Eur Spine J DOI 10.1007/s00586-015-3932-z
ORIGINAL ARTICLE
Smartphone apps for spinal surgery: is technology good or evil? Greg A. J. Robertson1 • Seng Juong Wong2 • Richard R. Brady3 • Ashok S. Subramanian1
Received: 22 March 2014 / Revised: 4 April 2015 / Accepted: 5 April 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose The increased utilization of smartphones together with their downloadable applications (apps) provides opportunity for doctors, including spinal surgeons, to integrate such technology into clinical practice. However, the clinical reliability of the medical app sector remains questionable. We reviewed available apps themed specifically towards spinal surgery and related conditions and assessed the level of medical professional involvement in their design and content. Method The most popular smartphone app stores (Android, Apple, Blackberry, Windows, Samsung, Nokia) were searched for spinal surgery-themed apps, using the disease terms Spinal Surgery, Back Surgery, Spine, Disc Prolapse, Sciatica, Radiculopathy, Spinal Stenosis, Scoliosis, Spinal Fracture and Spondylolisthesis. Results A total of 78 individual spinal surgery themed apps were identified, of which there were six duplicates (N = 72). According to app store classifications, there were 57 (79 %) medical themed apps, 11 (15 %) health and fitness themed apps, 1 (1 %) business and 3 (4 %) education themed apps. Forty-five (63 %) apps were available for download free of charge. For those that charged access, the prices ranged from £0.62 to £47.99. Only 44 % of spinal surgery apps had customer satisfaction ratings and & Greg A. J. Robertson [email protected] 1
Department of Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
2
University of Edinburgh Medical School, Edinburgh, UK
3
Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
56 % had named medical professional involvement in their development or content. Conclusions This is the first study to specifically address the characteristics of apps related to spinal surgery. We found that nearly half of spinal surgery apps had no named medical professional involvement, raising concerns over app content and evidence base for their use. We recommend increased regulation of spinal surgical apps to improve the accountability of app content. Keywords
Spinal surgery Smartphone Apps
Introduction Smartphone health-related downloadable applications (apps) are rapidly increasingly in number, with approximately 1000 new apps released each month [1] and 142 million annual downloads predicted by 2016 [2]. At present, there are more than 13,000 healthcare-related apps and this sector is predicted to rise by 25 % per annum over the next 5 years [3]. Smartphone usage is popular amongst health-care professionals, with one study reporting that 84 % of orthopaedic care providers in the USA owned a smartphone and 53 % used it in clinical practice [4]. The range of smartphone applications available has been reported in various specialties, including orthopaedics [4, 5], neurosurgery [6], plastic surgery [7], colorectal surgery [8], bariatric surgery [9], radiology [1], pain medicine [10], dermatology [11], infectious diseases [12] and microbiology [13]. Spinal surgery is a rapidly expanding field with rates of spinal operations reported to have increased by 27 % from 2007 to 2009 in Scotland alone [14]. Given further predicted expansion in spinal surgery as a speciality, increased
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access to relevant information will be required for both health-care professionals and patients. However, previous studies have found that Internet information relating to spinal surgery is limited and of variable quality [15–17]. Smartphone apps have been advocated as the future modality to convey such information [18, 19]. However, concerns regarding the lack of medical involvement in app design [14–16] and the reliability of app content [1, 8–11, 13] have been raised. Whilst regulations by the US Food and Drug Administration (FDA) exist for medical smartphone apps which directly influence patient treatment [20], most medical smartphone apps are not formally evaluated [21]. This study aims to identify contemporary smartphone apps relating to spinal surgery and assess the level of medical professional involvement in their design.
Method Six major online mobile platform application stores (Android, Apple, Blackberry, Nokia, Samsung, Windows) were searched for smartphone apps specifically relating to spinal surgery and related conditions using the search terms Spinal Surgery, Back Surgery, Spine, Disc Prolapse, Sciatica, Radiculopathy, Spinal Stenosis, Scoliosis, Spinal Fracture and Spondylolisthesis. The search was conducted by a single author on 24 Feb 2014. These terms were based on the commonest spinal surgery conditions seen by spinal surgeons [14]. The terms used in the search were generated from the overview of the apps content provided by the developer. Apps relating to back pain, but with no relation to surgical consultation were excluded. Similarly, nonEnglish language applications, games and wallpaper applications were excluded. Data were generated from the overview of the app’s content provided by the developer. Data recorded for every app included category of the application, implied target audience, documentation of medical professional involvement, evidence referenced, average rating, number of ratings, publisher information, commercial content and cost (prices in British pounds). All app links to publisher pages were followed to establish authorship, referenced evidence and links to commercial products. Commercial intent was judged by whether the app or the publisher page had links to private surgery, promoted a product or another app or required purchase. All apps that were free to download were accessed. Priced apps could not be accessed due to funding limitations for the study. The total cost of accessing the priced apps would have been £129.86. Data were grouped into subcategories by topic and target audience and summarized for clarity.
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Repeat applications found in different smartphone stores or almost identical apps found within the same smartphone store were marked as duplicates with only one version of the app counted. Univariate statistical comparisons between categorical variables were performed using the Chi-squared test. The significance level was set at p \ 0.05.
Results The search returned 78 apps in total. There were 6 (8 %) duplicates and hence only 72 apps were analysed. Eighteen (25 %) apps were identified on Apple, 48 (67 %) on Android, 2 (3 %) on Blackberry, 2 (3 %) on Samsung, 1 (1 %) on Nokia and 1 (1 %) on Windows (see Fig. 1). According to the App stores classifications, there were 57 (79 %) ‘medical’ themed apps, 11 (15 %) ‘health and fitness’ themed apps, one (1 %) ‘business’ themed app and three (4 %) ‘education’ themed apps. Forty-five (63 %) of the apps were available to download free of charge. For those that charged access, the prices ranged from £0.62 for an educational app with a patient target audience to £47.99 for a scoliosis curvature measuring app. The median cost of the apps was £2.53 and the mean £5.02. Eighteen (25 %) apps were updated in 2014 (1 January– 24 February), 31 (43 %) in 2013, 13 (18 %) in 2012, 7 (10 %) in 2011 and 1 (1 %) in 2010. Thirty-two apps (44 %) had customer satisfaction ratings. None had more than 100 reviews. Twenty-two (63 %) of the apps with customer satisfaction ratings were free, while 23 (58 %) without ratings were free (p = 0.451). Only 40 (55 %) apps had documented medical professional involvement. This was from a named clinician or organization in all 40 (100 %) of the apps. Twenty-four (60 %) of the apps with named medical professional involvement were free compared with 21 (66 %) without named medical professional involvement (p = 0.660). 3%
3%
Android Apple 25% Blackberry Samsung Windows 67% Nokia
Fig. 1 Apps distribution by app stores
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For the apps with no declared medical involvement that were free to download, information present in these included: descriptions of spinal operations with predicted outcomes, descriptions of post-operative rehabilitation methods following spinal surgery and management algorithms for patients with acute spinal injuries. One of these apps provided a scoliosis measuring tool on which to base clinical decisions. Commercial links were present in 45 (63 %) apps and links to private surgery were evident in 11 (24 %) apps. Apps were categorized into those aimed at patient education, those aimed at health-care education, those providing measuring aids for clinical purposes, those for advertising purposes and a number of miscellaneous categories (see Fig. 2). The apps search results are summarized in Table 1 and listed fully in Table 2. Educational apps for patients There were 23 (33 %) apps identified which implied that their content was for patient education. This represented the largest group of apps within the study. This category was subdivided into those which predominantly addressed: (a) information regarding spinal surgery conditions (n = 16); (b) information regarding spinal surgery techniques and procedures (n = 7). Only nine (39 %) of these apps had a named medical professional involvement and ten (43 %) had consumer reviews. Of the 16 apps which provided information on ‘spinal surgery conditions,’ 13 provided general information on a range of spinal conditions, 1 provided relevant terminologies for spinal disease, 1 provided information on scoliosis specifically and 1 provided information on managing spinal trauma. Medical professional involvement was evident in
25
20
Informaon on Spinal Condions
Informaon on Spinal Surgery
7
15
23 10
31 % of these. Two (9 %) apps made reference to evidence-based content. Overall, commercial links were evident in 19 apps (83 %) and links to pursue private spinal surgery was evident in 5 (22 %). Of the seven apps which provided information on ‘spinal surgery techniques,’ three provided patient information on discectomy, two gave patient information on scoliosis surgery and two provided information on a number of spinal surgery operations. Medical professional involvement was evident in 57 % of these. Only one app made reference to evidence-based content. Overall, commercial links were evident in six (86 %), and three (43 %) had links to pursue spinal surgery. Educational apps for health-care workers There were 23 apps that provided educational content aimed at health-care workers. This included three apps providing journal papers, three with examination practice questions, two on guidelines, one an anatomy textbook, one a newsletter, one an archive of surgical videos and 12 apps that offered quick reference to information on various spinal topics. Only three of these apps were dedicated to spinal surgery. Named medical professional involvement was evident in 13 (57 %) of these apps. One of these apps (the Open Operating Theatre App) was formally recommended by an editorial article in a peer-reviewed spinal surgery journal [22]. This category had costs ranging from £0.00 to £13.99 with a mean price of £4.22. User ratings were available for 12 (52 %) of these apps. Commercial intent was evident in 48 %, most commonly from the purchase cost of the app. Surgery advertising apps There were five (7 %) apps identified with links to private surgery. All of these had named medical professional or organization involvement and this was well advertised throughout. Three were advertising for individual clinicians, while two were advertising for centres. One provided links to multidisciplinary care. Of these apps, none had consumer reviews.
16 13
Society advertising apps
5
5
6
0
Fig. 2 Categories of smartphone applications
There were six (9 %) apps identified as advertising apps for conferences or societies. There were four conference advertising apps, providing information on programmes and locations of conferences and two spine society advertisement apps providing information on news and upcoming events of the society. Eighty-three percent of these had named medical professional involvement and this was well advertised throughout. Commercial links were present in
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123 Pts/HCW
Overall
Patients
Patients
HCW
HCW&Patients HCW&Patients
HCW HCW Patients
Knowledge of conditions
Information on surgery
Healthcare education
Surgery advertising
Measuring tools
Society/conference promotion
Implant company advertising
scoliosis forums
1
1
6
13
5
23
7
16
23
72
No. of apps
£0
£0
£0
£0–£47.99 [£10.03]
£0
£0–£13.99 [£4.22]
£0
£0–£4.99 [£1.80]
£0–£4.99 [£1.48]
£0–£47.99 [£5.02]
Price range [mean]
1/1 (100 %)
Nil
1/6 (17 %)
App Cost (7)
9/13 (69 %)
Surgery (5)
5/5 (100 %)
App Cost (12), Surgery (1)
11/23 (48 %)
Surgery (3)
6/7 (86 %)
Nil (0 %)
Nil (0 %)
5/6 (83 %)
8/13 (62 %)
5/5 (100 %)
13/23 (57 %)
4/7 (57 %)
1/1 (100 %)
Nil
2/6 (33 %)
7/13 (54 %)
Nil
12/23 (52 %)
5/7 (71 %)
Ratings 2.3
Votes 3
–
Mean 5
Votes 11
Mean 3.91
Range 3.5–4.7
Votes 212
–
Range 3.2–5 Mean 4.47
Votes 83
Mean 3.8
Range 1–5
Votes 24
Mean 3.07
Votes 59
App Cost (3)
5/16 (31 %)
Range 3–4.3
5/16 (31 %)
Surgery (2)
13/16 (81 %)
Mean 3.75
Votes 83
Total votes 394
Mean score 4.09
Customer rating out of 5 (No. of voters)
App Cost (10)
10/23 (43 %)
32/72 (44 %)
No. of apps with ratings
Range 1–5
9/23 (39 %)
40/72 (56 %)
Medical professional involvement
Surgery (5)
19/23 (83 %)
App Cost (29) Surgery (11)
45/72 (63 %)
Links to other commercial outlets
No. number, HCW health-care worker, N/A not applicable. Commercial: Surgery links to private surgery, Promo promotion of product, App cost cost of app alone, None no commercial links
Patients
Subcategories
Patient education
Target audience
Category
Table 1 Categorical overview of the spinal surgery apps, identified with respect to their cost, commercial links, medical professional involvement and consumer ratings
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Free Free
19/01/14
10/02/13
02/09/12
13/12/12
04/11/13
06/01/14
17/01/14
26/11/ 2012
16/09/13 25/01/13
22/02/11
21/04/13
10/06/13
27/02/12
Back pain management
Back pain relief
Scoliosis??
Spinal cord injury
Spine express
Spine health education models
Treat a spinal injury victim
Neurosurgery conditions
Spine glossary How to cure back pain!
Surgeon
Back pain
Spine conditions and treatment
Back pain: an algorithmic approach
19/10/13
07/02/14
01/01/14
Back pain by AZoMedical
Common Surgeries
Dr. Edgar Jimenez Masis
Free Free
Spinal Cord/Nerves flashcards
Atlas of Back and Thorax
For students
Spine Imaging Case Review
Free
Spinal Cord Injury, 650 MCQs Free
23/01/11
Back pain
NSG
OrtoTrauma
Neurointensive Care Guide
Spinal Cord Trauma
Medrills: Spinal Cord Injury OrthoRef
Spinal Cord Encyclopedia
Surgical Assistant
The Spine Journal
Spine Decide-Point of Care Patient Education for Healthcare Professionals by Orca Health
Spine
Spinal News International
SLIC
Orthopaedics Today Europe
Information on surgery
£4.99
£1.49
£1.25
£0.78
£0.62 £0.63
£0.62
Free
Free
Free
Free
Free
Open Operating Theatre
21/01/14
Back fix
Free
ISIS (International Spine Intervention Society) Emergency Protocols
Free
28/10/13
Health-care education (23)
All-pro orthopedics
Price
For doctors
Date updated DD/MM/ YY
Knowledge of conditions
Patient education (23)
Table 2 Listing of the spinal surgery apps, with their cost and date of update
22/02/13
26/04/13
13/01/14
14/01/14
11/12/12
05/11/13
15/09/12
17/09/13
10/01/14 Not Specified
18/02/10
06/04/13
13/07/13
10/12/13
08/10/13
26/10/12
20/01/12
04/09/13
23/09/13
21/01/14
Date updated DD/MM/ YY
Free
Free
£13.99
£9.26
£4.48
£3.73
£3.08
£2.99
£2.46 £2.59
£0.69
£0.63
Free
Free
Free
Free
Free
Free
Free
Free
Price
24/04/13
11/11/13
22/04/14
28/06/13
08/08/13
15/12/13
07/03/11
04/11/13 02/02/11
23/12/11
14/01/14
20/06/13
28/11/13
16/09/13
1/12/13
07/02/14
06/02/14
06/02/14
Date updated DD/MM/ YY
ASSICON 2015
22/01/14
Society/conference Promotion
SpineCurve
Cobb reader
CobbMeter CE
Scoliometer HD
ScolioTrack
Scolioscreen
Scoligauge
Scoliometer Vertebra (spine) Checker lite
Scoliosis measurement
Measure Angles
Goniometer Records
Goniometer Pro (G-pro) Preview
Measuring tools
Spine MD
Kayal Orthopaedic Center, PC
Dr Venu Gopal S Appointments
Dr Arun L Naik Appointment
Dr A.Mohan Krishna Appointment
Surgery advertising
Others (26)
Free
£47.99
£8.29
£5.60
£3.99
£2.99
£0.69
£0.69
Free Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Price
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Free
Free
16/04/13
10/06/11 FixScoliosis
Free 30/01/14 WorldSpine VI
Scoliosis forums
Free 05/08/13 Spine Line
S2S
Free 12/03/12 ISASS £9.30 21/10/11
Implant company advertising
Free
Free
13/11/12
19/11/13
DWG 2012
Not Specified
DWG 2013
£0.64
£1.00
21/01/14
Price Price Date updated DD/MM/ YY
Others (26)
Date updated DD/MM/ YY
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one (17 %) and links to private surgery were evident in none. Of these, two had consumer reviews. Spine tool apps A popular theme of the spinal surgery apps was measuring tools for clinical and radiological spinal surgery measures. Of these, nine were for clinical scoliosis measures, two were for radiological scoliosis measures, one was for measuring general spine-related X-ray angles and one was for use as a clinical goniometer. There was named professional involvement in eight (62 %) of these. Three of these had evidence-based measures to validate their use [23–26]. The price ranged from £0.00 to £47.99, with this being the most expensive category. There were commercial links on nine (69 %) of these apps. Seven (54 %) had consumer reviews, this being the category with most ratings. None declared approval by the FDA.
Netter’s: Back and Spinal Cord 16/03/12 Spine Care
Free
Surgery Reference
Surgery101
13/02/12 Sciatica relief
Free
31/08/12 MHSI
Free
Date updated DD/MM/ YY Patient education (23)
Table 2 continued
Price
Health-care education (23)
Discussion
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Smartphone apps are increasingly used by medical practitioners [27]. This technology has given clinicians the capability of merging information and communication resources into one condensed multipurpose device [12]. This has led to the rapid expansion of smartphone utilization in the clinical environment with numerous potential opportunities within health-care systems [27]. While the content and validity of smartphone applications have been studied in various medical fields [1, 4–13], this is the first to review smartphone applications relevant to spinal surgery. Here, we identified a wide variety of apps targeted at both medical and lay audiences. This included educational apps for both patients and medical professionals, apps advertising conferences and societies and apps providing clinical measuring tools. However, there were a number of concerning features relating to our search. While named medical professional involvement in spinal surgery-related apps was recorded at 54 %, a higher level than reported in other specialties [1, 8, 9], only 24 % of apps claimed use of evidence-based information. The rapid expansion of smartphone applications has made it easier for programmers, medically trained or not, to develop and publish medical-related information. This has obvious benefits; however there remain concerns regarding the accuracy of medical application content [1, 8–10, 13]. We found that apps with no declared medical involvement contained information that could directly influence clinical management. Given its potential to compromise patient safety, it is vital that publication of such information is performed in conjunction with medical professionals.
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Further concerns include difficulties for potential users to assess the accuracy of application content prior to purchase. Currently, application stores provide a short description of the app, along with customer ratings. While customer ratings can provide a peer-reviewed source of feedback, 56 % of applications in this study had no ratings. Furthermore, 68 % of those rated were based on less than ten ratings, reducing the reliability of the customer feedback. This remains a common problem amongst medical apps [10, 11]. Application advertising material should be regulated to provide clear information regarding the nature of app content and relevant qualifications of app developers. This allows potential users to make an informed assessment of an application’s reliability prior to purchase. At present, the FDA plans to regulate a subset of smartphone medical applications which can influence clinical diagnosis or practice (i.e. calculation of drug doses) and so may represent a risk to patients [20]. In the current study, the measuring tools identified potentially fall within this category. Despite this, only one of these apps had evidence-based validation [23] and none reported FDA approval. Given that such tools can influence the decision to direct patients towards major surgery, stricter regulations should be considered for their processing in the future. The majority of apps in this study, however, were educational in nature and so would not warrant FDA regulation [21]. Yet, with the potential for these apps to influence clinical management, one must strongly consider the need for quality control of their content. Having previously been used in the field of orthopaedics to effectively appraise orthopaedic-related Internet information [28], one must consider the potential of the ‘Health on the Net’ Foundation to provide such regulation [29]. This nonprofit, non-governmental organization promotes and guides the deployment of useful and reliable online health information for patients and professionals [29]. It has established a ‘Health On the Net’ Code which has acted as a stamp of validity for websites providing medical information [29]. We would recommend modification of this code for use in smartphone applications, allowing medical personnel and patients to identify those which provide quality sources of health information. Where possible, published recommendation of the app by the manufacturers through editorial journal articles in recognized peer-reviewed journals can provide a reassuring description of the app for the customer [22]. There was a high number of spine-related clinical measuring tool apps in our study. Their uses included clinical assessment of scoliosis and X-ray angle assessment. Use of such tools in the field of orthopaedic surgery is wide ranging, with apps available for goniometric knee assessment, radiographic hallux valgus angulation
assessment and acetabular cup alignment assessment in hip replacement surgery. However, evidence-based validation of such tools remains limited with only four studies available for orthopaedic apps [5]. In the field of spinal surgery, three such apps have been validated with published studies [23–26]. Of note, app scoliometers have been demonstrated to be an accurate easily accessible tool for use in clinical practice [23, 25, 26]. It would therefore appear that these tools offer an exciting prospect as measuring devices for clinicians. The study has some limitations. Firstly, information gathered from apps was taken from the overview pages and links to publishers’ websites, as funding limitations prohibited download of the full version of the apps. This method prevented direct verification of the validity and accuracy of the app content from the full version. However, this recreates the situation potential application purchasers currently encounter prior to purchase. The authors would suggest that these overview pages should provide potential customers with a comprehensive description of author credentials, content source, conflicts of interest and peer review by previous customers to guide appropriate purchase. Further limitations include the subjectivity of the customer rating tools, which are potentially biased, lack validation and are subject to regular change. Furthermore, whilst named medical involvement in app development provides assurances to the customer, there is currently no capacity for robust peer review of app content or declaration of evidence-based information within the app. Therefore, the degree of validity offered by such involvement remains questionable.
Conclusion Spinal surgery-related smartphone apps are becoming increasingly available with many potential benefits for patient and health-care workers. They provide a valuable, easily accessible medium of communication with which to provide information on spinal surgery. However, while named medical involvement in their design is higher than that of studies in other specialties, the limited use of evidence-based material and customer ratings limits the quality and content of some apps. We advocate basic measures to improve accountability and reliability of app content, which include requirement of full authorship disclosure, transparent display of regulatory approval and clearly defined quality control standards. Acknowledgments
No funding was received.
Conflict of interest
None.
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ORIGINAL ARTICLE
Smartphone apps for spinal surgery: is technology good or evil? Greg A. J. Robertson1 • Seng Juong Wong2 • Richard R. Brady3 • Ashok S. Subramanian1
Received: 22 March 2014 / Revised: 4 April 2015 / Accepted: 5 April 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract Purpose The increased utilization of smartphones together with their downloadable applications (apps) provides opportunity for doctors, including spinal surgeons, to integrate such technology into clinical practice. However, the clinical reliability of the medical app sector remains questionable. We reviewed available apps themed specifically towards spinal surgery and related conditions and assessed the level of medical professional involvement in their design and content. Method The most popular smartphone app stores (Android, Apple, Blackberry, Windows, Samsung, Nokia) were searched for spinal surgery-themed apps, using the disease terms Spinal Surgery, Back Surgery, Spine, Disc Prolapse, Sciatica, Radiculopathy, Spinal Stenosis, Scoliosis, Spinal Fracture and Spondylolisthesis. Results A total of 78 individual spinal surgery themed apps were identified, of which there were six duplicates (N = 72). According to app store classifications, there were 57 (79 %) medical themed apps, 11 (15 %) health and fitness themed apps, 1 (1 %) business and 3 (4 %) education themed apps. Forty-five (63 %) apps were available for download free of charge. For those that charged access, the prices ranged from £0.62 to £47.99. Only 44 % of spinal surgery apps had customer satisfaction ratings and & Greg A. J. Robertson [email protected] 1
Department of Orthopaedics, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
2
University of Edinburgh Medical School, Edinburgh, UK
3
Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK
56 % had named medical professional involvement in their development or content. Conclusions This is the first study to specifically address the characteristics of apps related to spinal surgery. We found that nearly half of spinal surgery apps had no named medical professional involvement, raising concerns over app content and evidence base for their use. We recommend increased regulation of spinal surgical apps to improve the accountability of app content. Keywords
Spinal surgery Smartphone Apps
Introduction Smartphone health-related downloadable applications (apps) are rapidly increasingly in number, with approximately 1000 new apps released each month [1] and 142 million annual downloads predicted by 2016 [2]. At present, there are more than 13,000 healthcare-related apps and this sector is predicted to rise by 25 % per annum over the next 5 years [3]. Smartphone usage is popular amongst health-care professionals, with one study reporting that 84 % of orthopaedic care providers in the USA owned a smartphone and 53 % used it in clinical practice [4]. The range of smartphone applications available has been reported in various specialties, including orthopaedics [4, 5], neurosurgery [6], plastic surgery [7], colorectal surgery [8], bariatric surgery [9], radiology [1], pain medicine [10], dermatology [11], infectious diseases [12] and microbiology [13]. Spinal surgery is a rapidly expanding field with rates of spinal operations reported to have increased by 27 % from 2007 to 2009 in Scotland alone [14]. Given further predicted expansion in spinal surgery as a speciality, increased
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access to relevant information will be required for both health-care professionals and patients. However, previous studies have found that Internet information relating to spinal surgery is limited and of variable quality [15–17]. Smartphone apps have been advocated as the future modality to convey such information [18, 19]. However, concerns regarding the lack of medical involvement in app design [14–16] and the reliability of app content [1, 8–11, 13] have been raised. Whilst regulations by the US Food and Drug Administration (FDA) exist for medical smartphone apps which directly influence patient treatment [20], most medical smartphone apps are not formally evaluated [21]. This study aims to identify contemporary smartphone apps relating to spinal surgery and assess the level of medical professional involvement in their design.
Method Six major online mobile platform application stores (Android, Apple, Blackberry, Nokia, Samsung, Windows) were searched for smartphone apps specifically relating to spinal surgery and related conditions using the search terms Spinal Surgery, Back Surgery, Spine, Disc Prolapse, Sciatica, Radiculopathy, Spinal Stenosis, Scoliosis, Spinal Fracture and Spondylolisthesis. The search was conducted by a single author on 24 Feb 2014. These terms were based on the commonest spinal surgery conditions seen by spinal surgeons [14]. The terms used in the search were generated from the overview of the apps content provided by the developer. Apps relating to back pain, but with no relation to surgical consultation were excluded. Similarly, nonEnglish language applications, games and wallpaper applications were excluded. Data were generated from the overview of the app’s content provided by the developer. Data recorded for every app included category of the application, implied target audience, documentation of medical professional involvement, evidence referenced, average rating, number of ratings, publisher information, commercial content and cost (prices in British pounds). All app links to publisher pages were followed to establish authorship, referenced evidence and links to commercial products. Commercial intent was judged by whether the app or the publisher page had links to private surgery, promoted a product or another app or required purchase. All apps that were free to download were accessed. Priced apps could not be accessed due to funding limitations for the study. The total cost of accessing the priced apps would have been £129.86. Data were grouped into subcategories by topic and target audience and summarized for clarity.
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Repeat applications found in different smartphone stores or almost identical apps found within the same smartphone store were marked as duplicates with only one version of the app counted. Univariate statistical comparisons between categorical variables were performed using the Chi-squared test. The significance level was set at p \ 0.05.
Results The search returned 78 apps in total. There were 6 (8 %) duplicates and hence only 72 apps were analysed. Eighteen (25 %) apps were identified on Apple, 48 (67 %) on Android, 2 (3 %) on Blackberry, 2 (3 %) on Samsung, 1 (1 %) on Nokia and 1 (1 %) on Windows (see Fig. 1). According to the App stores classifications, there were 57 (79 %) ‘medical’ themed apps, 11 (15 %) ‘health and fitness’ themed apps, one (1 %) ‘business’ themed app and three (4 %) ‘education’ themed apps. Forty-five (63 %) of the apps were available to download free of charge. For those that charged access, the prices ranged from £0.62 for an educational app with a patient target audience to £47.99 for a scoliosis curvature measuring app. The median cost of the apps was £2.53 and the mean £5.02. Eighteen (25 %) apps were updated in 2014 (1 January– 24 February), 31 (43 %) in 2013, 13 (18 %) in 2012, 7 (10 %) in 2011 and 1 (1 %) in 2010. Thirty-two apps (44 %) had customer satisfaction ratings. None had more than 100 reviews. Twenty-two (63 %) of the apps with customer satisfaction ratings were free, while 23 (58 %) without ratings were free (p = 0.451). Only 40 (55 %) apps had documented medical professional involvement. This was from a named clinician or organization in all 40 (100 %) of the apps. Twenty-four (60 %) of the apps with named medical professional involvement were free compared with 21 (66 %) without named medical professional involvement (p = 0.660). 3%
3%
Android Apple 25% Blackberry Samsung Windows 67% Nokia
Fig. 1 Apps distribution by app stores
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For the apps with no declared medical involvement that were free to download, information present in these included: descriptions of spinal operations with predicted outcomes, descriptions of post-operative rehabilitation methods following spinal surgery and management algorithms for patients with acute spinal injuries. One of these apps provided a scoliosis measuring tool on which to base clinical decisions. Commercial links were present in 45 (63 %) apps and links to private surgery were evident in 11 (24 %) apps. Apps were categorized into those aimed at patient education, those aimed at health-care education, those providing measuring aids for clinical purposes, those for advertising purposes and a number of miscellaneous categories (see Fig. 2). The apps search results are summarized in Table 1 and listed fully in Table 2. Educational apps for patients There were 23 (33 %) apps identified which implied that their content was for patient education. This represented the largest group of apps within the study. This category was subdivided into those which predominantly addressed: (a) information regarding spinal surgery conditions (n = 16); (b) information regarding spinal surgery techniques and procedures (n = 7). Only nine (39 %) of these apps had a named medical professional involvement and ten (43 %) had consumer reviews. Of the 16 apps which provided information on ‘spinal surgery conditions,’ 13 provided general information on a range of spinal conditions, 1 provided relevant terminologies for spinal disease, 1 provided information on scoliosis specifically and 1 provided information on managing spinal trauma. Medical professional involvement was evident in
25
20
Informaon on Spinal Condions
Informaon on Spinal Surgery
7
15
23 10
31 % of these. Two (9 %) apps made reference to evidence-based content. Overall, commercial links were evident in 19 apps (83 %) and links to pursue private spinal surgery was evident in 5 (22 %). Of the seven apps which provided information on ‘spinal surgery techniques,’ three provided patient information on discectomy, two gave patient information on scoliosis surgery and two provided information on a number of spinal surgery operations. Medical professional involvement was evident in 57 % of these. Only one app made reference to evidence-based content. Overall, commercial links were evident in six (86 %), and three (43 %) had links to pursue spinal surgery. Educational apps for health-care workers There were 23 apps that provided educational content aimed at health-care workers. This included three apps providing journal papers, three with examination practice questions, two on guidelines, one an anatomy textbook, one a newsletter, one an archive of surgical videos and 12 apps that offered quick reference to information on various spinal topics. Only three of these apps were dedicated to spinal surgery. Named medical professional involvement was evident in 13 (57 %) of these apps. One of these apps (the Open Operating Theatre App) was formally recommended by an editorial article in a peer-reviewed spinal surgery journal [22]. This category had costs ranging from £0.00 to £13.99 with a mean price of £4.22. User ratings were available for 12 (52 %) of these apps. Commercial intent was evident in 48 %, most commonly from the purchase cost of the app. Surgery advertising apps There were five (7 %) apps identified with links to private surgery. All of these had named medical professional or organization involvement and this was well advertised throughout. Three were advertising for individual clinicians, while two were advertising for centres. One provided links to multidisciplinary care. Of these apps, none had consumer reviews.
16 13
Society advertising apps
5
5
6
0
Fig. 2 Categories of smartphone applications
There were six (9 %) apps identified as advertising apps for conferences or societies. There were four conference advertising apps, providing information on programmes and locations of conferences and two spine society advertisement apps providing information on news and upcoming events of the society. Eighty-three percent of these had named medical professional involvement and this was well advertised throughout. Commercial links were present in
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123 Pts/HCW
Overall
Patients
Patients
HCW
HCW&Patients HCW&Patients
HCW HCW Patients
Knowledge of conditions
Information on surgery
Healthcare education
Surgery advertising
Measuring tools
Society/conference promotion
Implant company advertising
scoliosis forums
1
1
6
13
5
23
7
16
23
72
No. of apps
£0
£0
£0
£0–£47.99 [£10.03]
£0
£0–£13.99 [£4.22]
£0
£0–£4.99 [£1.80]
£0–£4.99 [£1.48]
£0–£47.99 [£5.02]
Price range [mean]
1/1 (100 %)
Nil
1/6 (17 %)
App Cost (7)
9/13 (69 %)
Surgery (5)
5/5 (100 %)
App Cost (12), Surgery (1)
11/23 (48 %)
Surgery (3)
6/7 (86 %)
Nil (0 %)
Nil (0 %)
5/6 (83 %)
8/13 (62 %)
5/5 (100 %)
13/23 (57 %)
4/7 (57 %)
1/1 (100 %)
Nil
2/6 (33 %)
7/13 (54 %)
Nil
12/23 (52 %)
5/7 (71 %)
Ratings 2.3
Votes 3
–
Mean 5
Votes 11
Mean 3.91
Range 3.5–4.7
Votes 212
–
Range 3.2–5 Mean 4.47
Votes 83
Mean 3.8
Range 1–5
Votes 24
Mean 3.07
Votes 59
App Cost (3)
5/16 (31 %)
Range 3–4.3
5/16 (31 %)
Surgery (2)
13/16 (81 %)
Mean 3.75
Votes 83
Total votes 394
Mean score 4.09
Customer rating out of 5 (No. of voters)
App Cost (10)
10/23 (43 %)
32/72 (44 %)
No. of apps with ratings
Range 1–5
9/23 (39 %)
40/72 (56 %)
Medical professional involvement
Surgery (5)
19/23 (83 %)
App Cost (29) Surgery (11)
45/72 (63 %)
Links to other commercial outlets
No. number, HCW health-care worker, N/A not applicable. Commercial: Surgery links to private surgery, Promo promotion of product, App cost cost of app alone, None no commercial links
Patients
Subcategories
Patient education
Target audience
Category
Table 1 Categorical overview of the spinal surgery apps, identified with respect to their cost, commercial links, medical professional involvement and consumer ratings
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Free Free
19/01/14
10/02/13
02/09/12
13/12/12
04/11/13
06/01/14
17/01/14
26/11/ 2012
16/09/13 25/01/13
22/02/11
21/04/13
10/06/13
27/02/12
Back pain management
Back pain relief
Scoliosis??
Spinal cord injury
Spine express
Spine health education models
Treat a spinal injury victim
Neurosurgery conditions
Spine glossary How to cure back pain!
Surgeon
Back pain
Spine conditions and treatment
Back pain: an algorithmic approach
19/10/13
07/02/14
01/01/14
Back pain by AZoMedical
Common Surgeries
Dr. Edgar Jimenez Masis
Free Free
Spinal Cord/Nerves flashcards
Atlas of Back and Thorax
For students
Spine Imaging Case Review
Free
Spinal Cord Injury, 650 MCQs Free
23/01/11
Back pain
NSG
OrtoTrauma
Neurointensive Care Guide
Spinal Cord Trauma
Medrills: Spinal Cord Injury OrthoRef
Spinal Cord Encyclopedia
Surgical Assistant
The Spine Journal
Spine Decide-Point of Care Patient Education for Healthcare Professionals by Orca Health
Spine
Spinal News International
SLIC
Orthopaedics Today Europe
Information on surgery
£4.99
£1.49
£1.25
£0.78
£0.62 £0.63
£0.62
Free
Free
Free
Free
Free
Open Operating Theatre
21/01/14
Back fix
Free
ISIS (International Spine Intervention Society) Emergency Protocols
Free
28/10/13
Health-care education (23)
All-pro orthopedics
Price
For doctors
Date updated DD/MM/ YY
Knowledge of conditions
Patient education (23)
Table 2 Listing of the spinal surgery apps, with their cost and date of update
22/02/13
26/04/13
13/01/14
14/01/14
11/12/12
05/11/13
15/09/12
17/09/13
10/01/14 Not Specified
18/02/10
06/04/13
13/07/13
10/12/13
08/10/13
26/10/12
20/01/12
04/09/13
23/09/13
21/01/14
Date updated DD/MM/ YY
Free
Free
£13.99
£9.26
£4.48
£3.73
£3.08
£2.99
£2.46 £2.59
£0.69
£0.63
Free
Free
Free
Free
Free
Free
Free
Free
Price
24/04/13
11/11/13
22/04/14
28/06/13
08/08/13
15/12/13
07/03/11
04/11/13 02/02/11
23/12/11
14/01/14
20/06/13
28/11/13
16/09/13
1/12/13
07/02/14
06/02/14
06/02/14
Date updated DD/MM/ YY
ASSICON 2015
22/01/14
Society/conference Promotion
SpineCurve
Cobb reader
CobbMeter CE
Scoliometer HD
ScolioTrack
Scolioscreen
Scoligauge
Scoliometer Vertebra (spine) Checker lite
Scoliosis measurement
Measure Angles
Goniometer Records
Goniometer Pro (G-pro) Preview
Measuring tools
Spine MD
Kayal Orthopaedic Center, PC
Dr Venu Gopal S Appointments
Dr Arun L Naik Appointment
Dr A.Mohan Krishna Appointment
Surgery advertising
Others (26)
Free
£47.99
£8.29
£5.60
£3.99
£2.99
£0.69
£0.69
Free Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Price
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Free
Free
16/04/13
10/06/11 FixScoliosis
Free 30/01/14 WorldSpine VI
Scoliosis forums
Free 05/08/13 Spine Line
S2S
Free 12/03/12 ISASS £9.30 21/10/11
Implant company advertising
Free
Free
13/11/12
19/11/13
DWG 2012
Not Specified
DWG 2013
£0.64
£1.00
21/01/14
Price Price Date updated DD/MM/ YY
Others (26)
Date updated DD/MM/ YY
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one (17 %) and links to private surgery were evident in none. Of these, two had consumer reviews. Spine tool apps A popular theme of the spinal surgery apps was measuring tools for clinical and radiological spinal surgery measures. Of these, nine were for clinical scoliosis measures, two were for radiological scoliosis measures, one was for measuring general spine-related X-ray angles and one was for use as a clinical goniometer. There was named professional involvement in eight (62 %) of these. Three of these had evidence-based measures to validate their use [23–26]. The price ranged from £0.00 to £47.99, with this being the most expensive category. There were commercial links on nine (69 %) of these apps. Seven (54 %) had consumer reviews, this being the category with most ratings. None declared approval by the FDA.
Netter’s: Back and Spinal Cord 16/03/12 Spine Care
Free
Surgery Reference
Surgery101
13/02/12 Sciatica relief
Free
31/08/12 MHSI
Free
Date updated DD/MM/ YY Patient education (23)
Table 2 continued
Price
Health-care education (23)
Discussion
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Smartphone apps are increasingly used by medical practitioners [27]. This technology has given clinicians the capability of merging information and communication resources into one condensed multipurpose device [12]. This has led to the rapid expansion of smartphone utilization in the clinical environment with numerous potential opportunities within health-care systems [27]. While the content and validity of smartphone applications have been studied in various medical fields [1, 4–13], this is the first to review smartphone applications relevant to spinal surgery. Here, we identified a wide variety of apps targeted at both medical and lay audiences. This included educational apps for both patients and medical professionals, apps advertising conferences and societies and apps providing clinical measuring tools. However, there were a number of concerning features relating to our search. While named medical professional involvement in spinal surgery-related apps was recorded at 54 %, a higher level than reported in other specialties [1, 8, 9], only 24 % of apps claimed use of evidence-based information. The rapid expansion of smartphone applications has made it easier for programmers, medically trained or not, to develop and publish medical-related information. This has obvious benefits; however there remain concerns regarding the accuracy of medical application content [1, 8–10, 13]. We found that apps with no declared medical involvement contained information that could directly influence clinical management. Given its potential to compromise patient safety, it is vital that publication of such information is performed in conjunction with medical professionals.
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Further concerns include difficulties for potential users to assess the accuracy of application content prior to purchase. Currently, application stores provide a short description of the app, along with customer ratings. While customer ratings can provide a peer-reviewed source of feedback, 56 % of applications in this study had no ratings. Furthermore, 68 % of those rated were based on less than ten ratings, reducing the reliability of the customer feedback. This remains a common problem amongst medical apps [10, 11]. Application advertising material should be regulated to provide clear information regarding the nature of app content and relevant qualifications of app developers. This allows potential users to make an informed assessment of an application’s reliability prior to purchase. At present, the FDA plans to regulate a subset of smartphone medical applications which can influence clinical diagnosis or practice (i.e. calculation of drug doses) and so may represent a risk to patients [20]. In the current study, the measuring tools identified potentially fall within this category. Despite this, only one of these apps had evidence-based validation [23] and none reported FDA approval. Given that such tools can influence the decision to direct patients towards major surgery, stricter regulations should be considered for their processing in the future. The majority of apps in this study, however, were educational in nature and so would not warrant FDA regulation [21]. Yet, with the potential for these apps to influence clinical management, one must strongly consider the need for quality control of their content. Having previously been used in the field of orthopaedics to effectively appraise orthopaedic-related Internet information [28], one must consider the potential of the ‘Health on the Net’ Foundation to provide such regulation [29]. This nonprofit, non-governmental organization promotes and guides the deployment of useful and reliable online health information for patients and professionals [29]. It has established a ‘Health On the Net’ Code which has acted as a stamp of validity for websites providing medical information [29]. We would recommend modification of this code for use in smartphone applications, allowing medical personnel and patients to identify those which provide quality sources of health information. Where possible, published recommendation of the app by the manufacturers through editorial journal articles in recognized peer-reviewed journals can provide a reassuring description of the app for the customer [22]. There was a high number of spine-related clinical measuring tool apps in our study. Their uses included clinical assessment of scoliosis and X-ray angle assessment. Use of such tools in the field of orthopaedic surgery is wide ranging, with apps available for goniometric knee assessment, radiographic hallux valgus angulation
assessment and acetabular cup alignment assessment in hip replacement surgery. However, evidence-based validation of such tools remains limited with only four studies available for orthopaedic apps [5]. In the field of spinal surgery, three such apps have been validated with published studies [23–26]. Of note, app scoliometers have been demonstrated to be an accurate easily accessible tool for use in clinical practice [23, 25, 26]. It would therefore appear that these tools offer an exciting prospect as measuring devices for clinicians. The study has some limitations. Firstly, information gathered from apps was taken from the overview pages and links to publishers’ websites, as funding limitations prohibited download of the full version of the apps. This method prevented direct verification of the validity and accuracy of the app content from the full version. However, this recreates the situation potential application purchasers currently encounter prior to purchase. The authors would suggest that these overview pages should provide potential customers with a comprehensive description of author credentials, content source, conflicts of interest and peer review by previous customers to guide appropriate purchase. Further limitations include the subjectivity of the customer rating tools, which are potentially biased, lack validation and are subject to regular change. Furthermore, whilst named medical involvement in app development provides assurances to the customer, there is currently no capacity for robust peer review of app content or declaration of evidence-based information within the app. Therefore, the degree of validity offered by such involvement remains questionable.
Conclusion Spinal surgery-related smartphone apps are becoming increasingly available with many potential benefits for patient and health-care workers. They provide a valuable, easily accessible medium of communication with which to provide information on spinal surgery. However, while named medical involvement in their design is higher than that of studies in other specialties, the limited use of evidence-based material and customer ratings limits the quality and content of some apps. We advocate basic measures to improve accountability and reliability of app content, which include requirement of full authorship disclosure, transparent display of regulatory approval and clearly defined quality control standards. Acknowledgments
No funding was received.
Conflict of interest
None.
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