Abstract
Background
Studies of the quality and accuracy of health and medical information available on the Internet have shown that many sources provide inadequate information. However, to our knowledge, there are no published studies analyzing the quality of information available online regarding vertebroplasty. Because this has been a high-volume procedure with highly debated efficacy, it is critical that patients receive complete, accurate, and well-balanced information before deciding a treatment course. Additionally, few studies have evaluated the merit of academic site authorship or site certification on information quality, but some studies have used measurements of quality that are based primarily on subjective criteria or information accuracy rather than information completeness.
Questions/purposes
The purposes of our study were (1) to evaluate and analyze the information on vertebroplasty available to the general public through the Internet; (2) to see if sites sponsored by academic institutions offered a higher quality of information; and (3) to determine whether quality of information varied according to site approval by a certification body.
Methods
Three search engines were used to identify 105 web sites (35 per engine) offering information regarding vertebroplasty. Sites were evaluated for authorship/sponsorship, content, and references cited. Information quality was rated as “excellent,” “high,” “moderate,” “low,” or “unacceptable.” Sites also were evaluated for contact information to set up an appointment. Data were analyzed as a complete set, then compared between authorship types, and finally evaluated by certification status. Academic sites were compared with other authorship groups and certified sites were compared with noncertified sites using Student’s t-test.
Results
Appropriate indications were referenced in 74% of sites, whereas only 45% discussed a contraindication to the procedure. Benefits were expressed by 100% of sites, but risks were outlined in only 53% (p < 0.001). Ninety-nine percent of sites provided step-by-step descriptions of the procedure, and 44% of sites also included images. Alternative treatments were mentioned by 51% of sites. Twenty-seven percent of sites referenced peer-reviewed literature, 41% offered experiential or noncited data based on American populations, and 7% offered analogous data from international populations. Thirty percent of sites provided contact information for patient appointment scheduling. Seven percent of sites were classified as excellent quality, 6% as high quality, 11% as moderate quality, 19% as poor quality, and 57% as unacceptable. Sixteen percent of sites were sponsored by academic institutions, 62% by private groups, 8% by biomedical device companies, and 14% were sponsored otherwise. Academic sites reported fewer risks of the procedure than private sites or other sites (p = 0.05 and p = 0.04), but reported more risks than industry sites (p = 0.007). Academic sites were more likely than sites classified as other to offer contact information for patient appointment scheduling (p = 0.004). Nine percent of sites evaluated were Health on the Net Foundation (HONCode) certified. No association with improved information quality was observed in these sites relative to noncertified sites (all p > 0.05).
Conclusions
Internet information regarding vertebroplasty is not only inadequate for proper patient education, but also potentially misleading as sites are more likely to present benefits of the procedure than risks. Although academic sites might be expected to offer higher-quality information than private, industry, or other sites, our data would suggest that they do not. HONCode certification cannot be used reliably as a means of qualifying website information quality. Academic sites should be expected to set a high standard and alter their Internet presence with adequate information distribution. Certification bodies also should alter their standards to necessitate provision of complete information in addition to emphasizing accurate information. Treating physicians may want to counsel their patients regarding the limitations of information present on the Internet and the pitfalls of current certification systems.
Level of Evidence
Level IV, economic and decision analyses. See the Instructions for Authors for a complete description of levels of evidence.
Introduction
Osteoporotic vertebral compression fractures are the most common type of osteoporotic fracture, and although frequently subclinical or responsive to conservative medical therapy (rest, analgesics, bracing), many result in significant pain and disability, reduced function and quality of life, and increased mortality [7, 23, 25, 30, 31, 36]. During the last 30 years, two FDA-approved techniques for minimally invasive cement augmentation used for treatment of refractory osteoporotic vertebral compression fractures have been developed: vertebroplasty and kyphoplasty. These procedures gained widespread popularity after multiple studies provided evidence that they reduced pain, limited analgesic medication requirements, and were associated with a low incidence of complications [11, 16, 22, 32, 33]. However, two prospective randomized clinical trials published in 2009 indicated that vertebroplasty was not associated with improvements in clinical outcome (pain, quality of life, disability) relative to a sham surgical procedure at 1-month and 6-month followups [6, 18]. Consequently, these procedures have become a controversial and frequently contested topic [2–4, 6, 8, 11, 12, 16, 18, 20–22, 32, 33, 38, 39]. Since 2009 numerous studies have reported the benefits of vertebroplasty and kyphoplasty relative to conservative medical therapy [2, 4, 8, 12, 20, 38, 39], whereas others have reported either mixed outcomes or data consistent with the 2009 studies [3, 21].
The advent of the Internet has had a substantial effect on information available to patients outside of the physician’s office. Patient use of the Internet for self-education on medical conditions and treatment options continues to increase in popularity, and patients frequently base their medical decisions on information that they encounter online, commonly doing so without discussing the online information with their physician [24, 35]. To date there have been numerous studies evidencing the lack of quality of medical information available on the Internet [1, 10, 13, 27, 34]. Given that vertebroplasty is such a hotly contested medical therapy [2–4, 6, 8, 11, 12, 16, 18, 20–22, 32, 33, 38, 39], the provision of well-balanced information for patient education is particularly significant for patients considering a vertebroplasty. Additionally, although some prior studies [5, 9, 14, 15, 37, 40] have evaluated the effects of site certification and others have investigated the effect of academic authorship [10, 18, 26, 29, 34], two elements affecting the trends of Internet information, these studies [5, 9, 10, 14, 15, 28, 29, 34, 37, 40] to date have used measurements of quality that are based primarily on subjective criteria or information accuracy rather than information completeness, an important distinction which needs to be addressed.
The objectives of our study were (1) to evaluate and analyze the information on vertebroplasty available to the general public through the Internet; (2) to see if sites sponsored by academic institutions offered higher-quality information; and (3) to determine whether quality of information varied according to site approval by a certification body.
Materials and Methods
We implemented an approach to mimic the patient experience searching for information pertaining to vertebroplasty in accordance with prior studies. An Internet browser devoid of search history, cookies, and cached data was used to prevent potential search bias from any prior medically related browsing history. Care also was taken to ensure that location services were as disabled as possible for the browser and each search engine. Google, Yahoo!, and Microsoft Bing were used to search for the general term “vertebroplasty.” The use of the search term “vertebroplasty” returned more than one million sites combined between Google, Yahoo!, and Bing. The first 35 sites returned by each search engine were identified and evaluated for a total of 105 sites. The number of sites reviewed was consistent with the number in a previously published study [10]. Each site was evaluated once. Repeat sites in the search engines were discarded. Sites that were identical with the exception of URL also were discarded. Search results linking to clinical trials published in academic journals were excluded.
Sites then were evaluated for provision of appropriate indications for vertebroplasty. Appropriate conditions included: painful vertebral compression fractures refractory to medical therapy, painful vertebral fracture or severe osteolysis with impending fracture related to benign or malignant tumor (hemangioma, myeloma, metastasis), painful vertebral fracture associated with osteonecrosis (Kummell’s disease), unstable compression fracture with demonstration of movement at the wedge deformity, multiple compression deformities resulting in osteoporotic collapse in a patient for whom further collapse would be detrimental, and chronic traumatic fractures in normal bone with nonunion of fracture fragments or internal cystic changes [17]. The total number of appropriate indications listed by each site and binary data regarding whether each site reported any appropriate indication were recorded.
Provision of contraindications to the procedure was assessed. Absolute contraindications included: asymptomatic stable fracture, improvement with medical therapy, prophylaxis in osteopenia with no evidence of acute fracture, osteomyelitis, acute traumatic fracture of a nonosteoporotic vertebra, uncorrectable coagulopathy, or allergy to any component integral to the procedure. Relative contraindications included: radicular pain or radiculopathy caused by a compressive syndrome unrelated to vertebral body collapse, retropulsion of fracture fragment causing significant spinal canal compromise, tumor extension into epidural space with significant spinal canal compromise, severe vertebral body collapse, stable fracture without pain and known to be more than 2 years old, and treatment of more than three levels at one time [17]. If sites referenced any contraindication outside these absolute or relative contraindications, the statement was recorded as an “other” contraindication. Contraindications were recorded as total absolute, total relative, and total other and in binary form for any contraindication at all.
Benefits of vertebroplasty outlined by each site were noted. Benefits reported included: pain reduction, improved mobility, decreased requirements for analgesia, early mobilization, minimally invasive nature of the procedure, height restoration, and improved quality of life. Data points were recorded for each of these benefits on an individual basis. The total number of benefits provided by each site also was recorded.
Potential complications associated with vertebroplasty reported by sites were determined. These risks included: bleeding, infection, cement leak, cord/root damage, pulmonary embolism, vertebral fracture, pneumothorax, cerebrospinal fluid leak, rib fracture, allergy, anesthetic complication, and death. Data points were recorded for each of these risks on an individual basis. The total number of risks outlined by each site and binary data regarding reporting of any risk or complication at all were recorded.
Sites were evaluated for reference to alternative methods of treatment including rest, bracing, analgesia, and surgery. Multiple sites mentioned the use of calcitonin and bisphosphonates as alternative therapy, and this also was recorded. Data points were recorded for each of the alternative methods on an individual basis. Total number of alternative methods noted by each site was recorded as well as binary data regarding the reporting of any alternative treatment method. Whether alternative treatments were discussed as options to consider in lieu of vertebroplasty, options for conservative medical therapy before vertebroplasty, or dated treatment methods used before the development of vertebroplasty were not differentiated.
The information cited by each site, if any, was analyzed. It was noted if sites provided specific reference to peer-reviewed literature. References to other sites and experiential data reported from interaction with US populations, without reference to a published study or other peer-reviewed source, were recorded as “American experience.”Analogous reports among international populations were recorded as “international experience.”
Sites then were evaluated for the provision of illustrations or images outlining the steps of the procedure and a step-by-step description of the surgical technique. We also recorded whether sites provided contact information for patient appointment scheduling.
After content data collection, each site was assigned a level of information quality based on several criteria (Table 1). These criteria were chosen on the basis of the elements of informed consent. Minimum criteria for acceptable quality of information included the discussion of at least one risk, one benefit, and one appropriate indication for the procedure.
Table 1.
Information quality criteria
| Rating | Requirements |
|---|---|
| Excellent | Indication, contraindication, benefit, risk, alternative, description, peer-reviewed literature |
| High | Indication, contraindication, benefit, risk, alternative, description |
| Moderate | Indication, benefit, risk, alternative, description |
| Poor | Indication, benefit, risk, description |
| Unacceptable | Omission of indication, benefit, risk, or description |
Moving to our second step in analysis, sites were categorized into four groups: academic, private, industry, or other. Academic sites were sponsored by either an accredited university or a university-affiliated healthcare institution. Private sites were either authored by a physician or physician group operating in private practice or edited by a physician or group of physicians operating for a private company. Industry sites were designed and sponsored by biomedical device companies. Other sites included online health databases not edited or sponsored by a private physician, vertebroplasty-specific sites not edited or sponsored by a private physician, and sites developed and sponsored by insurance companies.
After authorship classification, data were compiled for each authorship group. Academic sites then were compared with the other authorship groups at each major data point (ie, indications, risks, benefits, alternative therapies) using a nonpaired Student’s t-test.
During the final step in our analysis, sites were classified according to certification status. The specific certifying body was noted. Major data points were compared between certified and noncertified sites using a nonpaired Student’s t-test.
Results
Our first aim was to evaluate and analyze the information on vertebroplasty available to the general public via the Internet. In total, 74% of sites evaluated offered at least one appropriate indication for vertebroplasty while 45% of all sites evaluated indicated at least one contraindication to vertebroplasty (Table 2). In general, sites are more likely to provide indications than contraindications (p < 0.001). One hundred percent of sites reported a benefit to treatment with vertebroplasty (Table 3). In contrast only 53% reported a potential complication of the procedure (Table 4). Sites are more likely to provide benefits of vertebroplasty than to outline risks (p < 0.001).
Table 2.
Breakdown of sites by authorship and indications and contraindications reported
| Authorship | Web sites identified (%) | Median indications | Any indication (%) | Any contraindication (%) |
|---|---|---|---|---|
| Academic | 18 (17) | 1 | 14 (78) | 6 (33) |
| Private | 64 (61) | 1 | 47 (73) | 32 (50) |
| Industry | 8 (8) | 1 | 5 (62) | 3 (38) |
| Other | 15 (14) | 2 | 12 (80) | 6 (40) |
| Total | 105 (100) | 1 | 78 (74) | 47 (45) |
Table 3.
Benefits of vertebroplasty reported
| Authorship | Pain reduction (%) | Improved mobility (%) | Decreased analgesia (%) | Improved quality of life (%) | Height restoration (%) | Minimally invasive (%) | Early mobilization (%) | Any benefit | Mean total benefits |
|---|---|---|---|---|---|---|---|---|---|
| Academic | 18 (100) | 6 (33) | 5 (28) | 3 (17) | 2 (11) | 11 (61) | 9 (50) | 18 (100) | 3 |
| Private | 63 (98) | 23 (36) | 14 (22) | 7 (11) | 5 (8) | 53 (83) | 36 (56) | 64 (100) | 3 |
| Industry | 8 (100) | 6 (75) | 3 (38) | 4 (50) | 0 (0) | 8 (100) | 4 (50) | 8 (100) | 4 |
| Other | 15 (100) | 6 (40) | 2 (13) | 1 (7) | 2 (13) | 8 (53) | 8 (53) | 15 (100) | 3 |
| Total | 104 (99) | 41 (39) | 24 (23) | 15 (14) | 9 (9) | 80 (76) | 57 (54) | 105 (100) | 3 |
Table 4.
Potential complications of vertebroplasty reported
| Complication | Academic | Private | Industry | Other | Total |
|---|---|---|---|---|---|
| Bleeding (%) | 4 (22) | 26 (41) | 0 (0) | 6 (40) | 36 (34) |
| Infection (%) | 8 (44) | 34 (53) | 0 (0) | 7 (47) | 49 (47) |
| Cement leak (%) | 6 (33) | 33 (52) | 0 (0) | 9 (60) | 48 (46) |
| Neurologic damage (%) | 6 (33) | 34 (53) | 0 (0) | 10 (67) | 50 (48) |
| Pulmonary embolism (%) | 3 (17) | 22 (34) | 0 (0) | 8 (53) | 33 (31) |
| Vertebral fracture (%) | 2 (11) | 13 (20) | 0 (0) | 5 (33) | 20 (19) |
| Pneumothorax (%) | 0 (0) | 7 (11) | 0 (0) | 3 (20) | 10 (10) |
| Cerebrospinal fluid leak (%) | 0 (0) | 1 (2) | 0 (0) | 3 (20) | 4 (4) |
| Rib fracture (%) | 2 (11) | 17 (27) | 0 (0) | 4 (27) | 23 (22) |
| Allergy (%) | 0 (0) | 7 (11) | 0 (0) | 3 (20) | 10 (10) |
| Anesthetic complication (%) | 1 (6) | 7 (11) | 0 (0) | 2 (13) | 9 (9) |
| Death (%) | 0 (0) | 3 (5) | 0 (0) | 4 (27) | 7 (7) |
| Any complication (%) | 8 (47) | 38 (59) | 0 (0) | 10 (67) | 56 (53) |
| Mean total complications | 2 | 3 | 0 | 5 | 3 |
Fifty-one percent of sites discussed an alternative treatment method (Table 5). Peer-reviewed literature was referenced in 27% of sites evaluated whereas 41% percent of sites made reference to other sites and experiential data reported from interaction with US populations without reference to a published study or other peer-reviewed source and 7% of sites made references to analogous data from international populations (Table 6). A step-by-step description of the operative technique used in vertebroplasty was outlined in 99% of all sites evaluated, and 46% of sites included diagrams or images that illustrated steps of the operation (Table 7). Contact information for patient appointment scheduling was provided by 30% of sites, and 9% of sites were approved by a certification body (Table 8). The only certification body encountered during our search was Health on the Net Foundation (HONCode). Of all sites evaluated 7% were rated as excellent quality, 6% as high quality, 11% as moderate quality, and 19% as poor quality. Information quality was deemed to be unacceptable in 57% of sites (Table 9).
Table 5.
Alternative methods of treatments reported
| Authorship | Rest (%) | Bracing (%) | Analgesia (%) | Physical therapy (%) | Invasive surgery (%) | Any alternative (%) | Mean total alternatives |
|---|---|---|---|---|---|---|---|
| Academic | 5 (28) | 5 (28) | 7 (39) | 2 (11) | 1 (6) | 8 (44) | 1 |
| Private | 27 (42) | 26 (41) | 33 (52) | 4 (6) | 11 (17) | 36 (56) | 2 |
| Industry | 2 (25) | 2 (25) | 2 (25) | 1 (13) | 0 (0) | 3 (38) | 1 |
| Other | 6 (40) | 5 (33) | 6 (40) | 1 (7) | 1 (7) | 7 (47) | 1 |
| Total | 40 (38) | 38 (36) | 48 (46) | 8 (8) | 13 (12) | 54 (51) | 1 |
Table 6.
References offered
| Authorship | Peer-reviewed literature (%) | American experience (%) | International experience (%) |
|---|---|---|---|
| Academic | 2 (11) | 12 (67) | 0 (0) |
| Private | 16 (25) | 25 (39) | 4 (6) |
| Industry | 5 (62) | 2 (25) | 0 (0) |
| Other | 5 (33) | 4 (27) | 3 (20) |
| Total | 28 (27) | 43 (41) | 7 (7) |
Table 7.
Descriptions of vertebroplasty
| Authorship | Diagrams (%) | Procedural description (%) |
|---|---|---|
| Academic | 7 (39) | 18 (100) |
| Private | 32 (50) | 64 (98) |
| Industry | 4 (50) | 8 (100) |
| Other | 3 (20) | 15 (100) |
| Total | 46 (44) | 104 (99) |
Table 8.
Patient appointment contact information and certification body approval
| Authorship | Appointment contact information (%) | Official certification (%) |
|---|---|---|
| Academic | 7 (39) | 1 (6) |
| Private | 23 (36) | 6 (9) |
| Industry | 1 (13) | 0 (0) |
| Other | 0 (0) | 2 (13) |
| Total | 31 (30) | 9 (9) |
Table 9.
Site information quality distribution
| Authorship | Excellent (%) | High (%) | Moderate (%) | Poor (%) | Inadequate (%) |
|---|---|---|---|---|---|
| Academic | 1 (6) | 2 (11) | 2 (11) | 2 (11) | 11 (61) |
| Private | 6 (9) | 4 (6) | 7 (11) | 13 (20) | 34 (53) |
| Industry | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 8 (100) |
| Other | 0 (0) | 0 (0) | 3 (20) | 5 (33) | 7 (47) |
| Total | 7 (7) | 6 (6) | 12 (11) | 20 (19) | 60 (57) |
| Certified | 1 (11) | 0 (0) | 0 (0) | 2 (22) | 6 (67) |
| Noncertified | 6 (6) | 6 (6) | 12 (13) | 18 (19) | 54 (56) |
Our second objective was to determine whether information quality varied according to site authorship. Analysis revealed that 17% of sites were academic, 61% were private, 8% were industry, and 14% were other. Academic sites reported fewer potential complications of vertebroplasty than private or other sites (p = 0.05 and p = 0.04), but reported more risks than industry sites (p = 0.007). Academic sites were more likely than sites classified as other to offer contact information for patient appointment scheduling (p = 0.004). No other significant differences were identified between academic sites and other authorship groups, and all groups were equally as likely to present information of unacceptable quality.
Our final objective was to see if information quality varied according to site approval by an official certification body. Statistical analysis revealed no significant differences (all p > 0.05) across all data points between sites certified by HONCode and sites without certification (Tables 9, 10). Certified sites and noncertified sites were equally as likely to present inadequate information (p = 0.6).
Table 10.
Information reported by certified and noncertified sites
| Parameter | Noncertified sites | Certified sites |
|---|---|---|
| Number of sites (%) | 96 (100) | 9 (100) |
| Mean indications | 1 | 1 |
| Any indication (%) | 73 (76) | 5 (56) |
| Mean contraindications | 1 | 1 |
| Any contraindication (%) | 42 (44) | 5 (56) |
| Mean benefits | 3 | 3 |
| Any benefit (%) | 96 (100) | 9 (100) |
| Mean complications | 3 | 4 |
| Any complication | 51 (53) | 5 (56) |
| Mean alternatives | 1 | 2 |
| Any alternative | 43 (50) | 6 (67) |
| Peer reviewed literature (%) | 26 (27) | 2 (22) |
| Contact information (%) | 29 (30) | 2 (22) |
Discussion
Osteoporotic vertebral compression fractures are the most common type of osteoporotic fracture [7]. Efficacy of treatment of osteoporotic vertebral compression fractures through the widely used vertebroplasty has come into question [6, 18] and is a topic of conflict in the literature [2–4, 6, 8, 11, 12, 16, 18, 20–22, 32, 33, 38, 39]. An increasing number of patients access information on the Internet to improve their understanding of healthcare issues and treatment options, and many patients make medical decisions based primarily on Internet information without discussing it with their physicians [24, 35]. Some studies have shown inadequacies in Internet information with respect to specific treatment options [1, 10, 13, 27, 34]. Owing to the controversy and debate regarding efficacy and benefit of treatment with vertebroplasty [2–4, 6, 8, 11, 12, 16, 18, 20–22, 32, 33, 38, 39], it is critical that patients have an accurate understanding of the information available when considering the procedure. We (1) evaluated and analyzed the information on vertebroplasty available to the general public through the Internet (2) to see if sites sponsored by academic institutions offered higher-quality information and (3) to determine whether quality of information varied according to site approval by a certification body.
Our study had several limitations. It did not take into account the date of last update to each site. However, it was our intent to mimic the patient search experience as closely as possible, and we did not deem the date of update to bear significant impact on patient interpretation of presented information. In addition, we limited the number of sites that we searched, so the findings may relate to only a subset of all sites. We did not use an extensive array of search terms but rather selected a term that we thought patients would have been most likely to use, and one that most likely would lead to sites discussing vertebroplasty. We also assumed that searches such as “osteoporotic vertebral compression fracture,” “vertebral compression fracture,” or “vertebral compression fracture treatment” would inevitably lead patients to the sites encountered in our more direct search approach. Had we used other search terms we would have detected other sites, but it was the aim of our study to evaluate sites specific to the discussion of treatment with vertebroplasty.
In our efforts to determine the reliability and quality of Internet information on vertebroplasty we discovered a concerning inadequacy of appropriate and accurate information. Our information quality rating scale was founded on the expectation that sites offering information on vertebroplasty provide the most basic elements of informed consent, including benefits, risks, and alternative treatments. Our classification system did not require that sites outline all indications, contraindications, benefits, risks, or alternative treatments, but merely provide at least one accurate element from each category. Additionally, no distinction was made regarding whether alternative treatments were addressed as outdated treatment methods or as true alternative methods of treatment. Even with these minimal requirements 57% of sites provided information deemed “inadequate.” Underlying these inadequacies are several concerning issues. Sites are more likely to report indications than contraindications of the procedure (p < 0.001), and more importantly, they are more likely to report benefits of vertebroplasty than risks (p < 0.001). The most commonly reported benefit of vertebroplasty was pain reduction (99% of sites). However, at least two studies have indicated no benefit of vertebroplasty relative to placebo in terms of pain reduction [6, 18]. Additionally, 9% of sites reported height restoration to be a benefit of vertebroplasty, although this typically is not reported to be associated with the procedure. A limited number of sites referenced peer-reviewed literature (27%) despite the large volume of data published on vertebroplasty. Finally, the limited number of sites offering images or illustrations of the procedure (47%) is concerning given the low reading level of the general population [19] and the scientific nature of the surgical technique. Our results are in accordance with those reported in previous studies, all of which showed a low percentage of sites reporting complications in tandem with a high percentage of sites reporting benefits [1, 10, 13, 27, 34]. However, to our knowledge, our study is the first in which a rating system was developed to classify quality of information in its entirety rather than discussing percentages of sites that reported specific pieces of information.
Our analysis of the affect of site authorship on information quality yielded surprising results. Although sites sponsored and developed by universities and university-affiliated hospitals might be expected to offer higher-quality information than private, industry, or other sites, they do not, and academic sites are outperformed by private and other sites in terms of risks reported (p = 0.05 and p = 0.4). Additionally, academic sites were more likely than other sites to offer contact information for patient appointment scheduling (p = 0.004). Although one possible explanation for the lack of appropriate information provided by these institutions might be the assumption that patients eventually will speak directly with a physician, those creating these sites should be familiar with studies showing that patients frequently base their medical decisions on Internet information without discussing that information with physicians [24, 35].
Investigation of the association of information quality with site approval by an official certification body also yielded surprising results. Site certification was not commonly encountered, as only 9% of sites evaluated had been approved by a certification body. The only certification body identified during our study was HONCode. Although it might be expected that certified sites would offer a higher quality of information, no differences were discovered between information quality as a whole or in any component of information reported between certified and noncertified sites (all p > 0.05). This clearly raises a concern of the efficacy of HONCode certification as a means to assure website information quality. One factor likely contributing to these findings is inherent to the requirements for HONCode certification. Sites are evaluated only on the provision of data “attribution,” or the citation of published information when it is referenced, rather than on the provision of complete and/or balanced information. Consequently sites are able to exclusively discuss benefits of a procedure and still obtain HONCode certification.
The information available on the Internet clearly is not an acceptable substitute for the physician-patient relationship. A majority of sites present information that we believe is of an unacceptable quality for patient education. Sites are more likely to highlight indications and benefits of vertebroplasty than to discuss contraindications or risks of the procedure. Sites sponsored by universities and university-affiliated hospitals do not offer information of a higher quality, nor is approval by an official certifying body such as HONCode associated with an increased quality of information. In light of our findings, we believe an appropriate discussion of a patient’s understanding of a procedure is critical and that physicians should make efforts to inquire about Internet research, taking time to counsel patients regarding the limitations of Internet information. We should expect academic institutions to lead the charge for high-quality, accurate, and balanced information regarding medical procedures and treatments. If institutions are generating websites with the intent to inform patients about treatment options rather than to promote recruitment, we believe these institutions should invest the minimal additional time to produce a complete discussion of the treatment options that parallels, but does not substitute for, the basic elements of an informed consent. Our findings also indicate that changes are necessary in Internet certification bodies. These bodies should broaden their certification criteria to include an assessment of information completeness in addition to their focus on information accuracy. Currently, we cannot recommend that physicians instruct patients to rely on site certification as a means of guaranteeing a higher quality of information. Regulation of Internet information is a daunting task, but measurable and achievable steps can be taken to help improve the quality of healthcare information on which patients are increasing their reliance.
Footnotes
Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
This work was performed at University Hospitals Case Medical Center, Cleveland, OH, USA.
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