Whiplash injury is a combined flexion/extension soft-tissue injury of the cervical spine, commonly found in road traffic accidents and contact sports. There are two common modes of injury: hyperextension from a rear end shunt, or a rapid deceleration injury, which throws the head forward and flexes the cervical spine. Insurers pay £2 billion per year in claims for whiplash injury. The cost to the NHS of treating this injury has been estimated to be £8 million a year (Association of British Insurers, 2011). Many patients will seek further advice for their injuries and treatment.
In the last 10 years, Internet use in the UK has increased exponentially. A recent estimate of the number of users confirmed this to be 41.62 million, or 82.9% of the adult population (Office for National Statistics, 2011). Among users are patients seeking clinical information (Richard et al. 1998), including treatment options and possible sequelae (Roshandel et al. 2005). Of concern is that while there is extensive medical information available on the web, the quality and accuracy is questionable (Stinson et al, 2009). This could lead patients to make inappropriate decisions in regard to management and treatment.
In this study we have used a validated DISCERN tool (DISCERN, 2001; Rees et al. 2002; Griffiths and Christensen, 2005; Charnock et al, 2011) to determine the quality of website resources that can be accessed by patients seeking information appertaining to whiplash injury and its management.
Method
An initial search was made by the authors to ascertain possible synonyms for whiplash that the general public may use to find more information about the condition. Four search engines were used: Google, Bing, Yahoo, and Ask Jeeves. The final list of terms was agreed by consensus. The formal search was undertaken in the last week of October 2012. The terms searched were: ‘whiplash’, ‘whip lash’, ‘neck injury’ and ‘neck strain.’
As our initial results showed that Google incorporated all of the links to websites produced by the other three search engines, the search was conducted using Google alone. The combined searches identified over 21 million sites. As it is unlikely that patients would investigate more than the initial pages of their search (Ni Riordain and McCreary, 2009), we assessed the first 100 links (10 pages) found for each search term. We excluded news and video feeds, duplicate sites, discussion groups, and sites containing information irrelevant to the search term. The inclusion criteria for eligibility that we used were that the website must have provided information relevant to the disease or symptom search term, and that information was written in English. Sixteen websites were found to be appropriate for evaluation.
The chosen websites were analysed using the validated ‘DISCERN’ tool. DISCERN assesses the quality of written information on treatment choices for health problems. It consists of 15 questions concerning the reliability and quality of consumer health information, plus an overall quality rating (Table 1).
| Question number | What is being investigated? |
|---|---|
| 1 | Are the aims clear? |
| 2 | Does it achieve its aims? |
| 3 | Is it relevant? |
| 4 | Is it clear what sources of information were used to compile the publication (other than the author or producer)? |
| 5 | Is it clear when the information used or reported in the publication was produced? |
| 6 | Is it balanced and unbiased? |
| 7 | Does it provide details of additional sources of support and information? |
| 8 | Does it refer to areas of uncertainty? |
| 9 | Does it describe how each treatment works? |
| 10 | Does it describe the benefits of each treatment? |
| 11 | Does it describe the risks of each treatment? |
| 12 | Does it describe what would happen if no treatment is used? |
| 13 | Does it describe how the treatment choices affect overall quality of life? |
| 14 | Is it clear that there may be more than one possible treatment choice? |
| 15 | Does it provide support for shared decision making? |
| 16 | Based on the answers to all of the above questions, rate the overall quality of the publication as a source of information about treatment choices |
Each question can be scored from 1 to 5 depending on how well it adheres to the specific criteria. The maximum score attainable is 80. After scoring each website they were ranked to give a relative index of the quality of the consumer information contained. Each website was assessed and scored independently by two of the authors, and the mean score calculated.
Results
Of the 16 eligible websites, DISCERN indicated the majority fell well below the maximum score. The total DISCERN score for the information sources ranged from 30 to 64 (mean 47.9). The highest scoring source was eMedicineHealth (www.emedicinehealth.com), with a mean total score of 63, the lowest scoring source was Spine Research Institute of San Diego (www.srisd.com), with a mean total score of 30. The three highest rated sources by total DISCERN score are displayed in Table 2.
| Rank | Source | Total DISCERN score (mean) |
|---|---|---|
| 1 | www.emedicinehealth.com | 63 |
| 2 | www.nhs.uk | 60 |
| 3 | www.patient.co.uk | 59.5 |
The breakdown of mean DISCERN scores for each clinical criterion of the evaluation is shown in Figure 1. This demonstrates the lowest score was found for the description of the possible risks of treatments, and for no treatment being sought. Both recorded a mean score of below 2 out of 5.
The overall mean DISCERN score for all of the sources we reviewed was 3.4 (range 1–4), with no source scoring the possible maximum of 5 for its overall rating.
Discussion
The volume of Internet-based information available to patients makes it difficult for them to assess which information is the most reliable and accurate. While good quality information can be of benefit to both patients and medical practitioners, poor quality information can negatively influence the patient’s decision-making process and treatment choices, which can then impact on the doctor-patient relationship. Our study indicates that the quality of information available to patients on the Internet with respect to whiplash injury can be poor and variable in its quality.
This is the first study that seeks to measure the quality of information available to patients on the Internet for whiplash. However, we were only able to investigate the information available at a single point in time. Of its nature, the Internet is a dynamic environment. The best information should be constantly updated in line with best practice guidelines, current evidence and new research. The methodology was unable to track how the information provided developed over time and how this could impact on the quality of information presented. While information on the Internet can be frequently and easily updated, in comparison with hard-copy media, the negative aspect has to be considered, as any individual can produce a website for the general public without specialist knowledge.
Furthermore, while the DISCERN tool has been widely validated, it has been criticised for failing to critique Internet-based resources as effectively as other available tools. However, the DISCERN tool is freely available, validated and available to clinical teams so that the quality of written information that net sources provide to patients is easily accessible.
Further research might involve: providing DISCERN scores for patients before they access Internet-based data; tracking how the quality of information changes over time in line with the new evidence; and encouraging clinical teams to review the literature they provide.
Conclusions
The maximum score according to the DISCERN tool was 63 of 80, achieved by eMedicineHealth (www.emedicinehealth.com), but the majority of websites fell well below this. By directing patients to validated websites, health professionals can ensure patients find appropriate information. However, continual development of new and existing patient resources is required. Internet-based patient information should be updated on a regular basis to account for current recommendations and advances in medical management.