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The quality of online consumer health information at the intersection of complementary and alternative medicine and arthritis

The quality of online consumer health information at the intersection of complementary and... Background: Complementary and alternative medicine (CAM) use is prevalent among patients living with arthritis. Such patients often seek information online, for the purpose of gaining a second opinion to their healthcare provider or even self-medication. Little is known about the quality of web-based consumer health information at the intersection of CAM and arthritis; thus, investigating the quality of websites containing this information was the purpose of this study. Methods: Four unique search terms were searched on Google across four English-speaking countries. We assessed the first 20 results of each search, including them if they contained CAM consumer health information for the treatment and/or management of arthritis. Eligible websites were assessed in duplicate using the DISCERN instrument, which consists of 16-items designed to assess quality. Results: Of total of 320 webpages, 239 were duplicates, and a total of 38 unique websites were deemed eligible and assessed using the DISCERN instrument. The mean summed DISCERN scores across all websites was 55.53 (SD = 9.37). The mean score of the overall quality of each website was 3.71 (SD = 0.63), thus the majority of websites are ranked as slightly above ‘fair’ quality. Conclusion: Eligible websites generally received scores better than ‘moderate’ in terms of overall quality. Several shortcomings included a lack of transparency surrounding references used and underreporting of risks associated with treatment options. These results suggest that health providers should be vigilant of the variable quality of information their patients may be accessing online and educate them on how to identify high quality resources. Keywords: Arthritis, Complementary and alternative medicine, Quality of information, Consumer health information, Information assessment, DISCERN Background include degenerative (osteoarthritis), resulting from pro- Arthritis is one of the leading causes of disability among gressive cartilage breakdown, and autoimmune/inflam- North Americans [1], describing over 100 conditions matory (rheumatoid arthritis), characterized by an that affect joints, tissues around the joint, and other con- immune system that attacks the synovial membrane [2]. nective tissues [2]. The two main categories of arthritis Arthritis may also arise from infections or metabolic dis- orders (most commonly seen as gout) [1]. Symptoms in- * Correspondence: ngjy2@mcmaster.ca clude joint pain, swelling, stiffness, tenderness, and Department of Health Research Methods, Evidence, and Impact, Faculty of limited range of motion commonly found in the hands, Health Sciences, McMaster University, Michael G. DeGroote Centre for wrists, knees, hips, ankles, and spine [2]. The condition Learning and Discovery, Room 2112, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada is diagnosed with a physical exam, assessing blood or © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Ng et al. Advances in Rheumatology (2021) 61:6 Page 2 of 17 synovial fluid tests, and by using imaging techniques relating to ownership, currency, interactivity and navig- such as x-rays [3]. Arthritis is most common among ability, while results varied for authorship, balanced in- women. Approximately 20 million people worldwide formation and the use of sources [23]. Another study on were living with rheumatoid arthritis in 2017 with over a the quality of herbal product information on the internet million new cases being diagnosed each year [4]. Al- found serious shortcomings in terms of providing spe- though arthritis affects all ages, the risk increases as indi- cific safety information [24]. To our knowledge, no study viduals grow older. If left untreated, it can negatively has specifically focused on the quality of online informa- impact physical functioning and quality of life [2]. tion at the intersection of CAM and arthritis. The ob- Many arthritis patients seek out various treatment op- jective of this study is to analyse the quality of consumer tions to help them manage and cope with their condi- health information on CAM therapies that a “typical” tion, one of which includes complementary and patient with arthritis may encounter online. This study alternative medicine (CAM), which has gained popular- is of value to both healthcare providers and researchers, ity. CAM refers to a wide range of therapies and health as it provides them with a greater understanding and care practices that are not considered mainstream or insight into what types of information patients with arth- standard medical practice. “Complementary” medicine ritis may be accessing on their own. can be defined as an unconventional practice that is used in combination with conventional medicine [5], Methods while “alternative” medicine is primarily used in place of Search strategy conventional health care [5]. Furthermore, the term “in- A cross-sectional survey of the quality of websites con- tegrative practice” takes place when conventional and taining CAM consumer health information for the treat- complementary approaches are used collaboratively [5, ment and/or management of arthritis was undertaken. 6]. CAM treatments are popular among patients with JYN developed the search strategies which were exe- arthritis for a variety of reasons. A Malaysian study cuted by AV on Google on May 5th, 2020 as follows: ‘al- found that people with arthritis typically use CAM be- ternative medicine for arthritis’, ‘complementary and cause they believe there are fewer side effects associated alternative medicine for arthritis’, ‘complementary medi- with such therapies in comparison to conventional cine for arthritis’,and ‘integrative medicine for arthritis’. medicine [7]. Studies from South Korea, India, Turkey, All searches were conducted on Google Chrome in in- and Nigeria have found that the majority of patients turn cognito mode to ensure that the search results retrieved to CAM therapies because they believe it helps to allevi- were unaffected by prior browsing history and run ate pain, helps control morning stiffness, and is less ex- across four English-speaking countries: Australia pensive [8–11]. One report from the United Kingdom (Google.com.au), Canada (Google.ca), the United King- found that approximately 60% of arthritis patients have dom (Google.co.uk), and the United States (Google. used CAM therapies at least once [12]. One Canadian com). This was done to obtain a more internationally study found that 33.9% of patients with juvenile idio- representative selection of commonly-visited websites. pathic arthritis used CAM therapies [13]. Several studies The four search strategies were based on the most com- from the United States have estimated that 30–41% of mon terms used to refer to CAM [6] and were designed adults with arthritis use CAM [14–17], while CAM use to be simple, so as to replicate how a “typical” patient among youth with juvenile idiopathic arthritis has been with limited knowledge of medical or research topics found to be 72% [18]. Another study found that 40% of may seek health-related information online. We elected Australians who suffer from osteoarthritis use CAM to search only Google as it comprises over 90% of the [19]. Some of the most commonly-used CAM therapies search engine market share used worldwide as of August for arthritis include dietary supplements (including glu- 2020 [25], thereby retrieving websites that are much cosamine sulphate and chondroitin), chiropractic and more likely to be accessed and read by patients. It is manual therapies, massage therapy, herbal medicine, worth noting that the four next most popular search en- acupuncture, and meditative therapies (including yoga gines (Bing, Yahoo!, Baidu, and Yandex) only hold be- and tai chi). These are purportedly used to improve tween 0.44 and 2.78% of the search engine market share damaged cartilage, manage pain/stress, and increase mo- each [25]. Additionally, we only assessed the first 20 bility [20, 21]. webpage results of each Google search, given that it is One study that reviewed the quality of online content known that internet users typically only view the first found that information relating to osteoarthritis is gen- page of results that are generated and may occasionally erally ‘fair’ in quality [22]. Another research study inves- look through the second search engine results page [26]. tigating the quality of complementary and integrative With four search terms being generated across four health information on the internet typically found that countries (for a total of 16 searches and 20 websites for most websites did well in terms of information quality each), we sought to assess a total of 320 websites. Ng et al. Advances in Rheumatology (2021) 61:6 Page 3 of 17 Eligibility criteria balanced and unbiased, enabling readers to pursue further AV and TJ reviewed the 320 websites yielded across all sources of information and clarifying that more than one searches and removed all duplicates. Once all of the treatment option is available, identifying areas of uncer- URLs were collected, the authors assessed the inclusion tainty, providing background information on how a treat- criteria for each website. Websites were screened for eli- ment works, describing the benefits and risks of the gibility and included if they contained at least one web- treatment/lack of treatment, highlighting effects on the page that contained CAM consumer health information overall quality of life, and determining if the publica- for the treatment and/or management of arthritis. For tion (website) supports collaborative decision-making the purpose of this study, we identified and included [27]. The assessor is then asked to rate the publica- CAM therapies based on the operational definition pro- tion's overall quality (Question 16) by taking all of these vided by Cochrane, as follows: https://cam.cochrane.org/ areas into account and summarizing the results based on operational-definition-complementary-medicine.In how the majority of the questions were answered. This addition, websites had to have been published in the final question is an intuitive summary of the previous 15 English-language and be publicly available. Ineligible items of the DISCERN instrument [27]. websites that were excluded were as follows: Wikipedia We developed a standardized procedure to data extract pages, videos without text content (i.e. YouTube links), and assess each website for quality using the DISCERN as- Google images, broken URLs, websites published in sessment by first conducting a pilot test on three separate non-English languages, eBooks, peer-reviewed journals websites independently, followed by a meeting to discuss and articles, forums, and news articles that did not con- and resolve any discrepancies (JYN, AV, TJ). Following tain any consumer health information. A finalized list this, AV and TJ completed the data extraction and was developed to undergo further evaluation of content. assessed the quality of consumer health information using the DISCERN instrument, for each eligible website. The Data extraction and website quality assessment individual scores were reviewed by JYN and any remaining AV and TJ data extracted the following items: website discrepancies were resolved between AV and TJ without URL, website type, types of arthritis discussed, types of unduly altering original assessor ratings. Averages CAM therapies, types of non-CAM therapies (if present), were calculated across the two authors’ scores for every whether the website appeared in more than one search DISCERN question and for all websites assessed. In (different search terms and/or regions), whether the web- addition to the five-point scale intuitive summary score site was certified by Health on the Net Foundation Code for Question 16, an overall DISCERN score sum of of Conduct (HONcode), as well as the scores for the 16 questions 1–15 was also calculated (ranging from a score DISCERN questions. Different webpages from the same between 15 and 75). The mean score and standard website captured by searches were considered a single deviation were determined for each DISCERN item as item for the DISCERN instrument quality assessment; we well as the total mean score for all 16 items. therefore conducted a quality assessment of websites and not individual webpages. The DISCERN instrument is di- Results vided into a series of 16 key questions including an overall Search results rating on the quality of the information being assessed. It A total of 320 webpages were reviewed, of which 239 were is designed to examine what information is being provided duplicates, and 81 were unique. Twenty-seven websites rather than simply looking at how it is presented. It is or- were not eligible as they were peer-reviewed academic ar- ganized into three sections: Section 1 (Questions 1–8), ticles (n =20), Google images (n = 3), invalid addresses which address the reliability of the source, Section 2 (n =2), and news articles (n = 2). One additional website (Questions 9–15), which analyses the specific details re- did not mention CAM treatment for arthritis from a pa- garding treatment options, and Section 3 (Question 16), tient/consumer health information point of view, resulting which is the overall quality rating of the publication [27]. in a total of 53 eligible webpages. After collapsing web- To receive a ‘good’ quality rating, the majority of the ques- pages from the same website, a total of 38 websites were tions must be rated highly on a five-point rating scale ran- deemed eligible and assessed using the DISCERN instru- ging from ‘No’ to ‘Yes’ [27]. A rating of five indicates that ment. This process is depicted in Fig. 1. the answer to the question is a definite ‘Yes’,whilearating of one indicates a definite ‘No’. The ratings in between sig- General characteristics of eligible websites nify that the criterion for the question was only partially We organized eligible websites based on the following fulfilled. Questions that encompass DISCERN criteria in- categories: commercial, government, health portal, news, clude analysing the aims of the publication, determining if non-profit, professional, and other. For a website to be the information is relevant, identifying if sources and their categorized as commercial, it would have to either pur- dates were made explicit, judging if the information is chase or sell a product or service with the intent of Ng et al. Advances in Rheumatology (2021) 61:6 Page 4 of 17 Fig. 1 Web Information Search Strategy and Assessment Flowchart making a profit. An example of a commercial website in majority of websites (89.47%) also provided information this study is the Praana website (https://praanaim.com/). about non-CAM therapies – the most common types Government websites – such as HealthLink British being pharmaceutical medications and surgery. Most Columbia (https://www.healthlinkbc.ca/) – are websites websites (n = 29) appeared in more than one search, in- that are controlled by a governmental body. A health cluding those that were generated from the same coun- portal is any website that primarily discusses health try but through a different search term. Table 1 depicts topics, such as WebMD (https://www.webmd.com/). some of the general characteristics of the eligible The news categorization refers to websites like Medical websites. News Today (https://www.medicalnewstoday.com/) that take information from newspapers, magazines and televi- DISCERN instrument ratings sion and are a source of consumer health information. The total mean score across all websites for the sum of Non-profit websites are often linked to charities or orga- questions 1 through 15 in the DISCERN instrument was nizations that are not aiming to make a profit, as seen 55.53 (SD = 9.37) out of 75. The total mean score for ques- with the Arthritis Foundation website (https://www. tion 16, which assessed the overall rating of each website arthritis.org/). The majority of websites assessed (n = 13) was 3.71 (SD = 0.63) on a five-point scale. This shows that were categorized as professional, meaning that they were on average, most websites achieved a moderately high over- either affiliated with health experts, a university/hospital, all rating. Thus, the quality of most sources was better than or an authorized organization, as seen in the example ‘fair’, but still had room for improvement in terms of with the Mayo Clinic website (https://www.mayoclinic. obtaining the optimal standard. The Mayo Clinic and Upto- org/). Websites that did not fit into any of the previously Date websites scored the highest with both achieving a mentioned categories, were classified as ‘other’, which DISCERN score sum of 69.50. The overall quality rating for example was the case for the Creaky Joints website was a score of 4.64 (SD = 0.05) for both of these webpages. (https://creakyjoints.org/). Conversely,the Dr.Weiland Robert Schad Naturopathic Common types of CAM therapies discussed were diet- Clinic websites scored the lowest, with scores of 38.00 and ary and herbal supplements, which according to the Na- 32.00 respectively; the overall quality ratings were 2.53 and tional Center for Complementary and Integrative 2.14 respectively. A breakdown of the DISCERN instrument Health, includes vitamins, minerals, herbs, botanicals, ratings can be viewed in Table 2, which includes the total amino acids, enzymes, tissues from organs or glands, means and standard deviations for each question. and extracts [28]. Dietary and herbal supplements were mentioned in nearly all the websites assessed aside from Trends identified across resources assessed one (n = 37), proving to be the most frequent CAM ther- Website aims apy mentioned. Acupuncture was the next most com- The DISCERN instrument considers a source to be of mon therapy (n = 30), followed by exercise (n = 26), good quality if the aims of the publication are clearly in- when including tai chi and yoga. The overwhelming dicated. Question 1 assesses the extent to which a Ng et al. Advances in Rheumatology (2021) 61:6 Page 5 of 17 Table 1 General Characteristics of Eligible Websites Website Name URL Website Types of Arthritis Types of CAM Types of Non- Appeared Category Discussed Discussed CAM Therapies in More Discussed than One Search? Association of https://aanmc.org/ Professional Osteoarthritis, Diet, exercise, tai chi, Pharmaceuticals, Yes Accredited inflammatory arthritis, supplements, herbs, steroid Naturopathic rheumatoid arthritis, chiropractic, injections, Medical psoriatic arthritis, gout hydrotherapy, body surgery Colleges work American https://www.rheumatology.org/ Non-Profit Multiple types Herbs, supplements, Pharmaceuticals Yes College of acupuncture Rheumatology Arthritis https://arthritisaustralia.com.au/ Non-Profit Multiple types Acupuncture, massage, Pharmaceuticals, Yes Australia aromatherapy, vitamins, surgery supplements, herbs Arthritis https://www.arthritis.org/ Non-Profit Multiple types Supplements, vitamins, Pharmaceuticals, Yes Foundation acupuncture, massage, surgery tai chi, yoga, weight loss, physical therapy, topical gels, transcutaneous electrical nerve stimulation, relaxation therapy, energy healing Arthritis Health https://www.arthritis-health. Health Ankylosing spondylitis, Heat/cold, acupuncture, Pharmaceuticals, Yes com/ Portal bursitis, fibromyalgia, reiki healing, surgery general arthritis, gout, supplements, manual juvenile arthritis, therapies, tai chi, yoga, osteoarthritis, massage, nutrition polymyalgia rheumatica, pseudogout, psoriatic arthritis, reactive arthritis, rheumatoid arthritis Arthritis Society https://arthritis.ca/ Non-Profit Osteoarthritis, Heat/cold, visualization, Pharmaceuticals, Yes inflammatory arthritis, relaxation, massage, surgery general arthritis acupuncture, meditation/mindfulness, chiropractic, herbs, supplements Arthritis South https://arthritissa.org.au/ Non-Profit Ankylosing spondylitis, Acupuncture, massage, Pharmaceuticals, Yes Australia fibromyalgia, gout, aromatherapy, vitamins, surgery haemochromatotic herbs, minerals arthritis, juvenile idiopathic arthritis, osteoarthritis, polymyalgia rheumatica, psoriatic arthritis, reactive arthritis, rheumatoid arthritis, epidemic polyarthritis, scleroderma, sjögren’s syndrome, spondyloarthritis, BMI Healthcare https://www.bmihealthcare.co. Professional Osteoarthritis, Acupuncture, Pharmaceuticals, No uk/ rheumatoid arthritis, aromatherapy, massage, surgery psoriatic arthritis, reflexology, yoga general arthritis Center for http://holistic-medicine.com/ Professional Osteoarthritis, Hot/cold, diet, spinal Pharmaceuticals Yes Holistic rheumatoid arthritis decompression therapy, Medicine naprapathy, lasers, acupuncture The Chalkboard https://thechalkboardmag.com/ News Rheumatoid arthritis Diet, herbs, meditation, Pharmaceuticals No Mag yoga, mindfulness Ng et al. Advances in Rheumatology (2021) 61:6 Page 6 of 17 Table 1 General Characteristics of Eligible Websites (Continued) Website Name URL Website Types of Arthritis Types of CAM Types of Non- Appeared Category Discussed Discussed CAM Therapies in More Discussed than One Search? Consumer https://www.consumerreports. Non-Profit Osteoarthritis, general Yoga, tai chi, No Yes Reports org/cro/index.htm arthritis supplements, acupuncture, massage, chiropractic, homeopathy, exercise, weight loss Creaky Joints https://creakyjoints.org Other Multiple types Tai chi, acupuncture, Pharmaceuticals Yes yoga, exercise, massage, magnets, relaxation therapy, hydrotherapy, herbs, supplements, manipulation, chiropractic, weight management, physical therapy Department of https://www.fammed.wisc.edu/ Professional Osteoarthritis Exercise, mind-body Pharmaceuticals, Yes Family Medicine therapies, acupuncture, surgery and Community diet, supplements, Health massage University of Wisconsin Dr. Weil https://www.drweil.com/ Other Rheumatoid arthritis, Exercise, relaxation Pharmaceuticals No osteoarthritis, general techniques, arthritis hypnotherapy, diet, supplements Everyday Health https://www.everydayhealth. News Multiple types Herbs, spices, Pharmaceuticals Yes com/ supplements, acupuncture Health https://www.health.com/ News Multiple types Exercise, physical Pharmaceuticals No therapy, mind-body therapies, counselling, supplements, hot/cold, acupuncture, massage Healthline https://www.healthline.com/ Health Multiple types Herbs, massage, heat/ Pharmaceuticals, Yes Portal ice, exercise, tai chi, surgery yoga, bath & soaking therapies, stress management/mind- body medicine (biofeedback & meditation), diet, vitamin supplements, acupuncture, supportive shoes, weight management, magnets HealthLink https://www.healthlinkbc.ca/ Government General arthritis Supplements, vitamins, Pharmaceuticals, No British Columbia acupuncture, massage, assistive devices topicals, tai chi, yoga Integrative https://imcwc.com/ Professional General arthritis Herbs, vitamins, Pharmaceuticals Yes Medicine Center minerals, enzymes, oils of Western Colorado Integrated https://www. Professional General arthritis Exercise, chiropractic, Injections Yes Medical integratedmedicalsolutionsknox. diet, supplements, Solutions of com/ acupuncture Knoxville Johns Hopkins https://www.hopkinsarthritis. Professional Rheumatoid arthritis, Supplements, diet, Pharmaceuticals, Yes Arthritis Center org/ psoriatic arthritis, acupuncture, magnets, surgery ankylosing spondylitis, hydrotherapy, gout, osteoarthritis homeopathy, tai chi, Ng et al. Advances in Rheumatology (2021) 61:6 Page 7 of 17 Table 1 General Characteristics of Eligible Websites (Continued) Website Name URL Website Types of Arthritis Types of CAM Types of Non- Appeared Category Discussed Discussed CAM Therapies in More Discussed than One Search? yoga, mind-body ther- apy, energy medicine Markham https://integrative-medicine.ca/ Other Rheumatoid arthritis Diet, supplements, No Yes Integrative herbs, sauna therapy Medicine Mayo Clinic https://www.mayoclinic.org/ Professional Ankylosing spondylitis, Acupuncture, Pharmaceuticals, Yes gout, juvenile idiopathic supplements, yoga, tai surgery, assistive arthritis, osteoarthritis, chi, massage, heat/cold devices psoriatic arthritis, reactive arthritis, rheumatoid arthritis, septic arthritis, thumb arthritis Medical News https://www.medicalnewstoday. News General arthritis Aquatic exercise, tai chi, Pharmaceuticals Yes Today com/ yoga, hot/cold therapy, mindfulness meditation, massage, supplements, diet, herbs National Center https://www.nccih.nih.gov/ Government Rheumatoid arthritis, Mind-body practices, No Yes for osteoarthritis, gout supplements, herbs, Complementary acupuncture, massage, and Integrative tai chi, yoga, relaxation Health therapies, diet National Health https://www.nhs.uk/ Government Osteoarthritis, Diet, supplements, Pharmaceuticals, Yes Service United rheumatoid arthritis, acupuncture, massage, injections, Kingdom ankylosing spondylitis, chiropractic, osteopathy surgery cervical spondylosis, fibromyalgia, gout, psoriatic arthritis, enteropathic arthritis, reactive arthritis, secondary arthritis, polymyalgia rheumatica, juvenile idiopathic arthritis Nursing Times https://www.nursingtimes.net/ News Rheumatoid arthritis, Acupuncture, Pharmaceuticals Yes osteoarthritis homeopathy, herbs, osteopathy Philadelphia https://philly-im.com/ Professional Rheumatoid arthritis Mind-body techniques, Pharmaceuticals Yes Integrative nutrition, acupuncture, Medicine supplements, exercise, eliminating toxins Praana https://praanaim.com/ Commercial Rheumatoid arthritis Vitamins, exercise, diet, Pharmaceuticals Yes supplements, mind- body approach Practical Pain https://www. Health Fibromyalgia, Yoga, massage, dietary Pharmaceuticals, Yes Management practicalpainmanagement.com/ Portal inflammatory arthritis, supplements, injections, rheumatoid arthritis, acupuncture, monitoring with juvenile idiopathic balneotherapy, mind- lab tests arthritis, osteoarthritis, body therapies, chiro- polymyalgia rheumatica practic, relaxation tech- niques, prayer, naturopathy Robert Schad https://rsnc.ca/ Professional Rheumatoid arthritis, Nutrition, supplements, No No Naturopathic osteoarthritis herbs, traditional Clinic Chinese medicine, homeopathic medicine, physical medicine Ng et al. Advances in Rheumatology (2021) 61:6 Page 8 of 17 Table 1 General Characteristics of Eligible Websites (Continued) Website Name URL Website Types of Arthritis Types of CAM Types of Non- Appeared Category Discussed Discussed CAM Therapies in More Discussed than One Search? Spine Universe https://www.spineuniverse. Health Rheumatoid arthritis, Acupuncture, herbs, Pharmaceuticals Yes com/ Portal ankylosing spondylitis, massage, relaxation, fibromyalgia, juvenile mind-body therapies idiopathic arthritis, osteoarthritis St. Luke’s https://www.stlukes-stl.com/ Professional Osteoarthritis, Supplements, herbs, Pharmaceuticals, No Hospital rheumatoid arthritis, acupuncture, surgery, braces, gout, fibromyalgia, chiropractic, physical splints scleroderma, therapy, hydrotherapy, homeopathy, yoga, tai chi, exercise Up To Date https://www.uptodate.com/ Health Inflammatory and non- Acupuncture, mind- Pharmaceuticals Yes Portal inflammatory arthritis body techniques, exer- cise, diet, supplements, herbs, vitamins, hom- eopathy, magnets, mind-body therapies University of https://www.uwhealth.org/ Professional General arthritis Supplements, vitamins, Pharmaceuticals, No Wisconsin- acupuncture, massage, assistive devices, Madison Health topicals, tai chi, yoga surgery Versus Arthritis https://www.versusarthritis.org/ Non-Profit Osteoarthritis, gout, Diet, exercise, Pharmaceuticals, Yes rheumatoid arthritis, meditation, surgery spondyloarthritis, psychological exercises, ankylosing spondylitis, acupuncture, yoga, psoriatic arthritis, body techniques, juvenile idiopathic herbals arthritis WebMD https://www.webmd.com/ Health Osteoarthritis, Heat/cold, magnets, Pharmaceuticals, Yes Portal rheumatoid arthritis, acupuncture, injections, juvenile rheumatoid aromatherapy, surgery arthritis, infectious biofeedback, deep arthritis, ankylosing breathing, exercise, spondylitis, bone spurs, massage, meditation, gout, systemic lupus progressive muscle relaxation, tai chi, herbals, topical creams, gels, patches, visualization, yoga, supplements, chiropractic Zanjabee http://www.zanjabee.com/ Professional Osteoarthritis Diet, exercise, relaxation Pharmaceuticals, No techniques, heat/cold, injections, joint acupuncture, massage, replacement/ supplements, herbs, surgery Ayurveda website fulfils this requirement. The vast majority of websites information on the website are made clear to the viewer. ranked above average for this question with a total mean To achieve a good ranking for this question, the website score of 4.53 (SD = 0.56). The “About” page of a website typ- should include both in-text citations and a reference list ically included this information in the form of a mission/vi- at the end of the article. Twenty-two out of 38 web- sion statement, or it could sometimes be found in the sites scored a 3 or below on this question, meaning that introduction of an article. It is here where most websites the majority of websites did not include both in-text ci- identified their target audience and what kind of information tations and a formal reference list. The total mean score users could expect to find within the resource. was 2.76 (SD = 1.51). Some websites included a reference list but failed to have in-text citations and vice versa, Use of references while others showed no evidence of referencing at all. Question 4 of the DISCERN instrument evaluates Only 4 websites achieved a perfect ranking of 5 for this whether or not the sources used to compile the question. Ng et al. Advances in Rheumatology (2021) 61:6 Page 9 of 17 Table 2 DISCERN Instrument Ratings and HONcode Search Section SECTION 1 Is the publication reliable? DISCERN Question 1. Are 2. Does 3. Is it 4. Is it clear what sources of 5. Is it clear when the 6. Is it 7. Does it provide 8. Does it the it relevant? information were used to compile the information used or balanced details of additional refer to aims achieve publication (other than the author or reported in the publication and sources of support and areas of clear? its aims? producer)? was produced? unbiased? information? uncertainty? Mayo Clinic https://www.mayoclinic.org/ 5.00 4.50 4.50 4.00 5.00 5.00 4.50 5.00 UpToDate https://www.uptodate.com/ 5.00 5.00 5.00 5.00 5.00 5.00 5.00 5.00 Medical News Today https://www.medicalnewstoday. 4.50 5.00 4.50 4.50 5.00 4.00 4.50 5.00 com/ Johns Hopkins Arthritis https://www.hopkinsarthritis. 5.00 5.00 4.50 5.00 5.00 5.00 5.00 5.00 Center org/ National Center for https://www.nccih.nih.gov/ 5.00 5.00 5.00 4.00 5.00 5.00 4.50 5.00 Complementary and Integrative Health St. Luke’s Hospital https://www.stlukes-stl.com/ 3.00 5.00 5.00 4.00 5.00 5.00 4.50 5.00 WebMD https://www.webmd.com/ 5.00 5.00 5.00 4.00 4.00 5.00 4.50 5.00 Department of Family https://www.fammed.wisc.edu/ 4.50 5.00 5.00 4.00 4.00 4.00 3.50 5.00 Medicine and Community Health University of Wisconsin Arthritis Health https://www.arthritis-health. 4.50 4.50 4.50 5.00 5.00 5.00 5.00 5.00 com/ Everyday Health https://www.everydayhealth. 4.50 5.00 4.50 3.00 4.00 3.00 2.50 5.00 com/ Healthline https://www.healthline.com/ 4.50 5.00 4.50 4.00 4.50 4.00 5.00 5.00 Practical Pain https://www. 4.50 5.00 4.00 4.00 4.50 3.50 4.00 5.00 Management practicalpainmanagement.com/ Spine Universe https://www.spineuniverse. 4.50 4.00 4.50 2.50 3.50 3.50 3.00 3.00 com/ National Health Service https://www.nhs.uk/ 4.50 4.00 4.00 3.50 5.00 2.00 5.00 5.00 United Kingdom Arthritis Society https://arthritis.ca/ 5.00 5.00 5.00 2.00 1.50 3.00 3.00 4.00 The Chalkboard Mag https://thechalkboardmag.com/ 5.00 5.00 4.50 4.50 4.00 2.50 5.00 1.50 Arthritis Foundation https://www.arthritis.org/ 5.00 5.00 4.50 3.00 2.5.00 3.00 2.50 4.00 BMI Healthcare https://www.bmihealthcare.co. 4.00 4.00 3.50 4.50 2.00 3.00 5.00 1.50 uk/ Versus Arthritis https://www.versusarthritis.org/ 4.50 5.00 5.00 1.50 2.00 4.00 3.00 4.50 Nursing Times https://www.nursingtimes.net/ 5.00 5.00 4.00 5.00 5.00 5.00 1.50 5.00 Arthritis Australia https://arthritisaustralia.com.au/ 5.00 4.00 4.00 3.00 3.00 2.50 5.00 5.00 Praana https://praanaim.com/ 4.00 4.00 4.50 4.00 3.00 2.00 5.00 4.50 Arthritis South Australia https://arthritissa.org.au/ 5.00 3.50 4.00 1.00 2.00 2.50 5.00 5.00 Health https://www.health.com/ 5.00 4.50 3.50 1.00 2.50 2.50 1.00 5.00 Ng et al. Advances in Rheumatology (2021) 61:6 Page 10 of 17 Table 2 DISCERN Instrument Ratings and HONcode Search (Continued) Section SECTION 1 Is the publication reliable? DISCERN Question 1. Are 2. Does 3. Is it 4. Is it clear what sources of 5. Is it clear when the 6. Is it 7. Does it provide 8. Does it the it relevant? information were used to compile the information used or balanced details of additional refer to aims achieve publication (other than the author or reported in the publication and sources of support and areas of clear? its aims? producer)? was produced? unbiased? information? uncertainty? Markham Integrative https://integrative-medicine.ca/ 3.50 3.00 3.00 1.50 1.00 2.50 5.00 5.00 Medicine American College of https://www.rheumatology.org/ 4.50 3.00 3.00 1.00 2.50 3.00 5.00 5.00 Rheumatology HealthLink British https://www.healthlinkbc.ca/ 4.50 3.00 4.00 1.00 2.50 4.00 2.00 5.00 Columbia University of Wisconsin- https://www.uwhealth.org/ 5.00 3.50 4.00 1.00 2.50 4.00 1.00 5.00 Madison Health Creaky Joints https://creakyjoints.org 4.50 3.00 4.00 1.00 1.00 2.00 3.00 5.00 Consumer Reports https://www.consumerreports. 5.00 2.50 3.00 3.00 3.00 2.00 4.00 5.00 org/cro/index.htm Association of Accredited https://aanmc.org/ 5.00 3.00 5.00 3.00 2.50 2.50 4.00 1.00 Naturopathic Medical Colleges Integrative Medicine https://imcwc.com/ 5.00 3.50 3.50 1.00 1.00 1.00 2.00 5.00 Center of Western Colorado Philadelphia Integrative https://philly-im.com/ 4.50 2.00 2.50 1.50 4.00 2.50 4.00 5.00 Medicine Zanjabee http://www.zanjabee.com/ 4.00 3.50 4.00 1.00 1.00 2.00 1.50 1.50 Center for Holistic http://holistic-medicine.com/ 4.00 3.50 3.50 1.00 2.50 2.00 4.00 1.50 Medicine Integrated Medical https://www. 3.50 3.00 3.50 1.00 1.00 3.00 1.50 1.00 Solutions of Knoxville integratedmedicalsolutionsknox. com/ Dr. Weil https://www.drweil.com/ 4.50 3.00 3.00 1.00 1.00 3.00 3.00 1.00 Robert Schad https://rsnc.ca/ 3.00 3.50 2.50 1.00 1.00 1.50 1.00 1.00 Naturopathic Clinic TOTAL Means 4.53 4.08 4.09 2.76 3.12 3.26 3.62 4.08 TOTAL Standard Deviations 0.56 0.90 0.73 1.51 1.47 1.16 1.39 1.54 Section SECTION 2 How good is the quality of information on treatment choices? SECTION 3 Overall Rating of the HONcode Publication Search DISCERN Question 9. Does it 10.Does it 11. Does it 12. Does it 13. Does it 14. Is it clear that 15. Does it 16. Based on the answers to all of Standard DISC Is it describe describe the describe describe what describe how the there may be provide the above questions, rate the overall Deviation ERN certified how each benefits of the risks of would happen treatment choices more than one support for quality of the publication as a source of Overall Score by treatment each each if no treatment affect overall possible shared of information about treatment Score (Sum of HONcode works? treatment? treatment? is used? quality of life? treatment choice? decision- choices (Q16) Q1- (yes/no) making? Q15) Ng et al. Advances in Rheumatology (2021) 61:6 Page 11 of 17 Table 2 DISCERN Instrument Ratings and HONcode Search (Continued) Section SECTION 2 How good is the quality of information on treatment choices? SECTION 3 Overall Rating of the HONcode Publication Search DISCERN Question 9. Does it 10.Does it 11. Does it 12. Does it 13. Does it 14. Is it clear that 15. Does it 16. Based on the answers to all of Standard DISC Is it describe describe the describe describe what describe how the there may be provide the above questions, rate the overall Deviation ERN certified how each benefits of the risks of would happen treatment choices more than one support for quality of the publication as a source of Overall Score by treatment each each if no treatment affect overall possible shared of information about treatment Score (Sum of HONcode works? treatment? treatment? is used? quality of life? treatment choice? decision- choices (Q16) Q1- (yes/no) making? Q15) Mayo Clinic 4.00 5.00 3.00 5.00 5.00 5.00 5.00 4.64 0.05 69.50 Yes UpToDate 4.00 4.50 4.00 2.00 5.00 5.00 5.00 4.64 0.05 69.50 Yes Medical News 4.00 5.00 2.50 5.00 4.00 5.00 5.00 4.50 0.14 67.50 Yes Today Johns Hopkins 3.00 4.50 3.00 2.50 5.00 5.00 4.50 4.47 0.00 67.00 No Arthritis Center National Center for 3.00 5.00 4.50 4.00 2.00 5.00 5.00 4.47 0.09 67.00 No Complementary and Integrative Health St. Luke’s Hospital 3.00 4.50 3.50 3.50 5.00 5.00 5.00 4.43 0.14 66.00 No WebMD 3.00 4.50 3.00 5.00 2.50 5.00 5.00 4.37 0.05 65.50 Yes Department of 3.50 5.00 4.50 5.00 2.50 5.00 5.00 4.37 0.05 65.50 No Family Medicine and Community Health University of Wisconsin Arthritis Health 4.00 4.50 3.00 1.00 3.50 5.00 5.00 4.30 0.14 64.50 Yes Everyday Health 3.50 5.00 3.00 5.00 4.00 5.00 5.00 4.14 0.09 62.00 Yes Healthline 2.50 5.00 3.50 1.50 2.50 5.00 5.00 4.10 0.04 61.50 Yes Practical Pain 3.50 5.00 2.00 2.50 4.00 5.00 5.00 4.10 0.24 61.50 Yes Management Spine Universe 4.00 5.00 3.50 5.00 4.50 5.00 5.00 4.03 0.14 60.50 Yes National Health 5.00 5.00 4.00 2.00 1.00 5.00 5.00 4.10 0.14 60.00 No Service United Kingdom Arthritis Society 5.00 5.00 3.00 5.00 3.00 5.00 5.00 3.97 0.05 59.50 No The Chalkboard 3.50 4.50 1.50 3.00 5.00 5.00 5.00 3.97 0.05 59.50 No Mag Arthritis Foundation 4.50 5.00 3.50 1.00 4.50 5.00 5.00 3.87 0.09 58.00 No BMI Healthcare 3.50 5.00 1.50 5.00 5.00 5.00 5.00 3.84 0.05 57.50 No Versus Arthritis 4.00 4.50 4.00 2.00 3.00 5.00 5.00 3.80 0.00 57.00 No Nursing Times 1.00 3.50 3.50 2.00 1.50 4.50 5.00 3.77 0.14 56.50 No Arthritis Australia 4.00 4.00 4.00 1.00 1.50 5.00 5.00 3.74 0.09 56.00 Yes Praana 1.50 3.00 1.50 5.00 5.00 4.00 5.00 3.74 0.09 56.00 No Ng et al. Advances in Rheumatology (2021) 61:6 Page 12 of 17 Table 2 DISCERN Instrument Ratings and HONcode Search (Continued) Section SECTION 2 How good is the quality of information on treatment choices? SECTION 3 Overall Rating of the HONcode Publication Search DISCERN Question 9. Does it 10.Does it 11. Does it 12. Does it 13. Does it 14. Is it clear that 15. Does it 16. Based on the answers to all of Standard DISC Is it describe describe the describe describe what describe how the there may be provide the above questions, rate the overall Deviation ERN certified how each benefits of the risks of would happen treatment choices more than one support for quality of the publication as a source of Overall Score by treatment each each if no treatment affect overall possible shared of information about treatment Score (Sum of HONcode works? treatment? treatment? is used? quality of life? treatment choice? decision- choices (Q16) Q1- (yes/no) making? Q15) Arthritis South 5.00 5.00 5.00 1.00 1.50 5.00 5.00 3.70 0.04 55.50 No Australia Health 3.00 5.00 2.00 2.00 4.50 5.00 5.00 3.44 0.05 51.50 No Markham 3.50 4.00 3.50 3.00 4.00 4.00 5.00 3.44 0.23 51.50 No Integrative Medicine American College 2.50 3.00 4.00 1.00 3.00 5.00 5.00 3.37 0.05 50.50 No of Rheumatology HealthLink British 2.00 3.50 2.50 3.00 3.00 5.00 5.00 3.34 0.19 50.00 No Columbia University of 2.00 3.50 2.50 3.00 3.00 5.00 5.00 3.34 0.19 50.00 No Wisconsin-Madison Health Creaky Joints 3.50 4.00 3.50 2.00 2.50 5.00 5.00 3.27 0.19 49.00 No Consumer Reports 2.50 4.00 2.50 1.00 1.00 5.00 5.00 3.30 0.04 48.50 No Association of 4.00 5.00 1.50 1.00 2.50 5.00 2.50 3.17 0.05 47.50 No Accredited Naturopathic Medical Colleges Integrative 3.50 4.50 2.00 3.00 2.00 5.00 4.50 3.10 0.14 46.50 No Medicine Center of Western Colorado Philadelphia 2.00 3.00 2.00 1.00 3.00 5.00 2.50 2.97 0.05 44.50 No Integrative Medicine Zanjabee 4.00 4.50 1.00 4.00 3.00 5.00 4.00 2.94 0.19 44.00 No Center for Holistic 4.00 4.50 1.00 3.00 1.00 5.00 3.00 2.90 0.04 43.50 No Medicine Integrated Medical 3.00 5.00 1.00 4.00 1.50 5.00 3.00 2.67 0.19 40.00 No Solutions of Knoxville Dr. Weil 2.00 2.50 1.00 5.00 1.50 5.00 1.50 2.53 0.00 38.00 No Robert Schad 2.00 3.50 1.00 1.00 4.00 4.00 2.00 2.14 0.09 32.00 No Naturopathic Clinic TOTAL Means 3.30 4.38 2.78 2.92 3.16 4.91 4.54 3.71 0.10 55.53 TOTAL Standard 0.97 0.72 1.13 1.54 1.33 0.28 0.98 0.63 0.07 9.37 Deviations Ng et al. Advances in Rheumatology (2021) 61:6 Page 13 of 17 Risks associated with treatment Furthermore, these websites clearly outlined areas of un- To achieve a high ranking for question 11 of the DISC certainty in the research known about the disease, and ERN instrument, a website must include a description of highlighted the various treatment options that are avail- the risks associated with each treatment that is discussed. able to arthritis patients. The majority of these websites The mean score for this question was 2.78 (SD = 1.13). provided clear cited sources and, in our judgement, pro- None of the sources assessed received a perfect score of 5, vided information which remained unbiased. Many of which is of concern given that patients should be made these websites also referred consumers to further material aware of what to expect from a treatment, especially if any on the topic discussed, and provided sufficient details sur- adverse side effects are known. Many websites did not rounding the impacts a treatment option could have on a provide enough detail about the disadvantages of a treat- patient's overall quality of life. Additional details about ment, or only mentioned the risks for some of the CAM these websites are provided in Table 3. therapies discussed but failed to provide adequate details. Discussion Variety of treatment options The purpose of this study was to assess the quality of The overwhelming majority of websites analysed in this online CAM consumer health information for the treat- study scored highly on question 14 of the DISCERN in- ment and/or management of arthritis. Given the high strument. The question assesses whether or not a source prevalence of CAM use among patients with arthritis demonstrates that there are various treatment options for and their increasing reliance on the internet for arthritis patients. Thirty-four out of the 38 websites health information, it is important to critically evaluate assessed received a perfect score of 5, and no website was the online resources that this unique patient population graded lower than 4. This provided a mean score of 4.91 accesses. This is especially crucial given the fact that (SD = 0.28). Various forms of CAM therapies were often nearly half of all arthritis patients who utilize CAM ther- discussed, including dietary and herbal supplements, acu- apies do not disclose this to their physicians [29]. puncture, exercise, and manual therapies. Most of the Healthcare providers should, therefore, be aware of the websites provided additional information regarding con- online information that their patients may consult, either ventional treatment options as well, such as pharmaceuti- as a second opinion or in their absence, to help them cals, surgery, steroid injections and assistive devices. navigate appropriate resources and discern between websites of high quality and those providing misinforma- Shared decision-making tion or unsafe recommendations. Question 15 of the DISCERN instrument assesses the The present study found that the majority of eligible extent to which a website provides patients with support websites assessed were of ‘fair’ quality. Twenty-one out of for shared decision-making. The majority of the websites the 38 sources analysed received a moderate overall score assessed received a high ranking, with a mean score of (ranging from 2.90–3.97 out of 5). The total mean score 4.54 (SD = 0.98). Only 4 websites scored below a 3 for of 3.71 (SD = 0.63) and average DISCERN score of 55.53 this question. Most websites recommended that patients (SD = 9.37) suggests that most websites were slightly do not take any dietary and herbal supplements without above adequate quality but still had some shortcomings. It first consulting with their physician, stating that such should be noted that 14 out of 38 websites achieved a high products may interact with medications or potentially overall ranking of 4 or above and can be deemed of ‘good’ cause harm. Many sources also contained disclaimers quality. The websites that scored highest in this study may about how website content should not be a substitute serve as useful resources to healthcare providers who seek for professional medical advice and making healthcare to recommend high-quality resources for their patients. decisions in collaboration with a healthcare provider. While no websites assessed received an overall score below 2 (i.e. ‘poor’ quality), three websites ranked below Recommended websites for patients and consumers moderate (ranging from 2.14–2.67), suggesting that these The websites that scored highest in this study (an overall websites had some serious shortcomings (including a lack ranking of 4 or above for Question 16) may serve as good of transparency in terms of the sources used, dates of the quality sources for practitioners to recommend to arthritis articles, areas of uncertainty, and the risks associated with patients who seek additional CAM consumer health infor- each treatment while also not providing further reading). mation about arthritis. These websites were similar in the This study also found that the majority of sources out- sense that they typically scored a high rating above 4 lined the aims of the website, provided a wide variety of across many of the DISCERN questions. Each of the high- treatment options, and encouraged the use of shared est scoring websites received a score of 5 for question 8 decision-making between the patient and those who are (which assesses whether the website refers to any areas of involved in their care. In particular, adequate discussion uncertainty with the treatment) and question 14. surrounding different treatment options are beneficial for Ng et al. Advances in Rheumatology (2021) 61:6 Page 14 of 17 Table 3 Recommended Websites for Patients and Consumers Website Name URL DISCERN Overall Website Target Audience Frequency of Updates Score DISCERN Category (Sum of Score our (Question 75.00) 16, out of 5.00) Mayo Clinic https://www.mayoclinic.org/ 69.50 4.64 Professional Healthcare Website states that content is diseases-conditions/arthritis/ providers, updated regularly following a diagnosis-treatment/drc-2 researchers, schedule and whenever necessary 0350777 patients/public, to reflect new/revised findings. The prospective precise frequency of updates is not employees/ clear. volunteers UpToDate https://www.uptodate.com/ 69.50 4.64 Health Healthcare The content is updated daily. contents/complementary- Portal providers, and-alternative-therapies-for- researchers, rheumatoid-arthritis-beyond- patients/public the-basics Medical News https://www. 67.50 4.50 News Healthcare Website states that content is Today medicalnewstoday.com/ providers, continually reviewed and updated. articles/325760 researchers, The precise frequency of updates is https://www. patients/public not available. medicalnewstoday.com/ articles/324446 Johns Hopkins https://www.hopkinsarthritis. 67.00 4.47 Professional Healthcare Information on the precise Arthritis Center org/patient-corner/disease- providers, patients/ frequency of website updates is management/ra- public not clear. complementary-alternative- medicine/ National Center for https://www.nccih.nih.gov/ 67.00 4.47 Government Healthcare Website states that some parts are Complementary health/rheumatoid-arthritis- providers, updated daily while other areas of and Integrative in-depth researchers, the website may not be updated Health patients/public for weeks or months. St. Luke’s Hospital https://www.stlukes-stl.com/ 66.00 4.43 Professional Healthcare Information on the precise health-content/medicine/33/ providers, patients/ frequency of website updates is 000118.htm public not clear. WebMD https://www.webmd.com/ 65.50 4.37 Health Healthcare Website states that corrections and rheumatoid-arthritis/ Portal providers, updates to the material happen rheumatoid-arthritis-natural- researchers, regularly, but information on the treatments#1 patients/public precise frequency of website https://www.webmd.com/ updates is not clear. osteoarthritis/features/ alternative-arthritis- treatments#1 https://www.webmd.com/ rheumatoid-arthritis/ features/complementary- therapy#1 Department of https://www.fammed.wisc. 65.50 4.37 Professional Healthcare Information on the precise Family Medicine edu/integrative/resources/ providers, frequency of website updates is and Community modules/osteoarthritis/ researchers, not clear. Health University patients/public, of Wisconsin prospective medical students Arthritis Health https://www.arthritis-health. 64.50 4.30 Health Healthcare Information on the precise com/treatment/alternative- Portal providers, patients/ frequency of website updates is treatments/integrative- public not clear. medicine-arthritis-pain-relief https://www.arthritis-health. com/treatment/alternative- treatments Everyday Health https://www.everydayhealth. 62.00 4.14 News Healthcare Information on the precise com/ providers, patients/ frequency of website updates is public not clear. Ng et al. Advances in Rheumatology (2021) 61:6 Page 15 of 17 Table 3 Recommended Websites for Patients and Consumers (Continued) Website Name URL DISCERN Overall Website Target Audience Frequency of Updates Score DISCERN Category (Sum of Score our (Question 75.00) 16, out of 5.00) Healthline https://www.healthline.com/ 61.50 4.10 Health Healthcare Website states that articles are Portal providers, patients/ updated when new information public becomes available. Information on the precise frequency of website updates is not clear. Practical Pain https://www. 61.50 4.10 Health Healthcare Website states that content is Management practicalpainmanagement. Portal providers, patients/ updated regularly. Information on com/ public the precise frequency of website updates is not clear. Spine Universe https://www.spineuniverse. 60.50 4.03 Health Healthcare The content is updated daily. com/ Portal providers, patients/ public National Health https://www.nhs.uk/ 60.00 4.10 Government Healthcare The content is updated daily. Service United providers, Kingdom researchers, patients/public patients, so that they may be aware of the options that are promoted alternative medicine and that 80% of these web- available to them. While it is reassuring that numerous sites had clear financial aims [32]. Another study also websites encourage patients to consult their healthcare highlighted the importance of recommending websites providers before making any treatment decisions on their that draw on evidence-based medical literature; an ex- own, practitioners and researchers should be cautioned ample of such information could include a systematic re- that the majority of websites did not report all of the risks view that identified the quantity and assessed the quality that are associated with each CAM treatment and did not of CAM recommendations for osteoarthritis and rheuma- always provide explicit details about the references used to toid arthritis evidence-based clinical practice guidelines support their claims made about these therapies. These [33]. Guidelines and other evidence-based resources could findings illuminate an aspect of patient behaviour outside be used as a starting point for the improvement of con- of a clinical setting, given that many are unaware that vari- sumer health information on websites such as the ones we ous CAM therapies may lack efficacy and/or safety [30]; it assessed in the present study. is well-documented in the literature that, for example, Additionally, several studies have evaluated the quality many patients believe that natural remedies do not have of online CAM information as it relates to other condi- any harmful side effects or that “natural equals safe”, tions. A recent study assessed the quality of online con- which is an issue that healthcare providers need to be sumer health information at the intersection of CAM cognizant of and should strongly advocate that their pa- and low back pain using the DISCERN instrument, find- tients discuss their use of or concerns associated with ing that quality was quite variable across different web- CAM with them as opposed to self-medicating [30]. sites. The authors found that the mean overall rating To our knowledge, this is the first study to assess the across all websites was 3.47 (SD = 0.70), while the quality of websites containing CAM consumer health in- summed DISCERN scores ranged from 25.5-68.0, with a formation specifically in the context of arthritis. Despite mean of 53.25 (SD = 10.41) [34]. Another study also used this, our findings can be compared to other studies that the DISCERN instrument to evaluate information pro- have assessed the quality of consumer health information vided on chronic pain websites, and found that the over- on related topics. A previous study analysed the readability all quality of most were of moderate quality with several and quality of online information on osteoarthritis, includ- shortcomings. The overall average DISCERN score for ing conventional forms of treatment. This study found this study was 55.90 (however, they scored this total to that website information was considered ‘fair’ and that the include question 16, out of 80) [35]. readability was either equivalent to or more challenging than the recommended standard, as outlined by both the Strengths and limitations Journal of the American Medical Association and the One strength of the present study included the fact DISCERN criteria [22, 31]. Prior to this, another study that we specifically searched Google across four different found that 44% of web search results related to arthritis English-speaking countries (Australia, Canada, the Ng et al. Advances in Rheumatology (2021) 61:6 Page 16 of 17 United Kingdom and the United States) in order to yield Abbreviation CAM: Complementary and alternative medicine a more internationally-representative sample of websites. Another strength of this study included the use of the Acknowledgements DISCERN instrument, which has been found to be both JYN was funded by a Research Scholarship and an Entrance Scholarship from the Department of Health Research Methods, Evidence and Impact, Faculty reliable and valid in assessing the quality of consumer of Health Sciences at McMaster University. health information [36]. Additional strengths include the fact that we also piloted conducting data extractions and Authors’ contributions JYN: conceptualized and designed the study, collected the data, interpreted applying the DISCERN instrument; during the pilot and and analysed the data, drafted the manuscript, and gave final approval of the full-assessments, both steps were conducted independ- version to be published. AV: collected the data, interpreted and analysed the ently and in duplicate, before all three authors met to data, provided contributions and critically revised the manuscript, and gave final approval of the version to be published. TJ: collected the data, interpreted discuss and resolve discrepancies. and analysed the data, provided contributions and critically revised the One limitation includes the fact that our search only manuscript, and gave final approval of the version to be published. captured a cross-sectional snapshot of website informa- Funding tion; since the internet is a dynamic source that is subject This study was unfunded. to change, the results from this study may differ if repli- cated across future searches. Additionally, since the search Availability of data and materials strategy for this study only included the first 20 websites All relevant data are included in this manuscript. that were generated for each search term, less popular Ethics approval and consent to participate websites remain unassessed for quality. Furthermore, if This study involved a search and review of publicly available online different search terms were used, variable results could information only; it did not require ethics approval or consent to participate. have been generated. Yet another limitation would include Consent for publication the fact that the internet searches were only conducted in All authors consent to this manuscript’s publication. English, as were the eligibility criteria, thereby excluding Competing interests all websites that were written in other languages. Studies The authors declare that they have no competing interests. on the quality of non-English online consumer health in- formation are also limited, thus it is unclear as to whether Received: 7 September 2020 Accepted: 2 January 2021 our findings are generalizable to non-English websites and their respective patient populations that access and read References them. Multimedia platforms like videos and images were 1. Arthritis Foundation. What is arthritis?. 2020. Available from: https://www. excluded, even though these may also contribute to an un- arthritis.org/health-wellness/about-arthritis/understanding-arthritis/what-is- arthritis [cited 2020 Apr 26]. derstanding of patient health-seeking behaviour in the 2. Arthritis Society. The truth about arthritis. Toronto; 2020. Available from: context of CAM information for arthritis. Furthermore, https://arthritis.ca/about-arthritis/what-is-arthritis/the-truth-about-arthritis the DISCERN instrument is primarily designed to assess [cited 2020 Apr 26]. 3. Mayo Clinic. Arthritis.. 2019. Available from: https://www.mayoclinic.org/ the quality of health information, as opposed to determin- diseases-conditions/arthritis/symptoms-causes/syc-20350772 ing the accuracy of the content or the safety of the infor- [cited 2020 Apr 26]. mation written in the publication [27]. 4. Safiri S, Kolahi AA, Hoy D, Smith E, Bettampadi D, Mansournia MA, et al. 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The quality of online consumer health information at the intersection of complementary and alternative medicine and arthritis

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Abstract

Background: Complementary and alternative medicine (CAM) use is prevalent among patients living with arthritis. Such patients often seek information online, for the purpose of gaining a second opinion to their healthcare provider or even self-medication. Little is known about the quality of web-based consumer health information at the intersection of CAM and arthritis; thus, investigating the quality of websites containing this information was the purpose of this study. Methods: Four unique search terms were searched on Google across four English-speaking countries. We assessed the first 20 results of each search, including them if they contained CAM consumer health information for the treatment and/or management of arthritis. Eligible websites were assessed in duplicate using the DISCERN instrument, which consists of 16-items designed to assess quality. Results: Of total of 320 webpages, 239 were duplicates, and a total of 38 unique websites were deemed eligible and assessed using the DISCERN instrument. The mean summed DISCERN scores across all websites was 55.53 (SD = 9.37). The mean score of the overall quality of each website was 3.71 (SD = 0.63), thus the majority of websites are ranked as slightly above ‘fair’ quality. Conclusion: Eligible websites generally received scores better than ‘moderate’ in terms of overall quality. Several shortcomings included a lack of transparency surrounding references used and underreporting of risks associated with treatment options. These results suggest that health providers should be vigilant of the variable quality of information their patients may be accessing online and educate them on how to identify high quality resources. Keywords: Arthritis, Complementary and alternative medicine, Quality of information, Consumer health information, Information assessment, DISCERN Background include degenerative (osteoarthritis), resulting from pro- Arthritis is one of the leading causes of disability among gressive cartilage breakdown, and autoimmune/inflam- North Americans [1], describing over 100 conditions matory (rheumatoid arthritis), characterized by an that affect joints, tissues around the joint, and other con- immune system that attacks the synovial membrane [2]. nective tissues [2]. The two main categories of arthritis Arthritis may also arise from infections or metabolic dis- orders (most commonly seen as gout) [1]. Symptoms in- * Correspondence: ngjy2@mcmaster.ca clude joint pain, swelling, stiffness, tenderness, and Department of Health Research Methods, Evidence, and Impact, Faculty of limited range of motion commonly found in the hands, Health Sciences, McMaster University, Michael G. DeGroote Centre for wrists, knees, hips, ankles, and spine [2]. The condition Learning and Discovery, Room 2112, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada is diagnosed with a physical exam, assessing blood or © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Ng et al. Advances in Rheumatology (2021) 61:6 Page 2 of 17 synovial fluid tests, and by using imaging techniques relating to ownership, currency, interactivity and navig- such as x-rays [3]. Arthritis is most common among ability, while results varied for authorship, balanced in- women. Approximately 20 million people worldwide formation and the use of sources [23]. Another study on were living with rheumatoid arthritis in 2017 with over a the quality of herbal product information on the internet million new cases being diagnosed each year [4]. Al- found serious shortcomings in terms of providing spe- though arthritis affects all ages, the risk increases as indi- cific safety information [24]. To our knowledge, no study viduals grow older. If left untreated, it can negatively has specifically focused on the quality of online informa- impact physical functioning and quality of life [2]. tion at the intersection of CAM and arthritis. The ob- Many arthritis patients seek out various treatment op- jective of this study is to analyse the quality of consumer tions to help them manage and cope with their condi- health information on CAM therapies that a “typical” tion, one of which includes complementary and patient with arthritis may encounter online. This study alternative medicine (CAM), which has gained popular- is of value to both healthcare providers and researchers, ity. CAM refers to a wide range of therapies and health as it provides them with a greater understanding and care practices that are not considered mainstream or insight into what types of information patients with arth- standard medical practice. “Complementary” medicine ritis may be accessing on their own. can be defined as an unconventional practice that is used in combination with conventional medicine [5], Methods while “alternative” medicine is primarily used in place of Search strategy conventional health care [5]. Furthermore, the term “in- A cross-sectional survey of the quality of websites con- tegrative practice” takes place when conventional and taining CAM consumer health information for the treat- complementary approaches are used collaboratively [5, ment and/or management of arthritis was undertaken. 6]. CAM treatments are popular among patients with JYN developed the search strategies which were exe- arthritis for a variety of reasons. A Malaysian study cuted by AV on Google on May 5th, 2020 as follows: ‘al- found that people with arthritis typically use CAM be- ternative medicine for arthritis’, ‘complementary and cause they believe there are fewer side effects associated alternative medicine for arthritis’, ‘complementary medi- with such therapies in comparison to conventional cine for arthritis’,and ‘integrative medicine for arthritis’. medicine [7]. Studies from South Korea, India, Turkey, All searches were conducted on Google Chrome in in- and Nigeria have found that the majority of patients turn cognito mode to ensure that the search results retrieved to CAM therapies because they believe it helps to allevi- were unaffected by prior browsing history and run ate pain, helps control morning stiffness, and is less ex- across four English-speaking countries: Australia pensive [8–11]. One report from the United Kingdom (Google.com.au), Canada (Google.ca), the United King- found that approximately 60% of arthritis patients have dom (Google.co.uk), and the United States (Google. used CAM therapies at least once [12]. One Canadian com). This was done to obtain a more internationally study found that 33.9% of patients with juvenile idio- representative selection of commonly-visited websites. pathic arthritis used CAM therapies [13]. Several studies The four search strategies were based on the most com- from the United States have estimated that 30–41% of mon terms used to refer to CAM [6] and were designed adults with arthritis use CAM [14–17], while CAM use to be simple, so as to replicate how a “typical” patient among youth with juvenile idiopathic arthritis has been with limited knowledge of medical or research topics found to be 72% [18]. Another study found that 40% of may seek health-related information online. We elected Australians who suffer from osteoarthritis use CAM to search only Google as it comprises over 90% of the [19]. Some of the most commonly-used CAM therapies search engine market share used worldwide as of August for arthritis include dietary supplements (including glu- 2020 [25], thereby retrieving websites that are much cosamine sulphate and chondroitin), chiropractic and more likely to be accessed and read by patients. It is manual therapies, massage therapy, herbal medicine, worth noting that the four next most popular search en- acupuncture, and meditative therapies (including yoga gines (Bing, Yahoo!, Baidu, and Yandex) only hold be- and tai chi). These are purportedly used to improve tween 0.44 and 2.78% of the search engine market share damaged cartilage, manage pain/stress, and increase mo- each [25]. Additionally, we only assessed the first 20 bility [20, 21]. webpage results of each Google search, given that it is One study that reviewed the quality of online content known that internet users typically only view the first found that information relating to osteoarthritis is gen- page of results that are generated and may occasionally erally ‘fair’ in quality [22]. Another research study inves- look through the second search engine results page [26]. tigating the quality of complementary and integrative With four search terms being generated across four health information on the internet typically found that countries (for a total of 16 searches and 20 websites for most websites did well in terms of information quality each), we sought to assess a total of 320 websites. Ng et al. Advances in Rheumatology (2021) 61:6 Page 3 of 17 Eligibility criteria balanced and unbiased, enabling readers to pursue further AV and TJ reviewed the 320 websites yielded across all sources of information and clarifying that more than one searches and removed all duplicates. Once all of the treatment option is available, identifying areas of uncer- URLs were collected, the authors assessed the inclusion tainty, providing background information on how a treat- criteria for each website. Websites were screened for eli- ment works, describing the benefits and risks of the gibility and included if they contained at least one web- treatment/lack of treatment, highlighting effects on the page that contained CAM consumer health information overall quality of life, and determining if the publica- for the treatment and/or management of arthritis. For tion (website) supports collaborative decision-making the purpose of this study, we identified and included [27]. The assessor is then asked to rate the publica- CAM therapies based on the operational definition pro- tion's overall quality (Question 16) by taking all of these vided by Cochrane, as follows: https://cam.cochrane.org/ areas into account and summarizing the results based on operational-definition-complementary-medicine.In how the majority of the questions were answered. This addition, websites had to have been published in the final question is an intuitive summary of the previous 15 English-language and be publicly available. Ineligible items of the DISCERN instrument [27]. websites that were excluded were as follows: Wikipedia We developed a standardized procedure to data extract pages, videos without text content (i.e. YouTube links), and assess each website for quality using the DISCERN as- Google images, broken URLs, websites published in sessment by first conducting a pilot test on three separate non-English languages, eBooks, peer-reviewed journals websites independently, followed by a meeting to discuss and articles, forums, and news articles that did not con- and resolve any discrepancies (JYN, AV, TJ). Following tain any consumer health information. A finalized list this, AV and TJ completed the data extraction and was developed to undergo further evaluation of content. assessed the quality of consumer health information using the DISCERN instrument, for each eligible website. The Data extraction and website quality assessment individual scores were reviewed by JYN and any remaining AV and TJ data extracted the following items: website discrepancies were resolved between AV and TJ without URL, website type, types of arthritis discussed, types of unduly altering original assessor ratings. Averages CAM therapies, types of non-CAM therapies (if present), were calculated across the two authors’ scores for every whether the website appeared in more than one search DISCERN question and for all websites assessed. In (different search terms and/or regions), whether the web- addition to the five-point scale intuitive summary score site was certified by Health on the Net Foundation Code for Question 16, an overall DISCERN score sum of of Conduct (HONcode), as well as the scores for the 16 questions 1–15 was also calculated (ranging from a score DISCERN questions. Different webpages from the same between 15 and 75). The mean score and standard website captured by searches were considered a single deviation were determined for each DISCERN item as item for the DISCERN instrument quality assessment; we well as the total mean score for all 16 items. therefore conducted a quality assessment of websites and not individual webpages. The DISCERN instrument is di- Results vided into a series of 16 key questions including an overall Search results rating on the quality of the information being assessed. It A total of 320 webpages were reviewed, of which 239 were is designed to examine what information is being provided duplicates, and 81 were unique. Twenty-seven websites rather than simply looking at how it is presented. It is or- were not eligible as they were peer-reviewed academic ar- ganized into three sections: Section 1 (Questions 1–8), ticles (n =20), Google images (n = 3), invalid addresses which address the reliability of the source, Section 2 (n =2), and news articles (n = 2). One additional website (Questions 9–15), which analyses the specific details re- did not mention CAM treatment for arthritis from a pa- garding treatment options, and Section 3 (Question 16), tient/consumer health information point of view, resulting which is the overall quality rating of the publication [27]. in a total of 53 eligible webpages. After collapsing web- To receive a ‘good’ quality rating, the majority of the ques- pages from the same website, a total of 38 websites were tions must be rated highly on a five-point rating scale ran- deemed eligible and assessed using the DISCERN instru- ging from ‘No’ to ‘Yes’ [27]. A rating of five indicates that ment. This process is depicted in Fig. 1. the answer to the question is a definite ‘Yes’,whilearating of one indicates a definite ‘No’. The ratings in between sig- General characteristics of eligible websites nify that the criterion for the question was only partially We organized eligible websites based on the following fulfilled. Questions that encompass DISCERN criteria in- categories: commercial, government, health portal, news, clude analysing the aims of the publication, determining if non-profit, professional, and other. For a website to be the information is relevant, identifying if sources and their categorized as commercial, it would have to either pur- dates were made explicit, judging if the information is chase or sell a product or service with the intent of Ng et al. Advances in Rheumatology (2021) 61:6 Page 4 of 17 Fig. 1 Web Information Search Strategy and Assessment Flowchart making a profit. An example of a commercial website in majority of websites (89.47%) also provided information this study is the Praana website (https://praanaim.com/). about non-CAM therapies – the most common types Government websites – such as HealthLink British being pharmaceutical medications and surgery. Most Columbia (https://www.healthlinkbc.ca/) – are websites websites (n = 29) appeared in more than one search, in- that are controlled by a governmental body. A health cluding those that were generated from the same coun- portal is any website that primarily discusses health try but through a different search term. Table 1 depicts topics, such as WebMD (https://www.webmd.com/). some of the general characteristics of the eligible The news categorization refers to websites like Medical websites. News Today (https://www.medicalnewstoday.com/) that take information from newspapers, magazines and televi- DISCERN instrument ratings sion and are a source of consumer health information. The total mean score across all websites for the sum of Non-profit websites are often linked to charities or orga- questions 1 through 15 in the DISCERN instrument was nizations that are not aiming to make a profit, as seen 55.53 (SD = 9.37) out of 75. The total mean score for ques- with the Arthritis Foundation website (https://www. tion 16, which assessed the overall rating of each website arthritis.org/). The majority of websites assessed (n = 13) was 3.71 (SD = 0.63) on a five-point scale. This shows that were categorized as professional, meaning that they were on average, most websites achieved a moderately high over- either affiliated with health experts, a university/hospital, all rating. Thus, the quality of most sources was better than or an authorized organization, as seen in the example ‘fair’, but still had room for improvement in terms of with the Mayo Clinic website (https://www.mayoclinic. obtaining the optimal standard. The Mayo Clinic and Upto- org/). Websites that did not fit into any of the previously Date websites scored the highest with both achieving a mentioned categories, were classified as ‘other’, which DISCERN score sum of 69.50. The overall quality rating for example was the case for the Creaky Joints website was a score of 4.64 (SD = 0.05) for both of these webpages. (https://creakyjoints.org/). Conversely,the Dr.Weiland Robert Schad Naturopathic Common types of CAM therapies discussed were diet- Clinic websites scored the lowest, with scores of 38.00 and ary and herbal supplements, which according to the Na- 32.00 respectively; the overall quality ratings were 2.53 and tional Center for Complementary and Integrative 2.14 respectively. A breakdown of the DISCERN instrument Health, includes vitamins, minerals, herbs, botanicals, ratings can be viewed in Table 2, which includes the total amino acids, enzymes, tissues from organs or glands, means and standard deviations for each question. and extracts [28]. Dietary and herbal supplements were mentioned in nearly all the websites assessed aside from Trends identified across resources assessed one (n = 37), proving to be the most frequent CAM ther- Website aims apy mentioned. Acupuncture was the next most com- The DISCERN instrument considers a source to be of mon therapy (n = 30), followed by exercise (n = 26), good quality if the aims of the publication are clearly in- when including tai chi and yoga. The overwhelming dicated. Question 1 assesses the extent to which a Ng et al. Advances in Rheumatology (2021) 61:6 Page 5 of 17 Table 1 General Characteristics of Eligible Websites Website Name URL Website Types of Arthritis Types of CAM Types of Non- Appeared Category Discussed Discussed CAM Therapies in More Discussed than One Search? Association of https://aanmc.org/ Professional Osteoarthritis, Diet, exercise, tai chi, Pharmaceuticals, Yes Accredited inflammatory arthritis, supplements, herbs, steroid Naturopathic rheumatoid arthritis, chiropractic, injections, Medical psoriatic arthritis, gout hydrotherapy, body surgery Colleges work American https://www.rheumatology.org/ Non-Profit Multiple types Herbs, supplements, Pharmaceuticals Yes College of acupuncture Rheumatology Arthritis https://arthritisaustralia.com.au/ Non-Profit Multiple types Acupuncture, massage, Pharmaceuticals, Yes Australia aromatherapy, vitamins, surgery supplements, herbs Arthritis https://www.arthritis.org/ Non-Profit Multiple types Supplements, vitamins, Pharmaceuticals, Yes Foundation acupuncture, massage, surgery tai chi, yoga, weight loss, physical therapy, topical gels, transcutaneous electrical nerve stimulation, relaxation therapy, energy healing Arthritis Health https://www.arthritis-health. Health Ankylosing spondylitis, Heat/cold, acupuncture, Pharmaceuticals, Yes com/ Portal bursitis, fibromyalgia, reiki healing, surgery general arthritis, gout, supplements, manual juvenile arthritis, therapies, tai chi, yoga, osteoarthritis, massage, nutrition polymyalgia rheumatica, pseudogout, psoriatic arthritis, reactive arthritis, rheumatoid arthritis Arthritis Society https://arthritis.ca/ Non-Profit Osteoarthritis, Heat/cold, visualization, Pharmaceuticals, Yes inflammatory arthritis, relaxation, massage, surgery general arthritis acupuncture, meditation/mindfulness, chiropractic, herbs, supplements Arthritis South https://arthritissa.org.au/ Non-Profit Ankylosing spondylitis, Acupuncture, massage, Pharmaceuticals, Yes Australia fibromyalgia, gout, aromatherapy, vitamins, surgery haemochromatotic herbs, minerals arthritis, juvenile idiopathic arthritis, osteoarthritis, polymyalgia rheumatica, psoriatic arthritis, reactive arthritis, rheumatoid arthritis, epidemic polyarthritis, scleroderma, sjögren’s syndrome, spondyloarthritis, BMI Healthcare https://www.bmihealthcare.co. Professional Osteoarthritis, Acupuncture, Pharmaceuticals, No uk/ rheumatoid arthritis, aromatherapy, massage, surgery psoriatic arthritis, reflexology, yoga general arthritis Center for http://holistic-medicine.com/ Professional Osteoarthritis, Hot/cold, diet, spinal Pharmaceuticals Yes Holistic rheumatoid arthritis decompression therapy, Medicine naprapathy, lasers, acupuncture The Chalkboard https://thechalkboardmag.com/ News Rheumatoid arthritis Diet, herbs, meditation, Pharmaceuticals No Mag yoga, mindfulness Ng et al. Advances in Rheumatology (2021) 61:6 Page 6 of 17 Table 1 General Characteristics of Eligible Websites (Continued) Website Name URL Website Types of Arthritis Types of CAM Types of Non- Appeared Category Discussed Discussed CAM Therapies in More Discussed than One Search? Consumer https://www.consumerreports. Non-Profit Osteoarthritis, general Yoga, tai chi, No Yes Reports org/cro/index.htm arthritis supplements, acupuncture, massage, chiropractic, homeopathy, exercise, weight loss Creaky Joints https://creakyjoints.org Other Multiple types Tai chi, acupuncture, Pharmaceuticals Yes yoga, exercise, massage, magnets, relaxation therapy, hydrotherapy, herbs, supplements, manipulation, chiropractic, weight management, physical therapy Department of https://www.fammed.wisc.edu/ Professional Osteoarthritis Exercise, mind-body Pharmaceuticals, Yes Family Medicine therapies, acupuncture, surgery and Community diet, supplements, Health massage University of Wisconsin Dr. Weil https://www.drweil.com/ Other Rheumatoid arthritis, Exercise, relaxation Pharmaceuticals No osteoarthritis, general techniques, arthritis hypnotherapy, diet, supplements Everyday Health https://www.everydayhealth. News Multiple types Herbs, spices, Pharmaceuticals Yes com/ supplements, acupuncture Health https://www.health.com/ News Multiple types Exercise, physical Pharmaceuticals No therapy, mind-body therapies, counselling, supplements, hot/cold, acupuncture, massage Healthline https://www.healthline.com/ Health Multiple types Herbs, massage, heat/ Pharmaceuticals, Yes Portal ice, exercise, tai chi, surgery yoga, bath & soaking therapies, stress management/mind- body medicine (biofeedback & meditation), diet, vitamin supplements, acupuncture, supportive shoes, weight management, magnets HealthLink https://www.healthlinkbc.ca/ Government General arthritis Supplements, vitamins, Pharmaceuticals, No British Columbia acupuncture, massage, assistive devices topicals, tai chi, yoga Integrative https://imcwc.com/ Professional General arthritis Herbs, vitamins, Pharmaceuticals Yes Medicine Center minerals, enzymes, oils of Western Colorado Integrated https://www. Professional General arthritis Exercise, chiropractic, Injections Yes Medical integratedmedicalsolutionsknox. diet, supplements, Solutions of com/ acupuncture Knoxville Johns Hopkins https://www.hopkinsarthritis. Professional Rheumatoid arthritis, Supplements, diet, Pharmaceuticals, Yes Arthritis Center org/ psoriatic arthritis, acupuncture, magnets, surgery ankylosing spondylitis, hydrotherapy, gout, osteoarthritis homeopathy, tai chi, Ng et al. Advances in Rheumatology (2021) 61:6 Page 7 of 17 Table 1 General Characteristics of Eligible Websites (Continued) Website Name URL Website Types of Arthritis Types of CAM Types of Non- Appeared Category Discussed Discussed CAM Therapies in More Discussed than One Search? yoga, mind-body ther- apy, energy medicine Markham https://integrative-medicine.ca/ Other Rheumatoid arthritis Diet, supplements, No Yes Integrative herbs, sauna therapy Medicine Mayo Clinic https://www.mayoclinic.org/ Professional Ankylosing spondylitis, Acupuncture, Pharmaceuticals, Yes gout, juvenile idiopathic supplements, yoga, tai surgery, assistive arthritis, osteoarthritis, chi, massage, heat/cold devices psoriatic arthritis, reactive arthritis, rheumatoid arthritis, septic arthritis, thumb arthritis Medical News https://www.medicalnewstoday. News General arthritis Aquatic exercise, tai chi, Pharmaceuticals Yes Today com/ yoga, hot/cold therapy, mindfulness meditation, massage, supplements, diet, herbs National Center https://www.nccih.nih.gov/ Government Rheumatoid arthritis, Mind-body practices, No Yes for osteoarthritis, gout supplements, herbs, Complementary acupuncture, massage, and Integrative tai chi, yoga, relaxation Health therapies, diet National Health https://www.nhs.uk/ Government Osteoarthritis, Diet, supplements, Pharmaceuticals, Yes Service United rheumatoid arthritis, acupuncture, massage, injections, Kingdom ankylosing spondylitis, chiropractic, osteopathy surgery cervical spondylosis, fibromyalgia, gout, psoriatic arthritis, enteropathic arthritis, reactive arthritis, secondary arthritis, polymyalgia rheumatica, juvenile idiopathic arthritis Nursing Times https://www.nursingtimes.net/ News Rheumatoid arthritis, Acupuncture, Pharmaceuticals Yes osteoarthritis homeopathy, herbs, osteopathy Philadelphia https://philly-im.com/ Professional Rheumatoid arthritis Mind-body techniques, Pharmaceuticals Yes Integrative nutrition, acupuncture, Medicine supplements, exercise, eliminating toxins Praana https://praanaim.com/ Commercial Rheumatoid arthritis Vitamins, exercise, diet, Pharmaceuticals Yes supplements, mind- body approach Practical Pain https://www. Health Fibromyalgia, Yoga, massage, dietary Pharmaceuticals, Yes Management practicalpainmanagement.com/ Portal inflammatory arthritis, supplements, injections, rheumatoid arthritis, acupuncture, monitoring with juvenile idiopathic balneotherapy, mind- lab tests arthritis, osteoarthritis, body therapies, chiro- polymyalgia rheumatica practic, relaxation tech- niques, prayer, naturopathy Robert Schad https://rsnc.ca/ Professional Rheumatoid arthritis, Nutrition, supplements, No No Naturopathic osteoarthritis herbs, traditional Clinic Chinese medicine, homeopathic medicine, physical medicine Ng et al. Advances in Rheumatology (2021) 61:6 Page 8 of 17 Table 1 General Characteristics of Eligible Websites (Continued) Website Name URL Website Types of Arthritis Types of CAM Types of Non- Appeared Category Discussed Discussed CAM Therapies in More Discussed than One Search? Spine Universe https://www.spineuniverse. Health Rheumatoid arthritis, Acupuncture, herbs, Pharmaceuticals Yes com/ Portal ankylosing spondylitis, massage, relaxation, fibromyalgia, juvenile mind-body therapies idiopathic arthritis, osteoarthritis St. Luke’s https://www.stlukes-stl.com/ Professional Osteoarthritis, Supplements, herbs, Pharmaceuticals, No Hospital rheumatoid arthritis, acupuncture, surgery, braces, gout, fibromyalgia, chiropractic, physical splints scleroderma, therapy, hydrotherapy, homeopathy, yoga, tai chi, exercise Up To Date https://www.uptodate.com/ Health Inflammatory and non- Acupuncture, mind- Pharmaceuticals Yes Portal inflammatory arthritis body techniques, exer- cise, diet, supplements, herbs, vitamins, hom- eopathy, magnets, mind-body therapies University of https://www.uwhealth.org/ Professional General arthritis Supplements, vitamins, Pharmaceuticals, No Wisconsin- acupuncture, massage, assistive devices, Madison Health topicals, tai chi, yoga surgery Versus Arthritis https://www.versusarthritis.org/ Non-Profit Osteoarthritis, gout, Diet, exercise, Pharmaceuticals, Yes rheumatoid arthritis, meditation, surgery spondyloarthritis, psychological exercises, ankylosing spondylitis, acupuncture, yoga, psoriatic arthritis, body techniques, juvenile idiopathic herbals arthritis WebMD https://www.webmd.com/ Health Osteoarthritis, Heat/cold, magnets, Pharmaceuticals, Yes Portal rheumatoid arthritis, acupuncture, injections, juvenile rheumatoid aromatherapy, surgery arthritis, infectious biofeedback, deep arthritis, ankylosing breathing, exercise, spondylitis, bone spurs, massage, meditation, gout, systemic lupus progressive muscle relaxation, tai chi, herbals, topical creams, gels, patches, visualization, yoga, supplements, chiropractic Zanjabee http://www.zanjabee.com/ Professional Osteoarthritis Diet, exercise, relaxation Pharmaceuticals, No techniques, heat/cold, injections, joint acupuncture, massage, replacement/ supplements, herbs, surgery Ayurveda website fulfils this requirement. The vast majority of websites information on the website are made clear to the viewer. ranked above average for this question with a total mean To achieve a good ranking for this question, the website score of 4.53 (SD = 0.56). The “About” page of a website typ- should include both in-text citations and a reference list ically included this information in the form of a mission/vi- at the end of the article. Twenty-two out of 38 web- sion statement, or it could sometimes be found in the sites scored a 3 or below on this question, meaning that introduction of an article. It is here where most websites the majority of websites did not include both in-text ci- identified their target audience and what kind of information tations and a formal reference list. The total mean score users could expect to find within the resource. was 2.76 (SD = 1.51). Some websites included a reference list but failed to have in-text citations and vice versa, Use of references while others showed no evidence of referencing at all. Question 4 of the DISCERN instrument evaluates Only 4 websites achieved a perfect ranking of 5 for this whether or not the sources used to compile the question. Ng et al. Advances in Rheumatology (2021) 61:6 Page 9 of 17 Table 2 DISCERN Instrument Ratings and HONcode Search Section SECTION 1 Is the publication reliable? DISCERN Question 1. Are 2. Does 3. Is it 4. Is it clear what sources of 5. Is it clear when the 6. Is it 7. Does it provide 8. Does it the it relevant? information were used to compile the information used or balanced details of additional refer to aims achieve publication (other than the author or reported in the publication and sources of support and areas of clear? its aims? producer)? was produced? unbiased? information? uncertainty? Mayo Clinic https://www.mayoclinic.org/ 5.00 4.50 4.50 4.00 5.00 5.00 4.50 5.00 UpToDate https://www.uptodate.com/ 5.00 5.00 5.00 5.00 5.00 5.00 5.00 5.00 Medical News Today https://www.medicalnewstoday. 4.50 5.00 4.50 4.50 5.00 4.00 4.50 5.00 com/ Johns Hopkins Arthritis https://www.hopkinsarthritis. 5.00 5.00 4.50 5.00 5.00 5.00 5.00 5.00 Center org/ National Center for https://www.nccih.nih.gov/ 5.00 5.00 5.00 4.00 5.00 5.00 4.50 5.00 Complementary and Integrative Health St. Luke’s Hospital https://www.stlukes-stl.com/ 3.00 5.00 5.00 4.00 5.00 5.00 4.50 5.00 WebMD https://www.webmd.com/ 5.00 5.00 5.00 4.00 4.00 5.00 4.50 5.00 Department of Family https://www.fammed.wisc.edu/ 4.50 5.00 5.00 4.00 4.00 4.00 3.50 5.00 Medicine and Community Health University of Wisconsin Arthritis Health https://www.arthritis-health. 4.50 4.50 4.50 5.00 5.00 5.00 5.00 5.00 com/ Everyday Health https://www.everydayhealth. 4.50 5.00 4.50 3.00 4.00 3.00 2.50 5.00 com/ Healthline https://www.healthline.com/ 4.50 5.00 4.50 4.00 4.50 4.00 5.00 5.00 Practical Pain https://www. 4.50 5.00 4.00 4.00 4.50 3.50 4.00 5.00 Management practicalpainmanagement.com/ Spine Universe https://www.spineuniverse. 4.50 4.00 4.50 2.50 3.50 3.50 3.00 3.00 com/ National Health Service https://www.nhs.uk/ 4.50 4.00 4.00 3.50 5.00 2.00 5.00 5.00 United Kingdom Arthritis Society https://arthritis.ca/ 5.00 5.00 5.00 2.00 1.50 3.00 3.00 4.00 The Chalkboard Mag https://thechalkboardmag.com/ 5.00 5.00 4.50 4.50 4.00 2.50 5.00 1.50 Arthritis Foundation https://www.arthritis.org/ 5.00 5.00 4.50 3.00 2.5.00 3.00 2.50 4.00 BMI Healthcare https://www.bmihealthcare.co. 4.00 4.00 3.50 4.50 2.00 3.00 5.00 1.50 uk/ Versus Arthritis https://www.versusarthritis.org/ 4.50 5.00 5.00 1.50 2.00 4.00 3.00 4.50 Nursing Times https://www.nursingtimes.net/ 5.00 5.00 4.00 5.00 5.00 5.00 1.50 5.00 Arthritis Australia https://arthritisaustralia.com.au/ 5.00 4.00 4.00 3.00 3.00 2.50 5.00 5.00 Praana https://praanaim.com/ 4.00 4.00 4.50 4.00 3.00 2.00 5.00 4.50 Arthritis South Australia https://arthritissa.org.au/ 5.00 3.50 4.00 1.00 2.00 2.50 5.00 5.00 Health https://www.health.com/ 5.00 4.50 3.50 1.00 2.50 2.50 1.00 5.00 Ng et al. Advances in Rheumatology (2021) 61:6 Page 10 of 17 Table 2 DISCERN Instrument Ratings and HONcode Search (Continued) Section SECTION 1 Is the publication reliable? DISCERN Question 1. Are 2. Does 3. Is it 4. Is it clear what sources of 5. Is it clear when the 6. Is it 7. Does it provide 8. Does it the it relevant? information were used to compile the information used or balanced details of additional refer to aims achieve publication (other than the author or reported in the publication and sources of support and areas of clear? its aims? producer)? was produced? unbiased? information? uncertainty? Markham Integrative https://integrative-medicine.ca/ 3.50 3.00 3.00 1.50 1.00 2.50 5.00 5.00 Medicine American College of https://www.rheumatology.org/ 4.50 3.00 3.00 1.00 2.50 3.00 5.00 5.00 Rheumatology HealthLink British https://www.healthlinkbc.ca/ 4.50 3.00 4.00 1.00 2.50 4.00 2.00 5.00 Columbia University of Wisconsin- https://www.uwhealth.org/ 5.00 3.50 4.00 1.00 2.50 4.00 1.00 5.00 Madison Health Creaky Joints https://creakyjoints.org 4.50 3.00 4.00 1.00 1.00 2.00 3.00 5.00 Consumer Reports https://www.consumerreports. 5.00 2.50 3.00 3.00 3.00 2.00 4.00 5.00 org/cro/index.htm Association of Accredited https://aanmc.org/ 5.00 3.00 5.00 3.00 2.50 2.50 4.00 1.00 Naturopathic Medical Colleges Integrative Medicine https://imcwc.com/ 5.00 3.50 3.50 1.00 1.00 1.00 2.00 5.00 Center of Western Colorado Philadelphia Integrative https://philly-im.com/ 4.50 2.00 2.50 1.50 4.00 2.50 4.00 5.00 Medicine Zanjabee http://www.zanjabee.com/ 4.00 3.50 4.00 1.00 1.00 2.00 1.50 1.50 Center for Holistic http://holistic-medicine.com/ 4.00 3.50 3.50 1.00 2.50 2.00 4.00 1.50 Medicine Integrated Medical https://www. 3.50 3.00 3.50 1.00 1.00 3.00 1.50 1.00 Solutions of Knoxville integratedmedicalsolutionsknox. com/ Dr. Weil https://www.drweil.com/ 4.50 3.00 3.00 1.00 1.00 3.00 3.00 1.00 Robert Schad https://rsnc.ca/ 3.00 3.50 2.50 1.00 1.00 1.50 1.00 1.00 Naturopathic Clinic TOTAL Means 4.53 4.08 4.09 2.76 3.12 3.26 3.62 4.08 TOTAL Standard Deviations 0.56 0.90 0.73 1.51 1.47 1.16 1.39 1.54 Section SECTION 2 How good is the quality of information on treatment choices? SECTION 3 Overall Rating of the HONcode Publication Search DISCERN Question 9. Does it 10.Does it 11. Does it 12. Does it 13. Does it 14. Is it clear that 15. Does it 16. Based on the answers to all of Standard DISC Is it describe describe the describe describe what describe how the there may be provide the above questions, rate the overall Deviation ERN certified how each benefits of the risks of would happen treatment choices more than one support for quality of the publication as a source of Overall Score by treatment each each if no treatment affect overall possible shared of information about treatment Score (Sum of HONcode works? treatment? treatment? is used? quality of life? treatment choice? decision- choices (Q16) Q1- (yes/no) making? Q15) Ng et al. Advances in Rheumatology (2021) 61:6 Page 11 of 17 Table 2 DISCERN Instrument Ratings and HONcode Search (Continued) Section SECTION 2 How good is the quality of information on treatment choices? SECTION 3 Overall Rating of the HONcode Publication Search DISCERN Question 9. Does it 10.Does it 11. Does it 12. Does it 13. Does it 14. Is it clear that 15. Does it 16. Based on the answers to all of Standard DISC Is it describe describe the describe describe what describe how the there may be provide the above questions, rate the overall Deviation ERN certified how each benefits of the risks of would happen treatment choices more than one support for quality of the publication as a source of Overall Score by treatment each each if no treatment affect overall possible shared of information about treatment Score (Sum of HONcode works? treatment? treatment? is used? quality of life? treatment choice? decision- choices (Q16) Q1- (yes/no) making? Q15) Mayo Clinic 4.00 5.00 3.00 5.00 5.00 5.00 5.00 4.64 0.05 69.50 Yes UpToDate 4.00 4.50 4.00 2.00 5.00 5.00 5.00 4.64 0.05 69.50 Yes Medical News 4.00 5.00 2.50 5.00 4.00 5.00 5.00 4.50 0.14 67.50 Yes Today Johns Hopkins 3.00 4.50 3.00 2.50 5.00 5.00 4.50 4.47 0.00 67.00 No Arthritis Center National Center for 3.00 5.00 4.50 4.00 2.00 5.00 5.00 4.47 0.09 67.00 No Complementary and Integrative Health St. Luke’s Hospital 3.00 4.50 3.50 3.50 5.00 5.00 5.00 4.43 0.14 66.00 No WebMD 3.00 4.50 3.00 5.00 2.50 5.00 5.00 4.37 0.05 65.50 Yes Department of 3.50 5.00 4.50 5.00 2.50 5.00 5.00 4.37 0.05 65.50 No Family Medicine and Community Health University of Wisconsin Arthritis Health 4.00 4.50 3.00 1.00 3.50 5.00 5.00 4.30 0.14 64.50 Yes Everyday Health 3.50 5.00 3.00 5.00 4.00 5.00 5.00 4.14 0.09 62.00 Yes Healthline 2.50 5.00 3.50 1.50 2.50 5.00 5.00 4.10 0.04 61.50 Yes Practical Pain 3.50 5.00 2.00 2.50 4.00 5.00 5.00 4.10 0.24 61.50 Yes Management Spine Universe 4.00 5.00 3.50 5.00 4.50 5.00 5.00 4.03 0.14 60.50 Yes National Health 5.00 5.00 4.00 2.00 1.00 5.00 5.00 4.10 0.14 60.00 No Service United Kingdom Arthritis Society 5.00 5.00 3.00 5.00 3.00 5.00 5.00 3.97 0.05 59.50 No The Chalkboard 3.50 4.50 1.50 3.00 5.00 5.00 5.00 3.97 0.05 59.50 No Mag Arthritis Foundation 4.50 5.00 3.50 1.00 4.50 5.00 5.00 3.87 0.09 58.00 No BMI Healthcare 3.50 5.00 1.50 5.00 5.00 5.00 5.00 3.84 0.05 57.50 No Versus Arthritis 4.00 4.50 4.00 2.00 3.00 5.00 5.00 3.80 0.00 57.00 No Nursing Times 1.00 3.50 3.50 2.00 1.50 4.50 5.00 3.77 0.14 56.50 No Arthritis Australia 4.00 4.00 4.00 1.00 1.50 5.00 5.00 3.74 0.09 56.00 Yes Praana 1.50 3.00 1.50 5.00 5.00 4.00 5.00 3.74 0.09 56.00 No Ng et al. Advances in Rheumatology (2021) 61:6 Page 12 of 17 Table 2 DISCERN Instrument Ratings and HONcode Search (Continued) Section SECTION 2 How good is the quality of information on treatment choices? SECTION 3 Overall Rating of the HONcode Publication Search DISCERN Question 9. Does it 10.Does it 11. Does it 12. Does it 13. Does it 14. Is it clear that 15. Does it 16. Based on the answers to all of Standard DISC Is it describe describe the describe describe what describe how the there may be provide the above questions, rate the overall Deviation ERN certified how each benefits of the risks of would happen treatment choices more than one support for quality of the publication as a source of Overall Score by treatment each each if no treatment affect overall possible shared of information about treatment Score (Sum of HONcode works? treatment? treatment? is used? quality of life? treatment choice? decision- choices (Q16) Q1- (yes/no) making? Q15) Arthritis South 5.00 5.00 5.00 1.00 1.50 5.00 5.00 3.70 0.04 55.50 No Australia Health 3.00 5.00 2.00 2.00 4.50 5.00 5.00 3.44 0.05 51.50 No Markham 3.50 4.00 3.50 3.00 4.00 4.00 5.00 3.44 0.23 51.50 No Integrative Medicine American College 2.50 3.00 4.00 1.00 3.00 5.00 5.00 3.37 0.05 50.50 No of Rheumatology HealthLink British 2.00 3.50 2.50 3.00 3.00 5.00 5.00 3.34 0.19 50.00 No Columbia University of 2.00 3.50 2.50 3.00 3.00 5.00 5.00 3.34 0.19 50.00 No Wisconsin-Madison Health Creaky Joints 3.50 4.00 3.50 2.00 2.50 5.00 5.00 3.27 0.19 49.00 No Consumer Reports 2.50 4.00 2.50 1.00 1.00 5.00 5.00 3.30 0.04 48.50 No Association of 4.00 5.00 1.50 1.00 2.50 5.00 2.50 3.17 0.05 47.50 No Accredited Naturopathic Medical Colleges Integrative 3.50 4.50 2.00 3.00 2.00 5.00 4.50 3.10 0.14 46.50 No Medicine Center of Western Colorado Philadelphia 2.00 3.00 2.00 1.00 3.00 5.00 2.50 2.97 0.05 44.50 No Integrative Medicine Zanjabee 4.00 4.50 1.00 4.00 3.00 5.00 4.00 2.94 0.19 44.00 No Center for Holistic 4.00 4.50 1.00 3.00 1.00 5.00 3.00 2.90 0.04 43.50 No Medicine Integrated Medical 3.00 5.00 1.00 4.00 1.50 5.00 3.00 2.67 0.19 40.00 No Solutions of Knoxville Dr. Weil 2.00 2.50 1.00 5.00 1.50 5.00 1.50 2.53 0.00 38.00 No Robert Schad 2.00 3.50 1.00 1.00 4.00 4.00 2.00 2.14 0.09 32.00 No Naturopathic Clinic TOTAL Means 3.30 4.38 2.78 2.92 3.16 4.91 4.54 3.71 0.10 55.53 TOTAL Standard 0.97 0.72 1.13 1.54 1.33 0.28 0.98 0.63 0.07 9.37 Deviations Ng et al. Advances in Rheumatology (2021) 61:6 Page 13 of 17 Risks associated with treatment Furthermore, these websites clearly outlined areas of un- To achieve a high ranking for question 11 of the DISC certainty in the research known about the disease, and ERN instrument, a website must include a description of highlighted the various treatment options that are avail- the risks associated with each treatment that is discussed. able to arthritis patients. The majority of these websites The mean score for this question was 2.78 (SD = 1.13). provided clear cited sources and, in our judgement, pro- None of the sources assessed received a perfect score of 5, vided information which remained unbiased. Many of which is of concern given that patients should be made these websites also referred consumers to further material aware of what to expect from a treatment, especially if any on the topic discussed, and provided sufficient details sur- adverse side effects are known. Many websites did not rounding the impacts a treatment option could have on a provide enough detail about the disadvantages of a treat- patient's overall quality of life. Additional details about ment, or only mentioned the risks for some of the CAM these websites are provided in Table 3. therapies discussed but failed to provide adequate details. Discussion Variety of treatment options The purpose of this study was to assess the quality of The overwhelming majority of websites analysed in this online CAM consumer health information for the treat- study scored highly on question 14 of the DISCERN in- ment and/or management of arthritis. Given the high strument. The question assesses whether or not a source prevalence of CAM use among patients with arthritis demonstrates that there are various treatment options for and their increasing reliance on the internet for arthritis patients. Thirty-four out of the 38 websites health information, it is important to critically evaluate assessed received a perfect score of 5, and no website was the online resources that this unique patient population graded lower than 4. This provided a mean score of 4.91 accesses. This is especially crucial given the fact that (SD = 0.28). Various forms of CAM therapies were often nearly half of all arthritis patients who utilize CAM ther- discussed, including dietary and herbal supplements, acu- apies do not disclose this to their physicians [29]. puncture, exercise, and manual therapies. Most of the Healthcare providers should, therefore, be aware of the websites provided additional information regarding con- online information that their patients may consult, either ventional treatment options as well, such as pharmaceuti- as a second opinion or in their absence, to help them cals, surgery, steroid injections and assistive devices. navigate appropriate resources and discern between websites of high quality and those providing misinforma- Shared decision-making tion or unsafe recommendations. Question 15 of the DISCERN instrument assesses the The present study found that the majority of eligible extent to which a website provides patients with support websites assessed were of ‘fair’ quality. Twenty-one out of for shared decision-making. The majority of the websites the 38 sources analysed received a moderate overall score assessed received a high ranking, with a mean score of (ranging from 2.90–3.97 out of 5). The total mean score 4.54 (SD = 0.98). Only 4 websites scored below a 3 for of 3.71 (SD = 0.63) and average DISCERN score of 55.53 this question. Most websites recommended that patients (SD = 9.37) suggests that most websites were slightly do not take any dietary and herbal supplements without above adequate quality but still had some shortcomings. It first consulting with their physician, stating that such should be noted that 14 out of 38 websites achieved a high products may interact with medications or potentially overall ranking of 4 or above and can be deemed of ‘good’ cause harm. Many sources also contained disclaimers quality. The websites that scored highest in this study may about how website content should not be a substitute serve as useful resources to healthcare providers who seek for professional medical advice and making healthcare to recommend high-quality resources for their patients. decisions in collaboration with a healthcare provider. While no websites assessed received an overall score below 2 (i.e. ‘poor’ quality), three websites ranked below Recommended websites for patients and consumers moderate (ranging from 2.14–2.67), suggesting that these The websites that scored highest in this study (an overall websites had some serious shortcomings (including a lack ranking of 4 or above for Question 16) may serve as good of transparency in terms of the sources used, dates of the quality sources for practitioners to recommend to arthritis articles, areas of uncertainty, and the risks associated with patients who seek additional CAM consumer health infor- each treatment while also not providing further reading). mation about arthritis. These websites were similar in the This study also found that the majority of sources out- sense that they typically scored a high rating above 4 lined the aims of the website, provided a wide variety of across many of the DISCERN questions. Each of the high- treatment options, and encouraged the use of shared est scoring websites received a score of 5 for question 8 decision-making between the patient and those who are (which assesses whether the website refers to any areas of involved in their care. In particular, adequate discussion uncertainty with the treatment) and question 14. surrounding different treatment options are beneficial for Ng et al. Advances in Rheumatology (2021) 61:6 Page 14 of 17 Table 3 Recommended Websites for Patients and Consumers Website Name URL DISCERN Overall Website Target Audience Frequency of Updates Score DISCERN Category (Sum of Score our (Question 75.00) 16, out of 5.00) Mayo Clinic https://www.mayoclinic.org/ 69.50 4.64 Professional Healthcare Website states that content is diseases-conditions/arthritis/ providers, updated regularly following a diagnosis-treatment/drc-2 researchers, schedule and whenever necessary 0350777 patients/public, to reflect new/revised findings. The prospective precise frequency of updates is not employees/ clear. volunteers UpToDate https://www.uptodate.com/ 69.50 4.64 Health Healthcare The content is updated daily. contents/complementary- Portal providers, and-alternative-therapies-for- researchers, rheumatoid-arthritis-beyond- patients/public the-basics Medical News https://www. 67.50 4.50 News Healthcare Website states that content is Today medicalnewstoday.com/ providers, continually reviewed and updated. articles/325760 researchers, The precise frequency of updates is https://www. patients/public not available. medicalnewstoday.com/ articles/324446 Johns Hopkins https://www.hopkinsarthritis. 67.00 4.47 Professional Healthcare Information on the precise Arthritis Center org/patient-corner/disease- providers, patients/ frequency of website updates is management/ra- public not clear. complementary-alternative- medicine/ National Center for https://www.nccih.nih.gov/ 67.00 4.47 Government Healthcare Website states that some parts are Complementary health/rheumatoid-arthritis- providers, updated daily while other areas of and Integrative in-depth researchers, the website may not be updated Health patients/public for weeks or months. St. Luke’s Hospital https://www.stlukes-stl.com/ 66.00 4.43 Professional Healthcare Information on the precise health-content/medicine/33/ providers, patients/ frequency of website updates is 000118.htm public not clear. WebMD https://www.webmd.com/ 65.50 4.37 Health Healthcare Website states that corrections and rheumatoid-arthritis/ Portal providers, updates to the material happen rheumatoid-arthritis-natural- researchers, regularly, but information on the treatments#1 patients/public precise frequency of website https://www.webmd.com/ updates is not clear. osteoarthritis/features/ alternative-arthritis- treatments#1 https://www.webmd.com/ rheumatoid-arthritis/ features/complementary- therapy#1 Department of https://www.fammed.wisc. 65.50 4.37 Professional Healthcare Information on the precise Family Medicine edu/integrative/resources/ providers, frequency of website updates is and Community modules/osteoarthritis/ researchers, not clear. Health University patients/public, of Wisconsin prospective medical students Arthritis Health https://www.arthritis-health. 64.50 4.30 Health Healthcare Information on the precise com/treatment/alternative- Portal providers, patients/ frequency of website updates is treatments/integrative- public not clear. medicine-arthritis-pain-relief https://www.arthritis-health. com/treatment/alternative- treatments Everyday Health https://www.everydayhealth. 62.00 4.14 News Healthcare Information on the precise com/ providers, patients/ frequency of website updates is public not clear. Ng et al. Advances in Rheumatology (2021) 61:6 Page 15 of 17 Table 3 Recommended Websites for Patients and Consumers (Continued) Website Name URL DISCERN Overall Website Target Audience Frequency of Updates Score DISCERN Category (Sum of Score our (Question 75.00) 16, out of 5.00) Healthline https://www.healthline.com/ 61.50 4.10 Health Healthcare Website states that articles are Portal providers, patients/ updated when new information public becomes available. Information on the precise frequency of website updates is not clear. Practical Pain https://www. 61.50 4.10 Health Healthcare Website states that content is Management practicalpainmanagement. Portal providers, patients/ updated regularly. Information on com/ public the precise frequency of website updates is not clear. Spine Universe https://www.spineuniverse. 60.50 4.03 Health Healthcare The content is updated daily. com/ Portal providers, patients/ public National Health https://www.nhs.uk/ 60.00 4.10 Government Healthcare The content is updated daily. Service United providers, Kingdom researchers, patients/public patients, so that they may be aware of the options that are promoted alternative medicine and that 80% of these web- available to them. While it is reassuring that numerous sites had clear financial aims [32]. Another study also websites encourage patients to consult their healthcare highlighted the importance of recommending websites providers before making any treatment decisions on their that draw on evidence-based medical literature; an ex- own, practitioners and researchers should be cautioned ample of such information could include a systematic re- that the majority of websites did not report all of the risks view that identified the quantity and assessed the quality that are associated with each CAM treatment and did not of CAM recommendations for osteoarthritis and rheuma- always provide explicit details about the references used to toid arthritis evidence-based clinical practice guidelines support their claims made about these therapies. These [33]. Guidelines and other evidence-based resources could findings illuminate an aspect of patient behaviour outside be used as a starting point for the improvement of con- of a clinical setting, given that many are unaware that vari- sumer health information on websites such as the ones we ous CAM therapies may lack efficacy and/or safety [30]; it assessed in the present study. is well-documented in the literature that, for example, Additionally, several studies have evaluated the quality many patients believe that natural remedies do not have of online CAM information as it relates to other condi- any harmful side effects or that “natural equals safe”, tions. A recent study assessed the quality of online con- which is an issue that healthcare providers need to be sumer health information at the intersection of CAM cognizant of and should strongly advocate that their pa- and low back pain using the DISCERN instrument, find- tients discuss their use of or concerns associated with ing that quality was quite variable across different web- CAM with them as opposed to self-medicating [30]. sites. The authors found that the mean overall rating To our knowledge, this is the first study to assess the across all websites was 3.47 (SD = 0.70), while the quality of websites containing CAM consumer health in- summed DISCERN scores ranged from 25.5-68.0, with a formation specifically in the context of arthritis. Despite mean of 53.25 (SD = 10.41) [34]. Another study also used this, our findings can be compared to other studies that the DISCERN instrument to evaluate information pro- have assessed the quality of consumer health information vided on chronic pain websites, and found that the over- on related topics. A previous study analysed the readability all quality of most were of moderate quality with several and quality of online information on osteoarthritis, includ- shortcomings. The overall average DISCERN score for ing conventional forms of treatment. This study found this study was 55.90 (however, they scored this total to that website information was considered ‘fair’ and that the include question 16, out of 80) [35]. readability was either equivalent to or more challenging than the recommended standard, as outlined by both the Strengths and limitations Journal of the American Medical Association and the One strength of the present study included the fact DISCERN criteria [22, 31]. Prior to this, another study that we specifically searched Google across four different found that 44% of web search results related to arthritis English-speaking countries (Australia, Canada, the Ng et al. Advances in Rheumatology (2021) 61:6 Page 16 of 17 United Kingdom and the United States) in order to yield Abbreviation CAM: Complementary and alternative medicine a more internationally-representative sample of websites. Another strength of this study included the use of the Acknowledgements DISCERN instrument, which has been found to be both JYN was funded by a Research Scholarship and an Entrance Scholarship from the Department of Health Research Methods, Evidence and Impact, Faculty reliable and valid in assessing the quality of consumer of Health Sciences at McMaster University. health information [36]. Additional strengths include the fact that we also piloted conducting data extractions and Authors’ contributions JYN: conceptualized and designed the study, collected the data, interpreted applying the DISCERN instrument; during the pilot and and analysed the data, drafted the manuscript, and gave final approval of the full-assessments, both steps were conducted independ- version to be published. AV: collected the data, interpreted and analysed the ently and in duplicate, before all three authors met to data, provided contributions and critically revised the manuscript, and gave final approval of the version to be published. TJ: collected the data, interpreted discuss and resolve discrepancies. and analysed the data, provided contributions and critically revised the One limitation includes the fact that our search only manuscript, and gave final approval of the version to be published. captured a cross-sectional snapshot of website informa- Funding tion; since the internet is a dynamic source that is subject This study was unfunded. to change, the results from this study may differ if repli- cated across future searches. Additionally, since the search Availability of data and materials strategy for this study only included the first 20 websites All relevant data are included in this manuscript. that were generated for each search term, less popular Ethics approval and consent to participate websites remain unassessed for quality. 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Published: Jan 19, 2021

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