospital, Cleveland, in a statement by Kovaltry manufacturer Bayer. “Kovaltry may offer appropriate patients a twice-weekly prophylaxis dosing option.”

Dosing is 20-40 IU/kg of body weight 2-3 times per week in adolescents and adults, and 25-50 IU/kg of body weight 2-3 times per week or every other day in children aged 12 years or younger.

The most common adverse events associated with Kovaltry in the clinical trials were headache, fever, and pruritus.

[email protected]

Patients are learning about health and disease more independently than before, but such self-education may pose a unique challenge for practicing physicians. Although educated patients can assist in the critical appraisal of treatment options,¹ misinformed patients may have preconceived treatment biases and unrealistic expectations. More than 66 million Americans use the Internet daily, and recent surveys have shown 86% have used the Internet for health-related information.^2,3 With Internet use increasing, the number of patients turning to the web for medical information is increasing as well.⁴ For many patients, this information can be useful in making decisions about their health and health care.⁵

Although accessing medical information from the Internet has grown exponentially, analysis of information quality has grown considerably slower.⁶ With no regulatory body monitoring content, there is easy circumvention of the peer review process, an essential feature of academic publishing.⁷ With no external regulation, the information retrieved may be incorrect, outdated, or misleading. Many orthopedic studies have analyzed Internet content about numerous diagnoses.^3-6,8-18 Most of these studies have found this information highly variable and of poor quality.

We conducted a study to evaluate and analyze rotator cuff repair information available to the general public through the Internet; to assess changes in the quality of information over time; to determine if sites sponsored by academic institutions offered higher-quality information; and to assess whether the readability of the material varied according to DISCERN scores.

Rotator cuff repairs are among the most common surgeries performed by orthopedic surgeons. To our knowledge, this is the first study to assess the quality of web information about rotator cuff repairs. We hypothesized that the quality of information would positively correlate with the reading level of the material presented, that academic institutions would present the highest-quality information, and that the type of information presented would change over time.

Materials and Methods

We used the search phrase rotator cuff repair on the 3 most popular search engines: Google, Yahoo!, and Bing. Google is the dominant engine, taking 83.06% of total market share, followed by Yahoo! (6.86%) and Bing (4.27%).5 The first 50 websites identified by each search engine were selected for evaluation, excluding duplicates or overlapping websites. Similarly, advertisements and strictly video results lacking text were excluded. After each engine was queried, a master list of 150 websites was created for individual evaluation and assessment. To assess changes in results over time, we performed 2 searches, on November 16, 2011, and May 18, 2014.

The content of each website was analyzed for authorship, ability to contact the author, discussion of disorder, surgical treatment, complications, surgical eligibility, rehabilitation, other treatment options, and use of peer-reviewed sources. Authorship was placed in 1 of 6 categories:

1. Academic—university-affiliated physician or research group.

2. Private—physician or group without stated affiliation to an academic organization.

3. Industry—manufacturing or marketing company advertising a product or service for profit.

4. News source—bulletin or article without affiliation to a hospital or an academic institution.

5. Public education—individual or organization with noncommercial website providing third-party information (eg, Wikipedia, About.com).

6. Blog—website publishing an individual’s personal experiences in diary or journal form.

Websites were also assessed for accuracy and validity based on presence or absence of Health On the Net code (HONcode) certification and DISCERN score. Designed by the Health On the Net Foundation in 1996, HONcode provides a framework for disseminating high-quality medical information over the web.¹⁹ Website owners can request that their sites be evaluated for HONcode certification; a site that qualifies can display the HONcode seal.²⁰ The DISCERN project, initially funded by the National Health Service in the United Kingdom, judges the quality of written information available on health-related websites.²¹ It determines the quality of a publication on the basis of 16 questions: The first 8 address the publication’s reliability, the next 7 involve specific details of treatment choices, and the last is an overall rating of the website.

Website readability was assessed with the Flesch-Kincaid test. This test, designed under contract with the US Navy in 1975, has been used in other orthopedic studies.¹⁹ Regression analysis was performed to check for correlation between website readability and DISCERN score. Analysis of variance was used to analyze differences between scores.

Results

We performed a comprehensive analysis of the top 50 websites from each of the 3 search engines (N = 150 websites) (Figures 1–5, Table). Regarding authorship, our 2 searches demonstrated similar values (Figure 1). In 2011, 21% of websites were associated with an academic institution, 38% were authored by private physicians or hospital or physician groups not associated with an academic institution, 11.5% were industry-sponsored, 5% were news bulletins or media reports, 21.5% were public education websites, and 3% were personal blogs. Our 2014 search found a similar distribution of contributors. Between 2011 and 2014, the largest change was in academic authors, which decreased by 7%, from 21% to 14%. Percentage of websites authored by private physicians remained constant from the first to the second search: 38%.

When the 2011 and 2014 website content was compared, several changes were noted. Percentage of websites providing an author contact method increased from 21% to 50% (Figure 2), percentage detailing rotator cuff repairs increased from 82% to 91%, and percentage introducing treatment options in addition to surgical management increased from 11.5% to 61%. Percentage discussing surgical eligibility, however, decreased from 43% to 18%. Percentage citing peer-reviewed sources remained relatively constant (28%, 26%), as did percentage discussing surgical technique for rotator cuff repair (55%, 59%) (Figure 3). A major decrease was found in percentage of websites discussing surgical complications, 42% in 2011 down to 25% in 2014, whereas a major increase was found in percentage discussing rehabilitation, from 39% in 2011 up to 73% in 2014. In 2014, no websites discussed double- versus single-row surgery—compared with 6% in 2011. False claims remained low between 2011 and 2014. In both searches, no website guaranteed a return to sport, and few made claims of painless or bloodless surgery.

DISCERN scores for websites found during the 2014 search were averaged for each of the 6 authorship groups (Figure 4). The highest DISCERN scores were given to academic institution websites (51.6) and public education websites (49). For the academic websites, this difference was significant relative to news, blog, and private physician websites (Ps = .012, .001, .001) The lowest DISCERN scores were given to news organization websites and personal blogs. DISCERN scores were 43.8 for industry sources and 40.7 for private physician groups; the difference was not significant (P = .229). Overall mean DISCERN score for all websites was 44. Eleven percent of websites were HONcode-certified.

No correlation was found between website readability and DISCERN score; correlation coefficient r was .01 (Figure 5). For the websites in 2014, mean Flesch-Kincaid readability score was 50.17, and mean grade level was 10.98; coefficient of determination r² was 0.00012.

The Table compares our data with data from other orthopedic studies that have analyzed the quality of Internet information about various orthopedic injuries, diseases, and procedures.^{3-6,8,9,11-18} With its mean DISCERN score of 44, the present rotator cuff tear study was ranked third of 6 studies that have used this scoring system to analyze website content. Of these 6 studies, those reviewing osteosarcoma and juvenile idiopathic arthritis were ranked highest (mean scores, 49.8 and 48.9, respectively), and the study reviewing scoliosis surgery was ranked lowest (38.9). Bruce-Brand and colleagues9 recently found a mean DISCERN score of 41 for anterior cruciate ligament (ACL) reconstruction. When considering HONcode-certified websites, our Internet search for rotator cuff tears found the third lowest percentage, 10.5%, compared with the other studies (Table); the highest percentage, 30%, was found for websites discussing concussions in athletes. When considering authorship, our rotator cuff study found the third highest percentage, 76%, authored by academic centers, physicians, and public education websites; the highest percentage was found in websites discussing ACL reconstruction. Websites discussing ACL reconstruction also had the highest percentage of websites authored by industry.⁹

Discussion

To our knowledge, this is the first study specifically analyzing the quality of Internet information about rotator cuff repairs. A similar study, conducted by Starman and colleagues¹⁵ in 2010, addressed the quality of web information about 10 common sports medicine diagnoses, one of which was rotator cuff tears. In that study, only 16 of the websites included discussed rotator cuff tears. In addition, the authors used a customized, HONcode-based grading system to analyze each website, making their data difficult to compare across studies.

Ideally, a high-quality medical website should be written by a credible source and should cover a disorder, treatment options, eligibility, rehabilitation, and complications. As there is no standard grading system for analyzing web content about rotator cuff repairs, we analyzed the websites for specific information we thought should be included in a high-quality website (Figures 2, 3). When considering authorship, we found academic centers, private physicians, and educational sources comprised 76% of the sources; industry sources made up only 12%. Similar findings were noted by investigators analyzing Internet information about other orthopedic topics, including ACL reconstruction, lumbar arthroplasty, osteosarcoma, and cervical spine surgery.^5,11,22 Studies analyzing websites for information on ACL tears and distal radius fractures found have a higher percentage of industry-sponsored websites.^9,10

DISCERN showed that the highest-quality information came from websites with academic affiliations, consistent with previous studies,^3,9,17 and its mean score (51.6) was significantly higher than the scores for private physician websites, news sites, and blogs (Ps = .001, .016, .001); the least reliable information was from personal blogs and news outlets. Of note, mean DISCERN score was higher for the industry websites we found than for private physician websites (43.8 vs 40.7), though the difference was not significant (P = .229). Previous investigators considered number of industry-sponsored websites as a marker of poor quality of information relating to a given topic; however, given the DISCERN scores in our study, this might not necessarily be true.⁶ Based on the present study’s data, websites affiliated with academic institutions would be recommended for patients searching for high-quality information about rotator cuff tears.

Given DISCERN scores across studies, information about rotator cuff tears ranked below information about osteosarcoma and juvenile idiopathic arthritis but above information about scoliosis, cervical spine surgery, and ACL reconstruction (Table). DISCERN scores must be compared across studies, as there are no definitions for good and poor DISCERN scores.

Of the 4 studies that analyzed percentage of websites citing peer-reviewed sources, only our study and the study of cervical spine surgery¹⁸ analyzed that percentage as well as DISCERN score. Percentage citing peer-reviewed sources was 26% for rotator cuff tears and 24% for cervical spine surgery; the respective DISCERN scores were 44 and 43.6. As only these 2 studies could be compared, no real correlation between percentage of websites citing peer-reviewed sources and the quality of the content on a given topic can be assessed. More research into this relationship is needed. One already delineated association is the correlation between HONcode-certified sites and high DISCERN scores.²¹ For high-quality medical information, physicians can direct their patients both to academic institution websites and to HONcode-certified websites.

When we compared the present study with previous investigations, we found a large difference between search results for a given topic. In 2013, Duncan and colleagues⁶ and Bruce-Brand and colleagues⁹ used similar study designs (eg, search terms, search engines) for their investigations of quality of web information. Their results, however, were widely different. For example, percentages of industry authorship were 4.5% (Duncan and colleagues⁶) and 64% (Bruce-Brand and colleagues⁹). This inconsistency between studies conducted during similar periods might be related to what appears at the top of the results queue for a search. Duncan and colleagues⁶ analyzed 200 websites, Bruce-Brand and colleagues⁹ only 45. Industries may have made financial arrangements and used search engine optimization techniques to have their websites listed first in search results.

In our study, we also analyzed how web information has changed over time. On the Internet, information changes daily, and we hypothesized that the content found during our 2 searches (2011, 2014) would yield different results. Surprisingly, the data were similar, particularly concerning authorship (Figures 1, 2). In both searches, the largest authorship source was private physician or physician groups (38% in 2011 and 2014). Other authorship sources showed little change in percentage between searches. As for content, we found both increases and decreases in specific web information. Ability to contact authors increased from 21% (2011) to 50% (2014). We think it is important that websites offer a communication channel to people who read the medical information the sites provide. Percentage of websites discussing nonoperative treatment options increased from 11.5% to 61%. Therefore, patients in 2014 were being introduced to more options (in addition to surgery) for managing shoulder pain—an improvement in quality of information between the searches. Percentage of websites discussing surgical eligibility, however, decreased from 43% to 18%—a negative development in information quality. Another decrease, from 42% to 25%, was found for websites discussing surgical complications. Given the data as a whole, and our finding both negative and positive changes, it appears the quality of web content has not improved significantly. Interestingly, no websites discussed double- versus single-row surgery in 2014, but 6% did so in 2011.

Lost in the discussion of quality and reliability of information is whether patients comprehend what they are reading.²³ Yi and colleagues¹⁹ recentlyassessed the readability level of arthroscopy information in articles published online by the American Academy of Orthopaedic Surgeons (AAOS) and the Arthroscopy Association of North America (AANA). The investigators used the Flesch-Kincaid readability test to determine readability level in terms of grade level. They found that the majority of the patient education articles on the AAOS and AANA sites had a readability level far above the national average; only 4 articles were written at or below the eighth-grade level, the current average reading level in the United States.²⁴ Information that is not comprehensible is of no use to patients, and information that physicians and researchers consider high-quality might not be what patients consider high-quality. As we pursue higher-quality web content, we need to consider that its audience includes nonmedical readers, our patients. In the present study, we found that the readability of a website had no correlation with the site’s DISCERN score (Figure 5). Therefore, for information about rotator cuff repairs, higher-quality websites are no harder than lower-quality sites for patients to comprehend. The Flesch-Kincaid readability test is flawed in that it considers only total number of syllables per word and words per sentence, not nontextual elements of patient education materials, such as illustrations on a website. The 10.98 mean grade level found in our study is higher than the levels found for most studies reviewed by Yi and colleagues.¹⁹

This study had several limitations. During an Internet search, the number of websites a user visits drops precipitously after the first page of results. Studies have shown the top 20 sites in a given search receive 97% of the views, and the top 3 receive 58.4%. Whether patients visit websites far down in the list of 150 we found in our given search is unknown. Last, the Flesch-Kincaid readability test is flawed in several ways but nevertheless is used extensively in research. Grading is based on number of words and syllables used in a given sentence; it does not take into account the complexity or common usage of a given word or definition. Therefore, websites may receive low Flesch-Kincaid scores—indicating ease of reading—despite their use of complex medical terminology and jargon that complicate patients’ comprehension of the material.

Conclusion

Numerous authors have evaluated orthopedic patients’ accessing of medical information from the Internet. Although the Internet makes access easier, unreliable content can lead patients to develop certain notions about the direction of their care and certain expectations regarding their clinical outcomes. With there being no regulatory body monitoring content, the peer review process, an essential feature of academic publishing, can be easily circumvented.²⁵

In this study, the highest-quality websites had academic affiliations. Quality of information about rotator cuff repairs was similar to what was found for other orthopedic topics in comparable studies. Surprisingly, there was little change in authorship and content of web information between our 2 search periods (2011, 2014). Although there has been a rapid increase in the number of medical websites, quality of content seems not to have changed significantly. Patients look to physicians for guidance but increasingly are accessing the Internet for additional information. It is essential that physicians understand the quality of information available on the Internet when counseling patients regarding surgery.

Patients are learning about health and disease more independently than before, but such self-education may pose a unique challenge for practicing physicians. Although educated patients can assist in the critical appraisal of treatment options,¹ misinformed patients may have preconceived treatment biases and unrealistic expectations. More than 66 million Americans use the Internet daily, and recent surveys have shown 86% have used the Internet for health-related information.^2,3 With Internet use increasing, the number of patients turning to the web for medical information is increasing as well.⁴ For many patients, this information can be useful in making decisions about their health and health care.⁵

Although accessing medical information from the Internet has grown exponentially, analysis of information quality has grown considerably slower.⁶ With no regulatory body monitoring content, there is easy circumvention of the peer review process, an essential feature of academic publishing.⁷ With no external regulation, the information retrieved may be incorrect, outdated, or misleading. Many orthopedic studies have analyzed Internet content about numerous diagnoses.^3-6,8-18 Most of these studies have found this information highly variable and of poor quality.

We conducted a study to evaluate and analyze rotator cuff repair information available to the general public through the Internet; to assess changes in the quality of information over time; to determine if sites sponsored by academic institutions offered higher-quality information; and to assess whether the readability of the material varied according to DISCERN scores.

Rotator cuff repairs are among the most common surgeries performed by orthopedic surgeons. To our knowledge, this is the first study to assess the quality of web information about rotator cuff repairs. We hypothesized that the quality of information would positively correlate with the reading level of the material presented, that academic institutions would present the highest-quality information, and that the type of information presented would change over time.

Materials and Methods

We used the search phrase rotator cuff repair on the 3 most popular search engines: Google, Yahoo!, and Bing. Google is the dominant engine, taking 83.06% of total market share, followed by Yahoo! (6.86%) and Bing (4.27%).5 The first 50 websites identified by each search engine were selected for evaluation, excluding duplicates or overlapping websites. Similarly, advertisements and strictly video results lacking text were excluded. After each engine was queried, a master list of 150 websites was created for individual evaluation and assessment. To assess changes in results over time, we performed 2 searches, on November 16, 2011, and May 18, 2014.

The content of each website was analyzed for authorship, ability to contact the author, discussion of disorder, surgical treatment, complications, surgical eligibility, rehabilitation, other treatment options, and use of peer-reviewed sources. Authorship was placed in 1 of 6 categories:

1. Academic—university-affiliated physician or research group.

2. Private—physician or group without stated affiliation to an academic organization.

3. Industry—manufacturing or marketing company advertising a product or service for profit.

4. News source—bulletin or article without affiliation to a hospital or an academic institution.

5. Public education—individual or organization with noncommercial website providing third-party information (eg, Wikipedia, About.com).

6. Blog—website publishing an individual’s personal experiences in diary or journal form.

Websites were also assessed for accuracy and validity based on presence or absence of Health On the Net code (HONcode) certification and DISCERN score. Designed by the Health On the Net Foundation in 1996, HONcode provides a framework for disseminating high-quality medical information over the web.¹⁹ Website owners can request that their sites be evaluated for HONcode certification; a site that qualifies can display the HONcode seal.²⁰ The DISCERN project, initially funded by the National Health Service in the United Kingdom, judges the quality of written information available on health-related websites.²¹ It determines the quality of a publication on the basis of 16 questions: The first 8 address the publication’s reliability, the next 7 involve specific details of treatment choices, and the last is an overall rating of the website.

Website readability was assessed with the Flesch-Kincaid test. This test, designed under contract with the US Navy in 1975, has been used in other orthopedic studies.¹⁹ Regression analysis was performed to check for correlation between website readability and DISCERN score. Analysis of variance was used to analyze differences between scores.

Results

We performed a comprehensive analysis of the top 50 websites from each of the 3 search engines (N = 150 websites) (Figures 1–5, Table). Regarding authorship, our 2 searches demonstrated similar values (Figure 1). In 2011, 21% of websites were associated with an academic institution, 38% were authored by private physicians or hospital or physician groups not associated with an academic institution, 11.5% were industry-sponsored, 5% were news bulletins or media reports, 21.5% were public education websites, and 3% were personal blogs. Our 2014 search found a similar distribution of contributors. Between 2011 and 2014, the largest change was in academic authors, which decreased by 7%, from 21% to 14%. Percentage of websites authored by private physicians remained constant from the first to the second search: 38%.

When the 2011 and 2014 website content was compared, several changes were noted. Percentage of websites providing an author contact method increased from 21% to 50% (Figure 2), percentage detailing rotator cuff repairs increased from 82% to 91%, and percentage introducing treatment options in addition to surgical management increased from 11.5% to 61%. Percentage discussing surgical eligibility, however, decreased from 43% to 18%. Percentage citing peer-reviewed sources remained relatively constant (28%, 26%), as did percentage discussing surgical technique for rotator cuff repair (55%, 59%) (Figure 3). A major decrease was found in percentage of websites discussing surgical complications, 42% in 2011 down to 25% in 2014, whereas a major increase was found in percentage discussing rehabilitation, from 39% in 2011 up to 73% in 2014. In 2014, no websites discussed double- versus single-row surgery—compared with 6% in 2011. False claims remained low between 2011 and 2014. In both searches, no website guaranteed a return to sport, and few made claims of painless or bloodless surgery.

DISCERN scores for websites found during the 2014 search were averaged for each of the 6 authorship groups (Figure 4). The highest DISCERN scores were given to academic institution websites (51.6) and public education websites (49). For the academic websites, this difference was significant relative to news, blog, and private physician websites (Ps = .012, .001, .001) The lowest DISCERN scores were given to news organization websites and personal blogs. DISCERN scores were 43.8 for industry sources and 40.7 for private physician groups; the difference was not significant (P = .229). Overall mean DISCERN score for all websites was 44. Eleven percent of websites were HONcode-certified.

No correlation was found between website readability and DISCERN score; correlation coefficient r was .01 (Figure 5). For the websites in 2014, mean Flesch-Kincaid readability score was 50.17, and mean grade level was 10.98; coefficient of determination r² was 0.00012.

The Table compares our data with data from other orthopedic studies that have analyzed the quality of Internet information about various orthopedic injuries, diseases, and procedures.^{3-6,8,9,11-18} With its mean DISCERN score of 44, the present rotator cuff tear study was ranked third of 6 studies that have used this scoring system to analyze website content. Of these 6 studies, those reviewing osteosarcoma and juvenile idiopathic arthritis were ranked highest (mean scores, 49.8 and 48.9, respectively), and the study reviewing scoliosis surgery was ranked lowest (38.9). Bruce-Brand and colleagues9 recently found a mean DISCERN score of 41 for anterior cruciate ligament (ACL) reconstruction. When considering HONcode-certified websites, our Internet search for rotator cuff tears found the third lowest percentage, 10.5%, compared with the other studies (Table); the highest percentage, 30%, was found for websites discussing concussions in athletes. When considering authorship, our rotator cuff study found the third highest percentage, 76%, authored by academic centers, physicians, and public education websites; the highest percentage was found in websites discussing ACL reconstruction. Websites discussing ACL reconstruction also had the highest percentage of websites authored by industry.⁹

Discussion

To our knowledge, this is the first study specifically analyzing the quality of Internet information about rotator cuff repairs. A similar study, conducted by Starman and colleagues¹⁵ in 2010, addressed the quality of web information about 10 common sports medicine diagnoses, one of which was rotator cuff tears. In that study, only 16 of the websites included discussed rotator cuff tears. In addition, the authors used a customized, HONcode-based grading system to analyze each website, making their data difficult to compare across studies.

Ideally, a high-quality medical website should be written by a credible source and should cover a disorder, treatment options, eligibility, rehabilitation, and complications. As there is no standard grading system for analyzing web content about rotator cuff repairs, we analyzed the websites for specific information we thought should be included in a high-quality website (Figures 2, 3). When considering authorship, we found academic centers, private physicians, and educational sources comprised 76% of the sources; industry sources made up only 12%. Similar findings were noted by investigators analyzing Internet information about other orthopedic topics, including ACL reconstruction, lumbar arthroplasty, osteosarcoma, and cervical spine surgery.^5,11,22 Studies analyzing websites for information on ACL tears and distal radius fractures found have a higher percentage of industry-sponsored websites.^9,10

DISCERN showed that the highest-quality information came from websites with academic affiliations, consistent with previous studies,^3,9,17 and its mean score (51.6) was significantly higher than the scores for private physician websites, news sites, and blogs (Ps = .001, .016, .001); the least reliable information was from personal blogs and news outlets. Of note, mean DISCERN score was higher for the industry websites we found than for private physician websites (43.8 vs 40.7), though the difference was not significant (P = .229). Previous investigators considered number of industry-sponsored websites as a marker of poor quality of information relating to a given topic; however, given the DISCERN scores in our study, this might not necessarily be true.⁶ Based on the present study’s data, websites affiliated with academic institutions would be recommended for patients searching for high-quality information about rotator cuff tears.

Given DISCERN scores across studies, information about rotator cuff tears ranked below information about osteosarcoma and juvenile idiopathic arthritis but above information about scoliosis, cervical spine surgery, and ACL reconstruction (Table). DISCERN scores must be compared across studies, as there are no definitions for good and poor DISCERN scores.

Of the 4 studies that analyzed percentage of websites citing peer-reviewed sources, only our study and the study of cervical spine surgery¹⁸ analyzed that percentage as well as DISCERN score. Percentage citing peer-reviewed sources was 26% for rotator cuff tears and 24% for cervical spine surgery; the respective DISCERN scores were 44 and 43.6. As only these 2 studies could be compared, no real correlation between percentage of websites citing peer-reviewed sources and the quality of the content on a given topic can be assessed. More research into this relationship is needed. One already delineated association is the correlation between HONcode-certified sites and high DISCERN scores.²¹ For high-quality medical information, physicians can direct their patients both to academic institution websites and to HONcode-certified websites.

When we compared the present study with previous investigations, we found a large difference between search results for a given topic. In 2013, Duncan and colleagues⁶ and Bruce-Brand and colleagues⁹ used similar study designs (eg, search terms, search engines) for their investigations of quality of web information. Their results, however, were widely different. For example, percentages of industry authorship were 4.5% (Duncan and colleagues⁶) and 64% (Bruce-Brand and colleagues⁹). This inconsistency between studies conducted during similar periods might be related to what appears at the top of the results queue for a search. Duncan and colleagues⁶ analyzed 200 websites, Bruce-Brand and colleagues⁹ only 45. Industries may have made financial arrangements and used search engine optimization techniques to have their websites listed first in search results.

In our study, we also analyzed how web information has changed over time. On the Internet, information changes daily, and we hypothesized that the content found during our 2 searches (2011, 2014) would yield different results. Surprisingly, the data were similar, particularly concerning authorship (Figures 1, 2). In both searches, the largest authorship source was private physician or physician groups (38% in 2011 and 2014). Other authorship sources showed little change in percentage between searches. As for content, we found both increases and decreases in specific web information. Ability to contact authors increased from 21% (2011) to 50% (2014). We think it is important that websites offer a communication channel to people who read the medical information the sites provide. Percentage of websites discussing nonoperative treatment options increased from 11.5% to 61%. Therefore, patients in 2014 were being introduced to more options (in addition to surgery) for managing shoulder pain—an improvement in quality of information between the searches. Percentage of websites discussing surgical eligibility, however, decreased from 43% to 18%—a negative development in information quality. Another decrease, from 42% to 25%, was found for websites discussing surgical complications. Given the data as a whole, and our finding both negative and positive changes, it appears the quality of web content has not improved significantly. Interestingly, no websites discussed double- versus single-row surgery in 2014, but 6% did so in 2011.

Lost in the discussion of quality and reliability of information is whether patients comprehend what they are reading.²³ Yi and colleagues¹⁹ recentlyassessed the readability level of arthroscopy information in articles published online by the American Academy of Orthopaedic Surgeons (AAOS) and the Arthroscopy Association of North America (AANA). The investigators used the Flesch-Kincaid readability test to determine readability level in terms of grade level. They found that the majority of the patient education articles on the AAOS and AANA sites had a readability level far above the national average; only 4 articles were written at or below the eighth-grade level, the current average reading level in the United States.²⁴ Information that is not comprehensible is of no use to patients, and information that physicians and researchers consider high-quality might not be what patients consider high-quality. As we pursue higher-quality web content, we need to consider that its audience includes nonmedical readers, our patients. In the present study, we found that the readability of a website had no correlation with the site’s DISCERN score (Figure 5). Therefore, for information about rotator cuff repairs, higher-quality websites are no harder than lower-quality sites for patients to comprehend. The Flesch-Kincaid readability test is flawed in that it considers only total number of syllables per word and words per sentence, not nontextual elements of patient education materials, such as illustrations on a website. The 10.98 mean grade level found in our study is higher than the levels found for most studies reviewed by Yi and colleagues.¹⁹

This study had several limitations. During an Internet search, the number of websites a user visits drops precipitously after the first page of results. Studies have shown the top 20 sites in a given search receive 97% of the views, and the top 3 receive 58.4%. Whether patients visit websites far down in the list of 150 we found in our given search is unknown. Last, the Flesch-Kincaid readability test is flawed in several ways but nevertheless is used extensively in research. Grading is based on number of words and syllables used in a given sentence; it does not take into account the complexity or common usage of a given word or definition. Therefore, websites may receive low Flesch-Kincaid scores—indicating ease of reading—despite their use of complex medical terminology and jargon that complicate patients’ comprehension of the material.

Conclusion

Numerous authors have evaluated orthopedic patients’ accessing of medical information from the Internet. Although the Internet makes access easier, unreliable content can lead patients to develop certain notions about the direction of their care and certain expectations regarding their clinical outcomes. With there being no regulatory body monitoring content, the peer review process, an essential feature of academic publishing, can be easily circumvented.²⁵

In this study, the highest-quality websites had academic affiliations. Quality of information about rotator cuff repairs was similar to what was found for other orthopedic topics in comparable studies. Surprisingly, there was little change in authorship and content of web information between our 2 search periods (2011, 2014). Although there has been a rapid increase in the number of medical websites, quality of content seems not to have changed significantly. Patients look to physicians for guidance but increasingly are accessing the Internet for additional information. It is essential that physicians understand the quality of information available on the Internet when counseling patients regarding surgery.

Patients are learning about health and disease more independently than before, but such self-education may pose a unique challenge for practicing physicians. Although educated patients can assist in the critical appraisal of treatment options,¹ misinformed patients may have preconceived treatment biases and unrealistic expectations. More than 66 million Americans use the Internet daily, and recent surveys have shown 86% have used the Internet for health-related information.^2,3 With Internet use increasing, the number of patients turning to the web for medical information is increasing as well.⁴ For many patients, this information can be useful in making decisions about their health and health care.⁵

Although accessing medical information from the Internet has grown exponentially, analysis of information quality has grown considerably slower.⁶ With no regulatory body monitoring content, there is easy circumvention of the peer review process, an essential feature of academic publishing.⁷ With no external regulation, the information retrieved may be incorrect, outdated, or misleading. Many orthopedic studies have analyzed Internet content about numerous diagnoses.^3-6,8-18 Most of these studies have found this information highly variable and of poor quality.

We conducted a study to evaluate and analyze rotator cuff repair information available to the general public through the Internet; to assess changes in the quality of information over time; to determine if sites sponsored by academic institutions offered higher-quality information; and to assess whether the readability of the material varied according to DISCERN scores.

Rotator cuff repairs are among the most common surgeries performed by orthopedic surgeons. To our knowledge, this is the first study to assess the quality of web information about rotator cuff repairs. We hypothesized that the quality of information would positively correlate with the reading level of the material presented, that academic institutions would present the highest-quality information, and that the type of information presented would change over time.

Materials and Methods

We used the search phrase rotator cuff repair on the 3 most popular search engines: Google, Yahoo!, and Bing. Google is the dominant engine, taking 83.06% of total market share, followed by Yahoo! (6.86%) and Bing (4.27%).5 The first 50 websites identified by each search engine were selected for evaluation, excluding duplicates or overlapping websites. Similarly, advertisements and strictly video results lacking text were excluded. After each engine was queried, a master list of 150 websites was created for individual evaluation and assessment. To assess changes in results over time, we performed 2 searches, on November 16, 2011, and May 18, 2014.

The content of each website was analyzed for authorship, ability to contact the author, discussion of disorder, surgical treatment, complications, surgical eligibility, rehabilitation, other treatment options, and use of peer-reviewed sources. Authorship was placed in 1 of 6 categories:

1. Academic—university-affiliated physician or research group.

2. Private—physician or group without stated affiliation to an academic organization.

3. Industry—manufacturing or marketing company advertising a product or service for profit.

4. News source—bulletin or article without affiliation to a hospital or an academic institution.

5. Public education—individual or organization with noncommercial website providing third-party information (eg, Wikipedia, About.com).

6. Blog—website publishing an individual’s personal experiences in diary or journal form.

Websites were also assessed for accuracy and validity based on presence or absence of Health On the Net code (HONcode) certification and DISCERN score. Designed by the Health On the Net Foundation in 1996, HONcode provides a framework for disseminating high-quality medical information over the web.¹⁹ Website owners can request that their sites be evaluated for HONcode certification; a site that qualifies can display the HONcode seal.²⁰ The DISCERN project, initially funded by the National Health Service in the United Kingdom, judges the quality of written information available on health-related websites.²¹ It determines the quality of a publication on the basis of 16 questions: The first 8 address the publication’s reliability, the next 7 involve specific details of treatment choices, and the last is an overall rating of the website.

Website readability was assessed with the Flesch-Kincaid test. This test, designed under contract with the US Navy in 1975, has been used in other orthopedic studies.¹⁹ Regression analysis was performed to check for correlation between website readability and DISCERN score. Analysis of variance was used to analyze differences between scores.

Results

We performed a comprehensive analysis of the top 50 websites from each of the 3 search engines (N = 150 websites) (Figures 1–5, Table). Regarding authorship, our 2 searches demonstrated similar values (Figure 1). In 2011, 21% of websites were associated with an academic institution, 38% were authored by private physicians or hospital or physician groups not associated with an academic institution, 11.5% were industry-sponsored, 5% were news bulletins or media reports, 21.5% were public education websites, and 3% were personal blogs. Our 2014 search found a similar distribution of contributors. Between 2011 and 2014, the largest change was in academic authors, which decreased by 7%, from 21% to 14%. Percentage of websites authored by private physicians remained constant from the first to the second search: 38%.

When the 2011 and 2014 website content was compared, several changes were noted. Percentage of websites providing an author contact method increased from 21% to 50% (Figure 2), percentage detailing rotator cuff repairs increased from 82% to 91%, and percentage introducing treatment options in addition to surgical management increased from 11.5% to 61%. Percentage discussing surgical eligibility, however, decreased from 43% to 18%. Percentage citing peer-reviewed sources remained relatively constant (28%, 26%), as did percentage discussing surgical technique for rotator cuff repair (55%, 59%) (Figure 3). A major decrease was found in percentage of websites discussing surgical complications, 42% in 2011 down to 25% in 2014, whereas a major increase was found in percentage discussing rehabilitation, from 39% in 2011 up to 73% in 2014. In 2014, no websites discussed double- versus single-row surgery—compared with 6% in 2011. False claims remained low between 2011 and 2014. In both searches, no website guaranteed a return to sport, and few made claims of painless or bloodless surgery.

DISCERN scores for websites found during the 2014 search were averaged for each of the 6 authorship groups (Figure 4). The highest DISCERN scores were given to academic institution websites (51.6) and public education websites (49). For the academic websites, this difference was significant relative to news, blog, and private physician websites (Ps = .012, .001, .001) The lowest DISCERN scores were given to news organization websites and personal blogs. DISCERN scores were 43.8 for industry sources and 40.7 for private physician groups; the difference was not significant (P = .229). Overall mean DISCERN score for all websites was 44. Eleven percent of websites were HONcode-certified.

No correlation was found between website readability and DISCERN score; correlation coefficient r was .01 (Figure 5). For the websites in 2014, mean Flesch-Kincaid readability score was 50.17, and mean grade level was 10.98; coefficient of determination r² was 0.00012.

The Table compares our data with data from other orthopedic studies that have analyzed the quality of Internet information about various orthopedic injuries, diseases, and procedures.^{3-6,8,9,11-18} With its mean DISCERN score of 44, the present rotator cuff tear study was ranked third of 6 studies that have used this scoring system to analyze website content. Of these 6 studies, those reviewing osteosarcoma and juvenile idiopathic arthritis were ranked highest (mean scores, 49.8 and 48.9, respectively), and the study reviewing scoliosis surgery was ranked lowest (38.9). Bruce-Brand and colleagues9 recently found a mean DISCERN score of 41 for anterior cruciate ligament (ACL) reconstruction. When considering HONcode-certified websites, our Internet search for rotator cuff tears found the third lowest percentage, 10.5%, compared with the other studies (Table); the highest percentage, 30%, was found for websites discussing concussions in athletes. When considering authorship, our rotator cuff study found the third highest percentage, 76%, authored by academic centers, physicians, and public education websites; the highest percentage was found in websites discussing ACL reconstruction. Websites discussing ACL reconstruction also had the highest percentage of websites authored by industry.⁹

Discussion

To our knowledge, this is the first study specifically analyzing the quality of Internet information about rotator cuff repairs. A similar study, conducted by Starman and colleagues¹⁵ in 2010, addressed the quality of web information about 10 common sports medicine diagnoses, one of which was rotator cuff tears. In that study, only 16 of the websites included discussed rotator cuff tears. In addition, the authors used a customized, HONcode-based grading system to analyze each website, making their data difficult to compare across studies.

Ideally, a high-quality medical website should be written by a credible source and should cover a disorder, treatment options, eligibility, rehabilitation, and complications. As there is no standard grading system for analyzing web content about rotator cuff repairs, we analyzed the websites for specific information we thought should be included in a high-quality website (Figures 2, 3). When considering authorship, we found academic centers, private physicians, and educational sources comprised 76% of the sources; industry sources made up only 12%. Similar findings were noted by investigators analyzing Internet information about other orthopedic topics, including ACL reconstruction, lumbar arthroplasty, osteosarcoma, and cervical spine surgery.^5,11,22 Studies analyzing websites for information on ACL tears and distal radius fractures found have a higher percentage of industry-sponsored websites.^9,10

DISCERN showed that the highest-quality information came from websites with academic affiliations, consistent with previous studies,^3,9,17 and its mean score (51.6) was significantly higher than the scores for private physician websites, news sites, and blogs (Ps = .001, .016, .001); the least reliable information was from personal blogs and news outlets. Of note, mean DISCERN score was higher for the industry websites we found than for private physician websites (43.8 vs 40.7), though the difference was not significant (P = .229). Previous investigators considered number of industry-sponsored websites as a marker of poor quality of information relating to a given topic; however, given the DISCERN scores in our study, this might not necessarily be true.⁶ Based on the present study’s data, websites affiliated with academic institutions would be recommended for patients searching for high-quality information about rotator cuff tears.

Given DISCERN scores across studies, information about rotator cuff tears ranked below information about osteosarcoma and juvenile idiopathic arthritis but above information about scoliosis, cervical spine surgery, and ACL reconstruction (Table). DISCERN scores must be compared across studies, as there are no definitions for good and poor DISCERN scores.

Of the 4 studies that analyzed percentage of websites citing peer-reviewed sources, only our study and the study of cervical spine surgery¹⁸ analyzed that percentage as well as DISCERN score. Percentage citing peer-reviewed sources was 26% for rotator cuff tears and 24% for cervical spine surgery; the respective DISCERN scores were 44 and 43.6. As only these 2 studies could be compared, no real correlation between percentage of websites citing peer-reviewed sources and the quality of the content on a given topic can be assessed. More research into this relationship is needed. One already delineated association is the correlation between HONcode-certified sites and high DISCERN scores.²¹ For high-quality medical information, physicians can direct their patients both to academic institution websites and to HONcode-certified websites.

When we compared the present study with previous investigations, we found a large difference between search results for a given topic. In 2013, Duncan and colleagues⁶ and Bruce-Brand and colleagues⁹ used similar study designs (eg, search terms, search engines) for their investigations of quality of web information. Their results, however, were widely different. For example, percentages of industry authorship were 4.5% (Duncan and colleagues⁶) and 64% (Bruce-Brand and colleagues⁹). This inconsistency between studies conducted during similar periods might be related to what appears at the top of the results queue for a search. Duncan and colleagues⁶ analyzed 200 websites, Bruce-Brand and colleagues⁹ only 45. Industries may have made financial arrangements and used search engine optimization techniques to have their websites listed first in search results.

In our study, we also analyzed how web information has changed over time. On the Internet, information changes daily, and we hypothesized that the content found during our 2 searches (2011, 2014) would yield different results. Surprisingly, the data were similar, particularly concerning authorship (Figures 1, 2). In both searches, the largest authorship source was private physician or physician groups (38% in 2011 and 2014). Other authorship sources showed little change in percentage between searches. As for content, we found both increases and decreases in specific web information. Ability to contact authors increased from 21% (2011) to 50% (2014). We think it is important that websites offer a communication channel to people who read the medical information the sites provide. Percentage of websites discussing nonoperative treatment options increased from 11.5% to 61%. Therefore, patients in 2014 were being introduced to more options (in addition to surgery) for managing shoulder pain—an improvement in quality of information between the searches. Percentage of websites discussing surgical eligibility, however, decreased from 43% to 18%—a negative development in information quality. Another decrease, from 42% to 25%, was found for websites discussing surgical complications. Given the data as a whole, and our finding both negative and positive changes, it appears the quality of web content has not improved significantly. Interestingly, no websites discussed double- versus single-row surgery in 2014, but 6% did so in 2011.

Lost in the discussion of quality and reliability of information is whether patients comprehend what they are reading.²³ Yi and colleagues¹⁹ recentlyassessed the readability level of arthroscopy information in articles published online by the American Academy of Orthopaedic Surgeons (AAOS) and the Arthroscopy Association of North America (AANA). The investigators used the Flesch-Kincaid readability test to determine readability level in terms of grade level. They found that the majority of the patient education articles on the AAOS and AANA sites had a readability level far above the national average; only 4 articles were written at or below the eighth-grade level, the current average reading level in the United States.²⁴ Information that is not comprehensible is of no use to patients, and information that physicians and researchers consider high-quality might not be what patients consider high-quality. As we pursue higher-quality web content, we need to consider that its audience includes nonmedical readers, our patients. In the present study, we found that the readability of a website had no correlation with the site’s DISCERN score (Figure 5). Therefore, for information about rotator cuff repairs, higher-quality websites are no harder than lower-quality sites for patients to comprehend. The Flesch-Kincaid readability test is flawed in that it considers only total number of syllables per word and words per sentence, not nontextual elements of patient education materials, such as illustrations on a website. The 10.98 mean grade level found in our study is higher than the levels found for most studies reviewed by Yi and colleagues.¹⁹

This study had several limitations. During an Internet search, the number of websites a user visits drops precipitously after the first page of results. Studies have shown the top 20 sites in a given search receive 97% of the views, and the top 3 receive 58.4%. Whether patients visit websites far down in the list of 150 we found in our given search is unknown. Last, the Flesch-Kincaid readability test is flawed in several ways but nevertheless is used extensively in research. Grading is based on number of words and syllables used in a given sentence; it does not take into account the complexity or common usage of a given word or definition. Therefore, websites may receive low Flesch-Kincaid scores—indicating ease of reading—despite their use of complex medical terminology and jargon that complicate patients’ comprehension of the material.

Conclusion

Numerous authors have evaluated orthopedic patients’ accessing of medical information from the Internet. Although the Internet makes access easier, unreliable content can lead patients to develop certain notions about the direction of their care and certain expectations regarding their clinical outcomes. With there being no regulatory body monitoring content, the peer review process, an essential feature of academic publishing, can be easily circumvented.²⁵

In this study, the highest-quality websites had academic affiliations. Quality of information about rotator cuff repairs was similar to what was found for other orthopedic topics in comparable studies. Surprisingly, there was little change in authorship and content of web information between our 2 search periods (2011, 2014). Although there has been a rapid increase in the number of medical websites, quality of content seems not to have changed significantly. Patients look to physicians for guidance but increasingly are accessing the Internet for additional information. It is essential that physicians understand the quality of information available on the Internet when counseling patients regarding surgery.

BOSTON – Access to and acceptance of thyroid cancer surgery varies by race, with black patients in particular appearing to be disadvantaged, compared with whites, investigators reported.

A review of data on nearly 138,000 patients diagnosed with thyroid cancer showed that blacks were significantly less likely than were whites to be offered surgery – despite its generally excellent outcomes and low rates of morbidity and mortality, reported Dr. Herbert Castillo Valladares and his colleagues from the department of surgery at the Yale University in New Haven, Conn.

SciePro/Science Source

American Indians/Alaskan natives and Asian/Pacific Islanders were significantly more likely to refuse surgery than were whites, the investigators also reported in a poster session at the Society of Surgical Oncology annual cancer symposium.

“In this project, we wanted to focus on the provider-level factors that might be perpetuating these racial disparities, and it appears that we need to educate some providers about the recommendation of surgery or how to educate patients who refuse thyroid cancer surgery,” Dr. Valladares said in an interview.

The investigators noted that although incidence and prevalence rates of thyroid cancer are similar among various racial groups, survival differs by race, and they wanted to find out why. To do so, they polled the Surveillance, Epidemiology, and End Results (SEER) registry to identify 137,483 patients diagnosed with thyroid cancer during 1988-2012. Results were stratified by thyroid cancer type, either papillary, medullary, follicular, or anaplastic.

In all, 82% of the sample were white, 75% were female, 87% had a diagnosis of papillary thyroid cancer, and 95% underwent thyroid cancer surgery.

In logistic regression analysis that controlled for race, the investigators found that blacks, Asian/Pacific Islanders, and persons of unknown race were significantly less likely than whites were to have thyroid cancer surgery (odds ratios, 0.7, 0.82, and 0.34, respectively; P for each less than .0001).

Similarly, surgery was more frequently not recommended for blacks (OR, 1.34; P less than .0001), Asian/Pacific Islanders (OR, 1.2; P = .004) and those of unknown race (OR, 3.06; P less than .0001).

American Indians/Alaskan natives and Asian/Pacific Islanders were also significantly more likely than were whites to refuse surgery (OR, 4.45; P = .0001; OR, 2.96; P less than .0001, respectively).

Compared with whites, blacks – but not other races – had significantly worse 5-year survival (hazard ratio, 1.14; P = .0002).

In an analysis by cancer type, the investigators saw that race was not a predictor for surgery recommendation or refusal of surgery by patients with medullary or anaplastic cancer. However, among patients with papillary thyroid cancer, the most common type, surgery was recommended less often for blacks (OR, 1.2), Asian/Pacific Islanders (OR, 1.3), and patients of unknown race (OR, 3.1; all comparisons significant by 95% confidence interval).

Among patients with follicular histology, patients of unknown race were significantly less likely than were whites to have the surgery recommended (OR, 2.7; significant by 95% CI).

Dr. Valladares explained that the SEER data set does not include information about provider type, such as those in community based versus academic settings, so the next step will be to find a method for analyzing factors at both the patient level and the provider level that might influence recommendations for surgery or patient refusals to accept surgery.

The study was supported by the Paul H. Lavietes, M.D., Summer Research Fellowship of Yale University. The investigators reported no relevant conflicts of interest.

BOSTON – Access to and acceptance of thyroid cancer surgery varies by race, with black patients in particular appearing to be disadvantaged, compared with whites, investigators reported.

A review of data on nearly 138,000 patients diagnosed with thyroid cancer showed that blacks were significantly less likely than were whites to be offered surgery – despite its generally excellent outcomes and low rates of morbidity and mortality, reported Dr. Herbert Castillo Valladares and his colleagues from the department of surgery at the Yale University in New Haven, Conn.

SciePro/Science Source

American Indians/Alaskan natives and Asian/Pacific Islanders were significantly more likely to refuse surgery than were whites, the investigators also reported in a poster session at the Society of Surgical Oncology annual cancer symposium.

“In this project, we wanted to focus on the provider-level factors that might be perpetuating these racial disparities, and it appears that we need to educate some providers about the recommendation of surgery or how to educate patients who refuse thyroid cancer surgery,” Dr. Valladares said in an interview.

The investigators noted that although incidence and prevalence rates of thyroid cancer are similar among various racial groups, survival differs by race, and they wanted to find out why. To do so, they polled the Surveillance, Epidemiology, and End Results (SEER) registry to identify 137,483 patients diagnosed with thyroid cancer during 1988-2012. Results were stratified by thyroid cancer type, either papillary, medullary, follicular, or anaplastic.

In all, 82% of the sample were white, 75% were female, 87% had a diagnosis of papillary thyroid cancer, and 95% underwent thyroid cancer surgery.

In logistic regression analysis that controlled for race, the investigators found that blacks, Asian/Pacific Islanders, and persons of unknown race were significantly less likely than whites were to have thyroid cancer surgery (odds ratios, 0.7, 0.82, and 0.34, respectively; P for each less than .0001).

Similarly, surgery was more frequently not recommended for blacks (OR, 1.34; P less than .0001), Asian/Pacific Islanders (OR, 1.2; P = .004) and those of unknown race (OR, 3.06; P less than .0001).

American Indians/Alaskan natives and Asian/Pacific Islanders were also significantly more likely than were whites to refuse surgery (OR, 4.45; P = .0001; OR, 2.96; P less than .0001, respectively).

Compared with whites, blacks – but not other races – had significantly worse 5-year survival (hazard ratio, 1.14; P = .0002).

In an analysis by cancer type, the investigators saw that race was not a predictor for surgery recommendation or refusal of surgery by patients with medullary or anaplastic cancer. However, among patients with papillary thyroid cancer, the most common type, surgery was recommended less often for blacks (OR, 1.2), Asian/Pacific Islanders (OR, 1.3), and patients of unknown race (OR, 3.1; all comparisons significant by 95% confidence interval).

Among patients with follicular histology, patients of unknown race were significantly less likely than were whites to have the surgery recommended (OR, 2.7; significant by 95% CI).

Dr. Valladares explained that the SEER data set does not include information about provider type, such as those in community based versus academic settings, so the next step will be to find a method for analyzing factors at both the patient level and the provider level that might influence recommendations for surgery or patient refusals to accept surgery.

The study was supported by the Paul H. Lavietes, M.D., Summer Research Fellowship of Yale University. The investigators reported no relevant conflicts of interest.

BOSTON – Access to and acceptance of thyroid cancer surgery varies by race, with black patients in particular appearing to be disadvantaged, compared with whites, investigators reported.

A review of data on nearly 138,000 patients diagnosed with thyroid cancer showed that blacks were significantly less likely than were whites to be offered surgery – despite its generally excellent outcomes and low rates of morbidity and mortality, reported Dr. Herbert Castillo Valladares and his colleagues from the department of surgery at the Yale University in New Haven, Conn.

SciePro/Science Source

American Indians/Alaskan natives and Asian/Pacific Islanders were significantly more likely to refuse surgery than were whites, the investigators also reported in a poster session at the Society of Surgical Oncology annual cancer symposium.

“In this project, we wanted to focus on the provider-level factors that might be perpetuating these racial disparities, and it appears that we need to educate some providers about the recommendation of surgery or how to educate patients who refuse thyroid cancer surgery,” Dr. Valladares said in an interview.

The investigators noted that although incidence and prevalence rates of thyroid cancer are similar among various racial groups, survival differs by race, and they wanted to find out why. To do so, they polled the Surveillance, Epidemiology, and End Results (SEER) registry to identify 137,483 patients diagnosed with thyroid cancer during 1988-2012. Results were stratified by thyroid cancer type, either papillary, medullary, follicular, or anaplastic.

In all, 82% of the sample were white, 75% were female, 87% had a diagnosis of papillary thyroid cancer, and 95% underwent thyroid cancer surgery.

In logistic regression analysis that controlled for race, the investigators found that blacks, Asian/Pacific Islanders, and persons of unknown race were significantly less likely than whites were to have thyroid cancer surgery (odds ratios, 0.7, 0.82, and 0.34, respectively; P for each less than .0001).

Similarly, surgery was more frequently not recommended for blacks (OR, 1.34; P less than .0001), Asian/Pacific Islanders (OR, 1.2; P = .004) and those of unknown race (OR, 3.06; P less than .0001).

American Indians/Alaskan natives and Asian/Pacific Islanders were also significantly more likely than were whites to refuse surgery (OR, 4.45; P = .0001; OR, 2.96; P less than .0001, respectively).

Compared with whites, blacks – but not other races – had significantly worse 5-year survival (hazard ratio, 1.14; P = .0002).

In an analysis by cancer type, the investigators saw that race was not a predictor for surgery recommendation or refusal of surgery by patients with medullary or anaplastic cancer. However, among patients with papillary thyroid cancer, the most common type, surgery was recommended less often for blacks (OR, 1.2), Asian/Pacific Islanders (OR, 1.3), and patients of unknown race (OR, 3.1; all comparisons significant by 95% confidence interval).

Among patients with follicular histology, patients of unknown race were significantly less likely than were whites to have the surgery recommended (OR, 2.7; significant by 95% CI).

Dr. Valladares explained that the SEER data set does not include information about provider type, such as those in community based versus academic settings, so the next step will be to find a method for analyzing factors at both the patient level and the provider level that might influence recommendations for surgery or patient refusals to accept surgery.

The study was supported by the Paul H. Lavietes, M.D., Summer Research Fellowship of Yale University. The investigators reported no relevant conflicts of interest.