Abstract
Background
Free open‐access medical education (FOAM) resources have become highly utilized resources in emergency medicine education. However, FOAM content often lacks the traditional peer review process, leaving quality assessment to the readers. In this systematic online academic resource (SOAR) review, we apply a systematic methodology to assess the quality of FOAM resources on sickle cell disease (SCD).
Methods
We searched keywords for SCD using FOAM Search and the top 50 FOAM websites listed on the Social Media Index. Resources found were screened using inclusion/exclusion criteria, and a total of 53 resources underwent full‐text quality assessment using the revised Medical Education Translational Resources Impact and Quality (rMETRIQ) tool.
Results
The search yielded 520 resources, of which 53 met the criteria for quality assessment. A total of eight posts (15.1% of posts) were identified as high quality (rMETRIQ ≥ 16). The most commonly addressed topics within SCD topics included acute chest syndrome, acute pain crisis and general review of SCD. A total of 11 posts (21% of posts) were found to have an rMETRIQ score of less than 7, which may indicate poor quality. The most commonly identified type of resource was personalized reading (64%) and a number of posts were deemed to not have an appropriate use due to poor quality (15%).
Conclusions
We were able to systematically search a wide range of resources to identify, appraise, and organize FOAM resources on the topic of SCD. A final list of eight high‐quality resources can guide trainees, educator recommendations, and FOAM authors.
BACKGROUND
Free open‐access medical education (FOAM) resources are becoming a staple resource in emergency medicine for both formal and informal education curriculum. 1 , 2 , 3 , 4 The exponential growth of FOAM resources over the past 20 years has generated much discussion on the role of critical appraisal and quality assessment of online educational content. 5 , 6 Given that there is a large range of quality and content representation in the FOAM landscape, efforts have been made to curate quality educational resources for learners, including approved instructional resources (AIR) series and the SAEM systematic online academic resource (SOAR) series. 7 , 8 , 9 , 10 The aim of this paper is to contribute to the process of systematically assessing the quality of FOAM emergency medicine resources on the topic of sickle cell disease (SCD), as part of the ongoing SAEM SOAR series.
As opposed to other SOAR series reviews, we selected a smaller and focused topic rather than entire organ system for this review. The topic was selected by the authors since they are all interested in the interaction of FOAM and education topics related to racialized patients. We decided to choose the topic of sickle cell disease since it is a particular disease state that we were worried might get lost within a larger, broader review around hematology. SCD is a hereditary hemoglobinopathy that results in profound morbidity for patients. 12 Patients with SCD often present to the emergency department (ED) with high‐acuity complications. 13 However, the experience of sickle cell patients receiving care in the ED has been described as suboptimal. 14 , 15 , 16 Previous research has demonstrated that sickle cell patients disproportionately experience prolonged wait times and inadequate pain control. 16 , 17 Moreover, strategies for improving the quality of care for sickle cell patients that have been called for include educational interventions to increase provider knowledge and reduce stigma. 18 The topic of SCD was therefore chosen to identify high‐quality FOAM resources that in turn help SCD patients receive high‐quality evidence‐based care.
METHODS
Following the structure of previous SOAR reviews, this review adhered closely to the approach of systematic reviews and Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines 11 with some modifications consistent with previous articles of the same type. 9 , 10 The team that conducted this review included two trainees (one medical student and one resident physician) and an attending physician who was a pioneer of the SOAR review paper methodology.
Search strategy
Two keyword phrases (“sickle” and “sickle cell”) were used to conduct a search of FOAM websites that adequately covered the breadth and scope of sickle cell anemia as a topic. The first stage of the search was performed on FOAM Search (GoogleFOAM.com), to limit the scope of results to content targeted to medical professionals. Next, the keyword phrases were searched on each of the top 50 FOAM websites according to the 2021 Social Media Index (SMi) rankings, a tool that was developed to assess the impact of medical education websites. 19 , 20 Websites beyond the top 50 were excluded as they were found to be low yield in terms of relevant content, based on searches from this and previous SOAR reviews. For every keyword search within our selected websites, the top 100 results were collected.
Inclusion criteria
All open‐access educational resources listed on FOAM Search and found on the top 50 SMi websites related to SCD were included. Written podcast show notes were also included in this review.
Exclusion criteria
Each article was screened by an individual author (P.A.) and excluded if considered to be either irrelevant to the topic of sickle cell anemia or lacking sufficient content in regards to the topic of sickle cell anemia. Additionally, if the article focused on another subtopic (e.g., stroke where sickle cell anemia was mentioned on the differential diagnosis) then it was excluded. Content that was a link that lacked text to review, an audio file or video file without text (e.g., “show notes”), articles in peer‐reviewed journals, reposts, text not in English, or paid content were also excluded. The articles were then screened a second time by a second author (S.A.) to ensure that inclusion criteria were met for all remaining resources.
Data extraction and quality assessment
Data were abstracted and organized using a Google Form by a single reviewer for each item, including data such as resource article name, publication date, audience level, subtopic reviewed, author information, and quality assessment score. The resources were assessed for quality using the revised Medical Education Translational Resources: Impact and Quality (rMETRIQ) score, which contains seven categories with scores of 0 to 3 (see Appendix S1). 21
With regard to scoring, two authors (P.A., S.A.) each initially scored 15 articles. The shared article scores were then reviewed, inconsistencies were discussed and adjusted to ensure consensus, and subsequently each author scored the final 15 articles again with this new calibration in mind. Fortunately, the initial inter‐rater agreement as measure by an intraclass correlation coefficient (ICC) for the two raters was 0.77 (95% confidence interval [CI], 0.34–0.92, p < 0.01), which was sufficiently high (ICC > 0.75) for us to proceed on to independent ratings of the remaining articles. A quality cutoff of ≥16 was determined to be high quality based on the modified Angoff method as in the prior SOAR review studies. 9 , 10
RESULTS
The search yielded a total of 520 articles. Of note, 14 of the top 50 SMi sites had 0 results for a search of “sickle” or “sickle cell.” After duplicates and journal articles were excluded, we were left with 448 unique FOAM resources. After initial screening of unique FOAM resources, our yield was a total of 53 unique resources that proceeded to the final step of quality assessment (Figure 1).
FIGURE 1.
PRISMA‐inspired flow diagram for SOAR resource selection. SOAR, systematic online academic resource
Topic coverage
The authors preidentified relevant subtopics for SCD based on textbook chapters (e.g., Rosen's Emergency Medicine 22 ), as these have not been elaborated on in the 2019 Model of the Clinical Practice of Emergency Medicine (MCPEM) as with other SOAR reviews. 23 If a resource undergoing quality assessment was found to explore a subtopic not previously identified, then two authors (S.A., P.A.) discussed whether it fulfilled the inclusion criteria and how to best title the subtopic. The most represented subtopic covered by posts assessed was acute chest syndrome (n = 15). The other largest subtopic was general review of SCD (n = 12), followed by acute pain crisis (N = 8). Stroke appeared three times, and a variety of other subtopics were covered between one and two times.
Quality of posts
The rMETRIQ scores ranged from 0 to 17, with the mean (±SD) rMETRIQ score of 10.5 (±5.3). A total of eight posts (15.1%) reached the cutoff to be considered a high‐quality post (≥16; see Table 1). The topics covered by high‐quality posts included acute chest syndrome, acute pain crisis, general review of SCD, infection/fever and miscellaneous. A total of 11 posts (20.1%) had an rMETRIQ score of ≤7, which is likely to indicate poor quality. Table 2 displays the top posts found by the SOAR review ranked by rMETRIQ score in 2021.
TABLE 1.
SCD subtopic analysis from our SOAR review
| Subtopic | Total posts | High‐quality posts (rMETRIQ > 16) |
|---|---|---|
| Acute chest syndrome | 15 (28.2%) | 3 (37.5%) |
| Acute pain crisis | 8 (15.1%) | 2 (25%) |
| General review of SCD | 12 (22.6%) | 1 (12.5%) |
| Miscellaneous | 3 (5.7%) | 1 (12.5%) |
| Infection/fever | 2 (3.8%) | 1 (12.5%) |
| Stroke | 3 (5.7%) | 0 (0%) |
| Splenic sequestration | 2 (3.8%) | 0 (0%) |
| Equity and bias | 2 (3.8%) | 0 (0%) |
| Aplastic crisis | 1 (1.9%) | 0 (0%) |
| Dactylitis | 1 (1.9%) | 0 (0%) |
| Hepatic sequestration | 1 (1.9%) | 0 (0%) |
| Priapism | 1 (1.9%) | 0 (0%) |
| Osteomyelitis | 1 (1.9%) | 0 (0%) |
| Fat embolism syndrome | 1 (1.9%) | 0 (0%) |
| Total | 53 (100%) | 8 (100%) |
Abbreviations: rMETRIQ, revised Medical Education Translational Resources: Impact and Quality; SCD, sickle cell disease; SOAR, systematic online academic resource.
TABLE 2.
Top posts found by the SOAR review ranked by rMETRIQ score in 2021
| Subtopic | Name of first author | Name of blog post | URL | Level of trainee (starred = author; unstarred = team's recommendation) | rMETRIQ score |
|---|---|---|---|---|---|
| Acute chest syndrome | Josh Farkas | Sickle Cell Acute Chest Syndrome | https://emcrit.org/ibcc/sickle‐chest/ | Junior, senior, attending | 17 |
| Acute chest syndrome | Ken Milne | SGEM#166: WHICH FEBRILE CHILD WITH SICKLE CELL DISEASE SHOULD GET A CHEST X‐RAY? | https://thesgem.com/2016/12/sgem166‐which‐febrile‐child‐with‐sickle‐cell‐disease‐should‐get‐a‐chest‐x‐ray/ | Junior, senior, attending | 17 |
| Acute pain crisis | Adam Parks | Sickle Cell in the ED: An Update | https://emottawablog.com/2018/05/sickle‐cell‐in‐the‐ed‐an‐update/ | Intern, junior, senior, attending | 17 |
| Acute chest syndrome | Justin Morgenstern | Acute Chest Syndrome (Sickle Cell Disease) | https://first10em.com/acute‐chest‐syndrome‐sickle‐cell‐disease/ | Intern, junior, senior, attending | 16 |
| Acute pain crisis | David Cisewski | ED Management of Sickle Cell Vaso‐occlusive Crises: Myths, Facts, and A Novel Approach to Acute Pain Management | http://www.emdocs.net/ed‐management‐of‐sickle‐cell‐vaso‐occlusive‐crises‐myths‐facts‐and‐a‐novel‐approach‐to‐acute‐pain‐management/ | Intern, junior, senior, attending | 16 |
| General review of SCD | Anton Helman | Episode 68 Emergency Management of Sickle Cell Disease | https://emergencymedicinecases.com/emergency‐management‐of‐sickle‐cell‐disease/ | Intern, junior, senior, attending | 16 |
| Miscellaneous | Sean M. Fox | Sickle Cell Trait | https://pedemmorsels.com/sickle‐cell‐trait/ | Clerk, intern, junior | 16 |
| Infection/fever | Sean M. Fox | Sickle Cell Disease and Fever | https://pedemmorsels.com/sickle‐cell‐disease‐fever/ | Clerk, intern, junior, senior | 16 |
Abbreviations: rMETRIQ, revised Medical Education Translational Resources: Impact and Quality; SOAR, systematic online academic resource.
Frequency of resource type
Each resource that underwent full quality review was also categorized as to the perceived use for the resource. Resources were able to be categorized under multiple types if considered appropriate by the reviewing author. The most commonly identified use of the resources was personalized reading (64%; see Figure 2). The next most common were postshift reading assignment (36%) and flipped classroom preparation (32%). A number of resources were not determined to have a suitable use due to their poor quality and were therefore categorized as other (15%).
FIGURE 2.
Frequency of the types of open educational resources with the SCD SOAR review in 2021. III, individualized interactive instruction; SCD, sickle cell disease; SOAR, systematic online academic resource
Intended audience level
The 53 resources that underwent full quality review were also organized by the intended audience level. If the authors of the post itself indicated the intended audience level, this was chosen. If there was no indicated intended audience, the reviewing authors then made a determination of the most appropriate audience. Posts were identified to have multiple possible audience levels. The most commonly intended audience level identified was intern (79% of all posts) and junior (77%) learners (see Figure 3). Among high ‐quality posts, the most commonly intended audience level identified was junior (53% of high‐quality posts) and senior (47%) learners. In high‐quality posts, the intended audience level appeared to skew toward higher‐level learners, which mirrors the findings of previous SOAR reviews.
FIGURE 3.
Frequency of intended audience levels among all and high‐quality resources for the SCD SOAR review in 2021. SCD, sickle cell disease; SOAR, systematic online academic resource
DISCUSSION
In the previous SOAR studies, a general category from the MCPEM was chosen (e.g., renal and genitourinary disorders; endocrine, metabolic, and nutritional disorders). However, in this iteration we decided to focus on a more narrowly defined topic of SCD, which resulted in comparatively far less resources being extracted for quality assessment (53 vs. 756 and 341). 9 , 10 The topics in previous SOAR reviews were also predefined as per the MCPEM; however, in our review given that SCD was already considered a subtopic under the category of hematologic and oncologic disorders, the authors were required to generate their own subtopics.
Compared to previous SOAR reviews 9 , 10 the number of high‐quality posts, we found that SCD resources fared better than previous topic areas. Grock and colleagues 9 found that only 10% of articles met a similar quality threshold for the topic of genitourinary and renal disorders whereas the review by Hsiao and colleagues 10 found a similar percentage of high‐quality posts (15%).
Like the findings in the previous SOAR reviews, 9 , 10 the resources we found were rated worst in two domains of the rMETRIQ score: Q6 (editorial process and peer review) and Q7 (postpublication commentary). Consistent with previous literature around editorial processes, 25 in our review the cause for this is because many FOAM sites did not describe a process for peer review, and those that did merely mentioned a review process but did not elaborate on how it occurred or was maintained. Learners rarely assess the quality of evidence or review references of such resources. 1 Therefore, demonstration of a prepublication editorial process would be highly beneficial to help improve resources for potential use on shift or at the point of care. 26
Another weakness of many resources was the author attributions. Resources with multiple authors, or that relied on public contributions (e.g., WikiEM), at times did not have available biographical information, author qualifications, or disclosure of conflicts of interest.
The determination for the type of resources was made by the screening authors (P.A., S.A.), and the decisions were left up to their discretion. Both authors are from a Canadian context and the individualized interactive instruction credit is a feature of the ACGME and was not familiar to the authors, which may explain why it was not frequently chosen as a type of resource. Additionally, there was no consensus building around the use of the resource; therefore, the uses of resources may vary according to the reader and their level of training.
It was interesting to note how equity and bias was not a preidentified subtopic in SCD but this became a recurrent subtopic later noted during data extraction. This is likely a reflection of ongoing discourse of equity in health care and particularly how patients with SCD experience stigma during their care. 14 , 15 , 16 , 17 This finding suggests that instead of broad topics such as renal or endocrine, it may be worthy of selecting certain subtopics for a SOAR review, especially when the topic aims to help isolate high‐quality resources about the care of a population that is grossly mistreated or undertreated for a number of systemic reasons. Targeted reviews on specific topics for enhancing education about certain topics can help fight inequities in our system and possibly help to move the needle to convince educators to improve their curricula so that emergency medicine learners are better educated on topics such as these.
LIMITATIONS
There were a few identified limitations to this study. As our search only yielded 53 articles for formal evaluation, the thoroughness of our search strategy could have been lacking. We used the same search protocol, described in the previous SOAR reviews involving FOAM Search and a search of the top 50 SMi sites. Notably, 14 of the top 50 SMI sites did not yield any results regarding SCD, which may hint at a lack of coverage on the topic of SCD. However, another possible FOAM search engine Numose (https://numose.com/search) that was developed more recently could have been used to ensure an even more thorough resource search. Next, as both the Google FOAM and the SMi have some element of website traffic affecting the algorithms, it is entirely possible that low‐traffic or new websites with high‐quality resources may not have been found via our search strategy.
For the quality assessment, we utilized the rMETRIQ score, which was specifically designed to assess the quality of the FOAM resources. 21 While the tool has yet to accrue substantial validity evidence, its previous iteration of the METRIQ‐8 score was found to reliably correlate with gestalt quality assessments by expert educators. 24 Additionally, the rMETRIQ tool covers a large portion of quality indicators identified by an international iterative, consensus‐building, modified Delphi process among expert emergency medicine and critical care medicine FOAM educators. 6 However, the rMETRIQ was not designed to appraise the accuracy of the content of the FOAM resources and in this review we did not specifically verify the accuracy of the posts extracted.
CONCLUSIONS
In this third systematic online academic resource review, we were able to achieve a systematic quality assessment of free open‐access medical education resources on sickle cell disease and define core subtopics. We demonstrated that only 15.1% of resources achieved our high‐quality cutoff and that the breadth of subtopic coverage was broad but unevenly distributed. Learners will hopefully be able to use this information to identify and access appropriately leveled, high‐quality resources on the topic of sickle cell disease as well as identify sickle cell disease subtopics that lack adequate free open‐access medical education coverage. Educators may also use this information to determine how to improve ongoing free open‐access medical education efforts, identify features that will improve the quality of content, and possibly produce missing content—especially with regards to topics pertaining to underserved populations such as patients with sickle cell disease.
AUTHOR CONTRIBUTIONS
Sara Alavian contributed to study concept and design; data collection, analysis, and interpretation; and drafting of the manuscript. Prince Asare‐Agbo contributed to data collection, analysis, and interpretation; and drafting of the manuscript. Teresa M. Chan contributed to study concept and design and revision of the manuscript.
CONFLICT OF INTEREST
The authors declare no potential conflict of interest.
Supporting information
Appendix S1
Alavian S, Asare‐Agbo P, Chan TM. Systematic online academic resources (SOAR) review: Sickle cell disorders. AEM Educ Train. 2022;6:e10812. doi: 10.1002/aet2.10812
Supervising Editor: Dr. Michael Gottlieb
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Associated Data
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Supplementary Materials
Appendix S1