Online Information About the Effectiveness of Shoulder Surgery Is Not Based on the Best Available Evidence: A Content Analysis

doi:10.1016/j.apmr.2021.03.041

Archives of Physical Medicine and Rehabilitation

Volume 102, Issue 11, November 2021, Pages 2141-2149.e2

https://doi.org/10.1016/j.apmr.2021.03.041 Get rights and content

Highlights

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Most online information about shoulder surgery is not evidence based.
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Few webpages accurately portray the best available evidence for surgery.
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Few webpages mention the possible harms of surgery and to avoid surgery if possible.
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Most webpages mentioned alternatives to surgery and to delay surgery if possible.

Abstract

Objective

To summarize the proportion of consumer webpages on subacromial decompression and rotator cuff repair surgery that make an accurate portrayal of the evidence for these operations (primary outcome), mention the benefits and harms of surgery, outline alternatives to surgery, and make various surgical recommendations.

Design

Content analysis.

Setting

Online consumer information about subacromial decompression and rotator cuff repair surgery. Webpages were identified through (1) Google searches using terms synonymous with “shoulder pain” and “shoulder surgery” and searching “orthopedic surgeon” linked to each Australian capital city and (2) websites of relevant professional associations (eg, Australian Orthopaedic Association). Two reviewers independently identified webpages and extracted data.

Participants

Not applicable.

Interventions

Not applicable.

Main Outcome Measures

Whether the webpage made an accurate portrayal of the evidence for subacromial decompression or rotator cuff repair surgery (primary outcome), mentioned benefits and harms of surgery, outlined alternatives to surgery, and made various surgical recommendations (eg, delay surgery). Outcome data were summarized using counts and percentages.

Results

A total of 155 webpages were analyzed (n=89 on subacromial decompression, n=90 on rotator cuff repair, n=24 on both). Only 18% (n=16) and 4% (n=4) of webpages made an accurate portrayal of the evidence for subacromial decompression and rotator cuff repair surgery, respectively. For subacromial decompression and rotator cuff repair, respectively, 85% (n=76) and 80% (n=72) of webpages mentioned benefits, 38% (n=34) and 47% (n=42) mentioned harms, 94% (n=84) and 92% (n=83) provided alternatives to surgery, and 63% (n=56) and 62% (n=56) recommended delayed surgery (the most common recommendation).

Conclusions

Most online information about subacromial decompression and rotator cuff repair surgery does not accurately portray the best available evidence for surgery and may be inadequate to inform patient decision making.

Section snippets

Study design and inclusion and exclusion criteria

We performed a content analysis of online consumer information about subacromial decompression surgery and rotator cuff repair surgery for adults with shoulder pain (including people with subacromial pain syndrome or rotator cuff tears). We included any online information that was written in English, targeted to consumers, and addressed the decision to have surgery. This included links downloadable as Portable Document Formats or videos featuring relevant information (eg, resources routinely

Search results

We identified 463 webpages from our online searches. After removing duplicates and applying our exclusion criteria, 155 webpages were included (89 discussed subacromial decompression surgery, 90 discussed rotator cuff repair surgery, 24 discussed both procedures) (fig 1). The included webpages came from a variety of sources including both not-for-profit and for-profit web-based consumer information companies, Wikipedia, government funded institutes, health insurers, professional societies,

Summary of main findings

Our study showed that most publicly available online information about subacromial decompression surgery and rotator cuff repair surgery is not aligned with the best available evidence and may be inadequate to inform patient decision making. Few webpages accurately portrayed the best available evidence for surgery, few mentioned the possible harms of surgery, and few recommended people avoid surgery. Most webpages mentioned alternatives to surgery, which is positive. However, most webpages

Conclusions

Most publicly available online information about subacromial decompression surgery and rotator cuff repair surgery does not accurately portray the best available evidence for surgery and may be inadequate to inform patient decision making. Future research should determine what information consumers value most when considering treatment options for subacromial pain syndrome and use this information to inform the development and dissemination of accessible, easy-to-understand consumer resources.

Supplier

a.
Stata IC Version 13.1; StataCorp.

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Cited by (7)

Diagnostic labels and advice for rotator cuff disease influence perceived need for shoulder surgery: an online randomised experiment
2022, Journal of Physiotherapy
Citation Excerpt :
It provided encouragement to stay active and positive prognostic information. For treatment recommendation, examples of advice were searched for on webpages identified in a content analysis that was conducted examining the quality of online information for shoulder surgery.24 Reputable sources (eg, government, university) that presented contrasting advice to the guideline-based advice script were prioritised.
What are the effects of diagnostic labels and advice, and interactions between labels and advice, on perceived need for shoulder surgery for rotator cuff disease?
2×2 factorial online randomised experiment.
People with shoulder pain.
Participants read a scenario describing a patient with rotator cuff disease and were randomised to bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice, and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation stressed that treatment is needed for recovery.
Perceived need for surgery (primary outcome), imaging, an injection, a second opinion and to see a specialist; and perceived seriousness of the condition, recovery expectations, impact on work performance and need to avoid work.
A total of 2,024 responses (99.8% of 2,028 randomised) were analysed. Labelling as bursitis (versus rotator cuff tear) decreased perceived need for surgery (mean effect –0.5 on a 0-to-10 scale, 98.3% CI –0.7 to –0.2), imaging and to see a specialist, and perceived seriousness of the condition and need to avoid work. Guideline-based advice (versus treatment recommendation) decreased perceived need for surgery (mean effect –1.0, 98.3% CI –1.3 to –0.7), imaging, an injection, a second opinion and to see a specialist, and perceived seriousness of the condition and recovery expectations. There was little to no evidence of an advice label interaction for any outcome.
Labels and advice influenced perceived need for surgery and other secondary outcomes in people with rotator cuff disease, with larger effects for advice. There was evidence of little or no interaction between labels and advice for any outcome, but the additive effect of labels and advice appeared large for some outcomes (eg, perceived need for imaging and perceived seriousness of the condition).
ACTRN12621001370897.
Who writes this stuff? Musculoskeletal information quality and authorship of popular health websites: A systematic review
2022, Musculoskeletal Science and Practice
Citation Excerpt :
Our data supports previous research investigating the quality of online information for various musculoskeletal conditions, which almost ubiquitously characterized the quality of information as poor (Butler and Foster, 2003; Morr et al., 2010; Starman et al., 2010; Smith et al., 2012; Ferreira et al., 2019). A recent paper also showed inaccurate online portrayals of the evidence for common shoulder surgeries (Robertson et al., 2021). However, the present study differs in several ways from existing research.
Highly trafficked health websites are major sources of information, but the quality of their musculoskeletal information has not been thoroughly evaluated or their authorship characterized.
To review information about common musculoskeletal conditions on highly trafficked websites and characterize their credibility, authorship, accuracy of information (as compared to treatment guidelines), and consistency with best practice recommendations.
Systematic review.
We reviewed the top 15 most highly trafficked health websites, identified by web traffic data. Information about 7 common musculoskeletal conditions was identified and data extracted. Credibility was assessed using the Trust It or Trash It? tool, author backgrounds were identified, accuracy was determined by comparing webpage treatment recommendations to guidelines or systematic reviews, and consistency with best practice recommendations was assessed.
Of 1760 webpages screened, 87 were reviewed. Less than half (44.8%, 39/87) had appropriate sources listed, but 65.5% (57/87) were updated in the previous 5 years. Journalists authored most webpages (55.2%, 48/87). Physician involvement was mostly editorial, and they often lacked expertise in musculoskeletal conditions. Information accuracy was concordant with guidelines for 49.4% (43/87) of webpages, but varied by condition. About half of best practice recommendations were followed (49.1%, 427/870). Pages were unlikely to mention psychosocial factors (16.1%, 14/87), limitations of imaging (18.4%, 16/87), or staying at work (4.6%, 4/87).
Popular health websites scored poorly for credibility, accuracy, and consistency with best practice recommendations for musculoskeletal conditions. Authorship, bias, and unsupported information are potential sources of inaccuracies that should be addressed in future by these websites.
Online information about the management of anterior cruciate ligament ruptures in Australia: A content analysis
2022, Musculoskeletal Science and Practice
Citation Excerpt :
A content analysis of ‘trustworthy’ websites making treatment recommendations for low back pain (n = 79) found that less than half of websites made accurate recommendations (Ferreira et al., 2019). A content analysis of 155 webpages on shoulder surgery found that few webpages provided an accurate portrayal of the evidence for subacromial decompression surgery (18% of webpages) and rotator cuff repair surgery (4% of webpages) (Robertson et al., 2021). Studies of online information highlight the need to develop and disseminate evidence-based resources on the management of musculoskeletal and orthopaedic conditions.
Most people who suffer an anterior cruciate ligament (ACL) injury search for information online.
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Content analysis.
We examined webpage information on ACL ruptures identified through (1) Google searches using terms synonymous with ‘anterior cruciate ligament rupture’ and searching ‘knee surgeon’ linked to each Australian capital city, and (2) websites of professional associations. The primary outcome was the proportion of webpages that suggest people can return to at least some form of sport with non-surgical management. Secondary outcomes included webpage information on return to sport with ACL reconstruction (ACLR) and non-surgical management, benefits, harms, and risk of osteoarthritis related to these options, and activity modification.
Out of 115 webpages analysed, 48% suggested people can return to at least some form of sport with non-surgical management. Almost half of webpages suggested most people will return to some form of sport following ACLR (41%) and mentioned benefits of ACLR (43%). Fewer webpages mentioned benefits of non-surgical management (14%), approximately two in three people return to pre-injury level of sport following ACLR (4%), risk of re-injury following ACLR (23%), most people return to sport within 9 months of ACLR (27%), activity modification as a management approach (20%), and ACLR will reduce the risk of osteoarthritis (23%).
Most online information on ACL rupture management isn't aligned with the best available evidence. Inaccurate information could mislead patients' treatment choices and create unrealistic expectations for return to sport.
A content analysis of online information about the benefits and harms of spine surgery
2022, Brazilian Journal of Physical Therapy
Citation Excerpt :
We used a combination of terms described in Supplementary File - Table 1. These terms were defined by the study team, which includes professionals from various backgrounds including physical therapists and orthopaedic surgeons and based on previous studies investigating online information for musculoskeletal conditions.22 We searched the first 2 pages of results as people are unlikely to explore webpages beyond the second page of a Google search.18
It is unknown whether online information about the benefits and harms of surgery contains an accurate description of evidence.
To describe the proportion of webpages containing information about surgery for spinal pain (decompression and fusion) that accurately described the evidence on the benefits of surgery, described harms, and provided quantitative estimates of these harms.
We performed a content analysis of webpages containing information about spine surgery. Two reviewers identified webpages and extracted data. Primary outcomes were the proportion of webpages that accurately described the evidence on the benefits, described harms, and provided quantitative estimates of these harms.
We included 117 webpages. Only 29 (25%) webpages accurately described the evidence on the benefits of spine surgery, and more webpages on decompression accurately described the evidence compared to webpages on fusion (31% vs 15%, difference in proportions = 16%; 95% CI: 2%, 31%). Harms of surgery were described in most webpages (n = 76, 65%), but a much smaller proportion of webpages (n = 18, 15%) provided a quantitative estimate for the mentioned harms.
Most webpages failed to accurately describe the benefits and harms of decompression and fusion surgeries for spinal pain. Unbiased consumer resources and educating the public on how to critically evaluate health claims are important steps to improve knowledge on the benefits and harms of spine surgery.
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Education can reassure people with rotator cuff-related shoulder pain: a 3-arm, randomised, online experiment
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View all citing articles on Scopus

: Disclosures: All authors declare no support from any organization for the submitted work and no financial relationships with any organizations that might have an interest in the submitted work. Rachelle Buchbinder was an author on the 2 Cochrane reviews of subacromial decompression surgery and rotator cuff repair surgery that we used to classify webpages as making an accurate portrayal of the evidence for these operations. The views expressed in this research article do not necessarily represent those of the South Eastern Sydney Local Health District or New South Wales Health.

View full text

ORIGINAL RESEARCHOnline Information About the Effectiveness of Shoulder Surgery Is Not Based on the Best Available Evidence: A Content Analysis

Highlights

Abstract

Objective

Design

Setting

Participants

Interventions

Main Outcome Measures

Results

Conclusions

Section snippets

Study design and inclusion and exclusion criteria

Search results

Summary of main findings

Conclusions

Supplier

Arthroscopy

Lancet

Lancet

General practice activity in Australia 2015-16

In the clinic. Rotator cuff disease

Ann Intern Med

Longitudinal study of use and cost of subacromial decompression surgery: the need for effective evaluation of surgical procedures to prevent overtreatment and wasted resources

BMJ Open

Subacromial decompression surgery for rotator cuff disease

Cochrane Database Syst Rev

Surgery for rotator cuff tears

Cochrane Database Syst Rev

Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England

Bone Joint J

Increasing incidence of rotator cuff repairs—a nationwide registry study in Finland

BMC Musculoskelet Disord

National trends in rotator cuff repair

J Bone Joint Surg Am

ORIGINAL RESEARCH
Online Information About the Effectiveness of Shoulder Surgery Is Not Based on the Best Available Evidence: A Content Analysis