Systematic Review of Quality of Patient Information on Liposuction in the Internet

Abstract

Background:
A large number of patients who are interested in esthetic surgery actively search the Internet, which represents nowadays the first source of information. However, the quality of information available in the Internet on liposuction is currently unknown. The aim of this study was to assess the quality of patient information on liposuction available in the Internet.

Methods:
The quantitative and qualitative assessment of Web sites was based on a modified Ensuring Quality Information for Patients tool (36 items). Five hundred Web sites were identified by the most popular web search engines.

Results:
Two hundred forty-five Web sites were assessed after duplicates and irrelevant sources were excluded. Only 72 (29%) Web sites addressed >16 items, and scores tended to be higher for professional societies, portals, patient groups, health departments, and academic centers than for Web sites developed by physicians, respectively. The Ensuring Quality Information for Patients score achieved by Web sites ranged between 8 and 29 of total 36 points, with a median value of 16 points (interquartile range, 14-18). The top 10 Web sites with the highest scores were identified.

Conclusions:
The quality of patient information on liposuction available in the Internet is poor, and existing Web sites show substantial shortcomings. There is an urgent need for improvement in offering superior quality information on liposuction for patients intending to undergo this procedure.

Full text

www.PRSGlobalOpen.com 1
Liposuction is an esthetic procedure that removes fat
from many different sites of the body, of which the most
common are abdomen, thighs, buttocks, backs of the
arms, and neck.1 The majority of patients considering lipo-
suction may actively search for information in the Internet
before consultation by a health professional.2,3 The Internet
provides direct and fast access to patient information, and
there was an enormous growth of this medium in the last
decades including the field of esthetic surgery.4 However, ev-
eryone can create his or her own Web site with uncontrolled
and not peer-reviewed information, including physicians, in-
stitutions, patient representatives, and the industry. The con-
cern about the quality of patient information in the Internet
is increasing.5–9 Liposuction is the world’s most frequently
performed esthetic surgery procedure. In 2011, plastic sur-
geons performed >1.2 million liposuctions worldwide which
made 19% of all plastic surgery procedures.10 Economic anal-
yses predict a further increase of esthetic procedures being
performed in the near future.11 The need for reliable and
comprehensive information on this topic will grow too. Sev-
eral instruments to evaluate patient information were pro-
posed.3,12 The modified Ensuring Quality Information for
Patients (EQIP) is a reliable, easy to use, validated, and re-
producible tool to analyze the quality of patient information
in the Internet.12,13 To the best of our knowledge, assessment
of available information on liposuction with a validated tool
was never reported. The aim of this study was therefore to
assess systematically whether the Internet provides adequate
quality of information for patients interested in liposuction.
MATERIALS AND METHODS
Eligibility Criteria, Information Sources, and Study Selection
Data were collected in November and December 2013 by 1
investigator using the 5 most popular search engines: Google,
Received for publication November 12, 2014; accepted April 29,
2016.
Copyright © 2016 The Authors. Published by Wolters Kluwer
Health, Inc. on behalf of The American Society of Plastic Surgeons.
All rights reserved. This is an open-access article distributed under
the terms of the Creative Commons Attribution-Non Commercial-No
Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to
download and share the work provided it is properly cited. The work
cannot be changed in any way or used commercially.
DOI: 10.1097/GOX.0000000000000798
From the *Department of Surgery, Citizens’ Hospital Solothurn,
Solothurn, Switzerland; †Department of Plastic Surgery and
Hand Surgery, University Hospital Zurich, Zurich, Switzerland;
‡Department of Surgery, University Hospital Zurich, Zurich,
Switzerland; §Department of Surgery, Cantonal Hospital Olten,
Olten, Switzerland; and ¶Department of Plastic Surgery and Hand
Surgery, University Hospital Bern, Bern, Switzerland.
Background: A large number of patients who are interested in esthetic surgery
actively search the Internet, which represents nowadays the first source of informa-
tion. However, the quality of information available in the Internet on liposuction is
currently unknown. The aim of this study was to assess the quality of patient infor-
mation on liposuction available in the Internet.
Methods: The quantitative and qualitative assessment of Web sites was based on a
modified Ensuring Quality Information for Patients tool (36 items). Five hundred
Web sites were identified by the most popular web search engines.
Results: Two hundred forty-five Web sites were assessed after duplicates and irrel-
evant sources were excluded. Only 72 (29%) Web sites addressed >16 items, and
scores tended to be higher for professional societies, portals, patient groups, health
departments, and academic centers than for Web sites developed by physicians, re-
spectively. The Ensuring Quality Information for Patients score achieved by Web sites
ranged between 8 and 29 of total 36 points, with a median value of 16 points (inter-
quartile range, 14–18). The top 10 Web sites with the highest scores were identified.
Conclusions: The quality of patient information on liposuction available in the Inter-
net is poor, and existing Web sites show substantial shortcomings. There is an urgent
need for improvement in offering superior quality information on liposuction for pa-
tients intending to undergo this procedure. (Plast Reconstr Surg Glob Open 2016;4:e759;
doi: 10.1097/GOX.0000000000000798; Published online 28 June 2016.)
Grzegorz Zuk, MD*
Adrian Fernando Palma, MD†
Gertraud Eylert, MD†
Dimitri Aristotle Raptis, MD,
MSc, PhD‡§
Merlin Guggenheim, MD†
Maziar Shafighi, MD¶
Systematic Review of Quality of Patient Information
on Liposuction in the Internet
Disclosure: The authors have no financial interest to de-
clare in relation to the content of this article. The Article Pro-
cessing Charge was paid by the authors.
Quality of Patient Information on Liposuction
Zuk et al.
XXX
xxx
6
Ujwala
Plastic & Reconstructive Surgery-Global Open
2016
4
Original Article
10.1097/GOX.0000000000000798
29April2016
12November2014
© 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society
of Plastic Surgeons. All rights reserved.
Cosmetic
ORIGINAL ARTICLE

PRS Global Open • 2016
2
Bing, Yahoo, Ask.com, and AOL.14 The keyword “liposuction”
was used and the first 100 Web sites for each search engine
were identified. This was based on the assumption that most
people limit their search to a number below 100 (ie, the first
10 search results pages), as previously described.15 From the
initial number of 500 Web sites in English, the following were
eliminated: duplicates, irrelevant Web sites, such as those
covering the keyword in different context than providing in-
formation on liposuction, and Web pages including scientific
articles such as those from scientific journals which are pri-
marily intended for professionals due to specialized vocabu-
lary and have restricted access to subscribers.15
The source of the eligible 245 Web sites was categorized
into 10 groups: (a) academic/educational institutions, (b)
encyclopedias, (c) health departments, (d) hospitals, (e)
the industry, (f) news services (ie, the press), (g) patient
groups, (h) practitioners, (i) professional societies, and
(j) Web portals.
Medical Information Assessment Tool
Eligible Web sites were assessed using the modified
EQIP instrument,12,13 which provides a checklist composed
of 36 items that evaluate the content, identification, and
structure data of online available patient information
(Table 1). This instrument was successfully used by other
authors,16 and we decided to adapt its modified version15
using the binary scale of yes versus no or NA (not applica-
ble) for items not applicable to liposuction. The modifica-
tion consisted in not using the answer partially yes, which
is of subjective nature and of low reliability, as previously
described.13,17
Morbidity and Mortality Risks
Items 9 and 10 of the modified EQIP instrument assess
information on complications, morbidity, and mortality
risk (Table 1). Liposuction can be associated with a vari-
ety of complications, which may be local, such as edema,
ecchymosis, hematoma, and infection or systemic such as
significant blood loss, visceral perforation, thromboembo-
lism, or even death (Item 9, Table 1).18 Item 10 evaluates
the description of quantitative risks represented as a pro-
portion or a ratio, such as infection rates after liposuction.
Various authors report incidence of <1%,19–21 but lethal
complications were also reported.22
Table 1. Overall Results of the Included Web Sites According to the Modied Ensuring Quality Information for Patients
Instrument
Item Criteria Yes (%) No (%)
Does Not
Apply (%)
Content data
1 Initial definition of which subjects will be covered 244 (99.6) 1 (0.4) 0 (0)
2 Coverage of the previously defined subjects (NA if the answer is “no” for Item 1) 244 (99.6) 1 (0.4) 0 (0)
3 Description of the medical problem 222 (90.6) 23 (9.4) 0 (0)
4 Definition of the purpose of the surgical intervention 206 (84.1) 39 (15.9) 0 (0)
5 Description of treatment alternatives 93 (38.0) 152 (62.0) 0 (0)
6 Description of the sequence of the surgical procedure 65 (26.5) 180 (73.5) 0 (0)
7 Description of the qualitative benefits to the recipient 58 (23.7) 187 (76.3) 0 (0)
8 Description of the quantitative benefits to the recipient 57 (23.3) 188 (76.7) 0 (0)
9 Description of the qualitative risks and side effects 69 (28.2) 176 (71.8) 0 (0)
10 Description of the quantitative risks and side effects 68 (27.8) 177 (72.2) 0 (0)
11 Addressing quality-of-life issues 54 (22.0) 191 (78.0) 0 (0)
12 Description of how complications are handled 16 (6.5) 229 (93.5) 0 (0)
13 Description of the precautions that the patient may take 80 (32.7) 165 (67.3) 0 (0)
14 Mention of alert signs that the patient may detect 43 (17.6) 202 (82.4) 0 (0)
15 Addressing medical intervention costs and insurance issues 169 (69.0) 76 (31.0) 0 (0)
16 Specific contact details for hospital services 13 (5.3) 0 (0) 232 (94.7)
17 Specific details of other sources of reliable information/support 11 (4.5) 234 (95.5) 0 (0)
18 Coverage of all relevant issues for the topic (summary item for all content criteria) 0 (0) 244 (99.6) 0 (0)
Identification data
19 Date of issue or revision 207 (84.5) 38 (15.5) 0 (0)
20 Logo of the issuing body 164 (66.9) 81 (33.1) 0 (0)
21 Names of the persons or entities that produced the document 215 (87.8) 30 (12.2) 0 (0)
22 Names of the persons or entities that financed the document 10 (4.1) 235 (95.9) 0 (0)
23 Short bibliography of the evidence-based data used in the document 13 (5.3) 232 (94.7) 0 (0)
24 Statement about whether and how patients were involved/consulted in the document’s
production
24 (9.4) 221 (90.2) 0 (0)
Structure data
25 Use of everyday language and explanation of complex words or jargon 244 (99.6) 1 (0.4) 0 (0)
26 Use of generic names for all medications or products (NA if no medications described) 71 (29.0) 30 (12.2) 144 (58.8)
27 Use of short sentences (<15 words on average) 243 (99.2) 2 (0.8) 0 (0)
28 Personal address to the reader 244 (99.6) 1 (0.4) 0 (0)
29 Respectful tone 245 (100.0) 0 (0) 0 (0)
3 Clear information (no ambiguities or contradictions) 238 (97.1) 7 (2.9) 0 (0)
31 Balanced information on risks and benefits 18 (7.3) 227 (92.7) 0 (0)
32 Presentation of information in a logical order 92 (37.6) 153 (62.4) 0 (0)
33 Satisfactory design and layout (excluding figures or graphs) 202 (82.4) 42 (17.1) 0 (0)
34 Clear and relevant figures or graphs (NA if absent) 12 (4.9) 2 (0.8) 231 (94.3)
35 Inclusion of a named space for the reader’s note or questions 1 (0.4) 243 (99.2) 0 (0)
36 Inclusion of a printed consent form contrary to recommendations (NA if not from
hospitals)
0 (0) 14 (5.7) 231 (94.3)

Zuk et al. • Quality of Patient Information on Liposuction
3
Quality of Life
In esthetic surgery procedures, such as liposuction, the
primary determinants of success are patient satisfaction
and quality of life.23 This issue (Item 11) should provide
information on what patients’ expectations towards sur-
gery can be, and if they can always be achieved, given that
this information being available in the literature.24
Statistical Analysis
SPSS version 21 for Mac (IBM Corp., Armonk, N.Y.)
was used to perform statistical analysis. Data derived
from categorical variables were compared with the χ2
or Fischer’s tests; the one-way analysis of variance or
Student t tests were used to compare continuous vari-
ables where appropriate. The P values <0.05 were con-
sidered statistically significant, and all of them were
2-sided. The Web sites were scored from 0 to 36, and
equal weight of importance was given to every item. All
Web sites were assessed by 1 investigator to maintain
consistency in the review. The EQIP score was dichoto-
mized by using the 75th quartile as a cutoff point to
discriminate high-score Web sites from low-score ones,
as previously described.15
RESULTS
Web Sites Providing Medical Information on Liposuction for
Patients
Five hundred Web sites developed in English contain-
ing the keyword “liposuction” were identified with Google,
Bing, Ask.com, Yahoo, and AOL Internet search engines.
After elimination of duplicates, irrelevant Web sites, and
those intended for scientists with access restricted only to
professionals, 245 eligible Web sites underwent qualitative
and quantitative assessment (Fig. 1). From these eligible
Web sites, 163 (66.5%) were developed by medical prac-
titioners, followed by 50 (20.4%) by portal developers,
9 (3.7%) by hospitals, 8 (3.3%) by academic centers, 4
(1.6%) by encyclopedias, 4 by news services, and 4 by pro-
fessional societies and 1 (0.4%) by a health department, 1
by the industry, and 1 by a patient group.
A total of 216 Web sites originated from the United
States (88.2%), followed by 9 (3.7%) from Australia, and
9 from the United Kingdom, and 11 (4.4%) from other
countries such as Canada, Dominican Republic, India,
Mexico, New Zealand, Singapore, South Africa, and the
United Arab Emirates.
EQIP Score Achieved by All Web Sites
The median score of 16 points [interquartile range
(IQR), 14–18] was achieved according to the EQIP scor-
ing system. Web sites obtaining a score of more than 18,
which corresponds to the 75th percentile, were defined
as high-score Web sites15 and those obtaining a score of
≤18 were defined as low-score Web sites. A high score was
obtained by 72 Web sites (29%), and low score by the re-
maining 173 (71%; Fig. 2; Table 1).
Fig. 1. Flow chart showing how relevant Web site were identied, screened, and included to our study.
Fig. 2. Histogram presenting the number of Web sites (vertical axis)
and their scores according to the modied EQIP instrument (hori-
zontal axis).

PRS Global Open • 2016
4
The 12 top-rated Web sites15 obtained a score of more
than the 95th percentile (EQIP ≥ 23; Table 2). Most of the
top-rated Web sites originated from the United States fol-
lowed by Australia. The highest-scored Web site received
29 of total 36 points.25
EQIP Score Achieved by First 30 Web Site Search Results
Under the assumption that most users limit their
search for a keyword to the first 3 pages (ie, 30 Web site
results, 10 per page), a subgroup analysis was performed
to compare the overall quality of patient information of
the first 30 search results for the keyword “liposuction”
with the median EQIP score calculated according to the
EQIP scoring system. There was a statistically significant
difference of only 1 EQIP point favoring the first 30 Web
site results (median, 16; IQR, 14–19 vs median 15; IQR,
14–17; P = 0.003).
Overall Quality of Medical Information Assessed with the
Modified EQIP Tool
The lowest score achieved was 8 by 2 Web sites,26,27 the
maximum score of 29 was achieved by a Web site developed
by an academic center, the University of California, Los An-
geles.25 None of the assessed Web sites provided information
on all 36 items of the modified EQIP tool. There were 72
Web sites that covered >18 items and classified as high-score
Web sites. Regarding the source of information, profes-
sional societies, portals, patient groups, health departments,
and academic center Web sites scored higher as assessed by
the modified EQIP instrument when compared with those
developed by private practicing surgeons alone (Fig. 3).
Furthermore, 77% (126/163) of the Web sites developed
by private practicing surgeons were scored low (P = 0.035)
when compared with other sources. In an attempt to iden-
tify the reason why these Web sites scored low, we performed
a subgroup analysis assessing the reporting of complications
and mortality. A surprising 76% (136/177) of the Web sites
developed by private practicing surgeons did not mention
any risks associated with liposuction when compared to Web
sites developed from other sources (P < 0.001).
Year First Published
The oldest Web site origins from 1994 but most of
them (62%) were first published or fully updated in 2013.
Figure 4 illustrates how the quality of the Web sites based
on the EQIP score did not significantly change with time.
Length of Professional Experience in Private Practicing
Surgeons
Figure 5 demonstrates the relation between the profes-
sional experience of Web site developers and the EQIP
score achieved by their Web sites. In this subgroup analy-
sis, we focused on Web sites from American single surgeon
private practices, as most of the screened Web sites origi-
nated from the United States. The verification of time
since board certification issuance and Web site develop-
Table 2. The Top-rated Web Sites (>95th Percentile According to the Modied EQIP Instrument)
Ranking Website Country of Origin Source of Information Score
1 http://cosmeticsurgery.ucla.edu/body.cfm?id=35 United States Academic center 29
2 http://westcountyplasticsurgeons.wustl.edu/Procedures/Body-
Procedures/Tumescent-Liposuction
United States Academic center 26
2 http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/
liposuction
Australia Health department 26
2 http://www.cosmosclinic.com.au/tummy/liposuction Australia Practitioner 26
5 http://www.answers.com/topic/liposuction United States Portal 25
5 http://www.deramonpsi.com/liposuction-harrisburg.html United States Practitioner 25
7 http://www.buzzle.com/articles/liposuction United States Portal 24
7 http://www.plasticsurgery.org/cosmetic-procedures/liposuction.html United States Professional society 24
9 http://www.austinplasticsurgerycenter.com/liposuction.php United States Practitioner 23
9 http://www.emedicinehealth.com/liposuction/article_em.htm United States Portal 23
9 http://www.surgery.com/procedure/liposuction United States Portal 23
9 http://www.thevictoriancosmeticinstitute.com.au/liposuction Australia Practitioner 23
Fig. 3. Box plot presenting Web site scoring based on the modied
EQIP tool depending on source of information. The horizontal thick
line within the box plot represents the median. The upper line of
the box plot represents the 75th percentile while the lower the 25th
percentile. The upper whisker line represents the maximum value,
while the lower the minimum value. Outliers are shown as circles.
The median EQIP score was 16 points (dotted line). Health depart-
ments, industry, and patient groups were excluded as each of them
provided only 1 Web site.

Zuk et al. • Quality of Patient Information on Liposuction
5
ment using the official register of the American Society of
Plastic Surgeons28 was possible in 72 cases.
DISCUSSION
This is the first study to assess the quality of patient
information on liposuction using the validated modified
EQIP instrument. The most important findings of the
study were, first that the overall quality of information on
liposuction for patients was poor. Second, private practic-
ing surgeons, representing over two thirds of the assessed
Web sites, developed the lowest quality Web sites. Third,
according to the type of data covered, content data items
were addressed insufficiently whereas the identification
and structure data were well presented. Fourth, only few
Web sites reported the estimated morbidity and mortality
rates.
We used the validated modified EQIP instrument
to systematically assess the eligible Web sites.29 This
tool guarantees reproducibility of the results as already
shown by other authors.12,13,30 The initial EQIP tool was
developed with a 20-item scoring system13 and later vali-
dated and expanded into a 36-item assessment tool ad-
dressing the content, structure, and identification data
of patient information documents. It was developed by
rating the quality of 73 documents describing medical
care procedures, used at the University Hospital of Ge-
neva, Switzerland. The assessment rules were defined on
25 documents, and the remaining 48 documents were
independently rated by 2 assessors. The inter-rater reli-
ability was very good (κ statistic = 0.84) and the intraclass
correlation coefficient was as high as 0.95. The authors
recommended that all efforts should focus on respect-
ing guidelines and including patients when producing
patient information material.12
According to our results, the overall quality of infor-
mation on liposuction for patients is very poor. Although
the slightly better quality of patient information in the
Internet after reducing the screened Web site number to
30 hits, as opposed to the first 100, was shown to be statis-
tically significant, as assessed by the median EQIP score,
nevertheless this difference was relatively small.
Many plastic surgeons that practice in the private set-
tings advertise their service using the Internet. This may
explain the fact that two thirds of the assessed Web sites
were developed by physicians compared with one-third by
other providers. In a study on advertisement in esthetic
surgery, plastic surgeons had the highest average over-
all ethical code scores compared with other specialties,2
therefore the low quality of the Web sites found in this
study is disappointing. Even the top 10 Web sites show
substantial shortcomings as assessed by the modified
EQIP instrument. Better quality of patient information
is needed especially in terms of the surgical procedure,
qualitative and quantitative benefits, and risks for the
patient, how complications are handled, and what pre-
cautions patients can take. Different surgical techniques
and alternatives to surgery should also be better covered.
An appropriate patient selection is another important is-
sue that should be addressed while considering an inter-
vention in previously obese patients after massive weight
loss.18 Furthermore, it was insufficiently mentioned that
the results of liposuction are not permanent if no further
lifestyle changes are taken.19
Photographs of previously operated on patients fol-
lowed by board certification, training, hospital affiliations,
and costs of surgery are most frequently searched informa-
tion on a plastic surgeon’s Web site.2 Item 34 of the modi-
fied EQIP tool assessed whether images of the body are
used, but it would have been interesting to show how poor
the overall quality of photographs can be. Very few Web
sites used fair photographs, meaning same size and same
projection. As a matter of fact, unprofessional Web sites
may discourage patients from making an appointment.
Fig. 4. Scatter plot with the year of Web site publication on the hori-
zontal axis and their scores awarded by the modied EQIP instru-
ment on the vertical axis. The solid line represents the mean EQIP
score of the Web sites, and the dotted lines represent the 95% con-
dence intervals.
Fig. 5. Scatter plot with the years of private practicing surgeon’s pro-
fessional experience on the horizontal axis and scores that their Web
sites were granted by the modied EQIP instrument on the vertical
axis. The solid line represents the mean EQIP score of the Web sites.

PRS Global Open • 2016
6
In case video tools were used, the Web sites were all
well prepared and provided adequate information. Fur-
thermore, in many Web sites, a liposuction video devel-
oped from the American Society of Plastic Surgeons was
repeatedly available.31 Clearly, the currently best liposuc-
tion Web site which could be recommended to physicians
to suggest to their patients was provided by University of
California, Los Angeles.25 This Web site used the Emmi
tool (Emmi Solutions, LLC, Chicago, Ill), an interactive
introduction video which takes approximately 15 minutes,
and presents the different considerations in liposuction as
risks, benefits, and alternatives fairly.
The fact that most of the Web sites were developed
recently in contrary to the oldest one, created almost 20
years ago, does not necessarily mean they are better, as
assessed by the modified EQIP criteria. Although there is
a great amount of research on the topic ‘patient informa-
tion’, it seems to be staying at experimental level.32
The overall complication rate after liposuction was re-
ported as high as 1 in every 10 patients in an analysis of
2398 cases,33 and the mortality rate is estimated to be 1 in
every 5000 procedures.34 However, in our study less than a
third of the Web sites mentioned potential postoperative
complications or even death after liposuction. A surpris-
ing 76% of the Web sites developed by private practicing
surgeons did not mention any risks associated with liposuc-
tion when compared with Web sites from other sources. In
contrary, over half of the Web sites providing donor in-
formation for living donor liver transplantation reported
risk of complications and death after donation.15 This may
reflect the fact that liposuction is a customer-oriented pro-
cedure, and despite ethical concerns, Web site developers
may be discouraged from reporting these risks to attract
more patients/customers.35 This commercial aspect may
also explain why Web sites developed by academic centers
and other non-profit organizations scored better than
those developed by private practicing surgeons (Fig. 4).
This study has some limitations. Web sites developed
in any other language rather than English were excluded
from the study due to our linguistic limitations, and thus,
the quality of the Web sites published in other languages
remains unknown. However, English is spoken as first or
second language in most of the developed countries.36 The
modified EQIP instrument was developed to assess any
type of patient information and does not refer specifically
to liposuction—this may be a limitation of the assessment
tool itself. Some elements of the international recommen-
dations for developers of new decision aids in health care,
established by the International Patient Decision Aids
Standards (IPDAS) collaboration, were not addressed
in this study as the modified EQIP tool does not include
all the items of the IPDAS checklist.12,15,37 However, it was
shown that the modified EQIP instrument has higher
inter-rater reliability; it is highly reproducible and simpler
than the IPDAS checklist. Another potential shortcoming
could be the fact that only a single investigator performed
the assessment of the Web sites in our study. Due to work
and time constraint, we did not consider having the Web
sites assessed by an additional independent investigator as
the modified EQIP tool was shown to be highly reproduc-
ible and objective.
In this study, we focused on the evaluation of the ex-
isting patient information on liposuction with a validated
and reproducible tool, and to our best knowledge, this
was done for the first time. We did not consider any other
form of assessment, for instance to create our own as-
sessment instrument, as shown by Jejurikar et al9 or to
review the patient information by an experienced health
professional, as shown by Gordon et al,8 as this would
lack validation.
Based on the findings of this study, we recommend
that Web site developers use of modified EQIP instrument
to ensure good quality of their Web sites. An inclusion of
a tag “Quality of information published on this Web site
was checked with modified EQIP tool” at its bottom would
be a characteristic distinguishing it from other Web sites
published without any peer-review process. Alternatively,
a review and certification from a national board of plastic
and reconstructive surgeons may be useful to be included.
One’s contribution to improve the overall quality of infor-
mation presented in the Internet would be to meet all of
the modified EQIP criteria: the positive ones which can at-
tract patients and the possibly negative ones, like morbid-
ity and mortality risks (but in a careful way, eg, in a form
of percentage or ratio and well interpreted) to promote
patient transparency.
CONCLUSIONS
According to the best of our knowledge, this is the
first study to assess the quality of patient information on
liposuction in the Internet using the modified EQIP in-
strument. Our results show that the overall quality of the
Web sites based on the validated modified EQIP instru-
ment seems to be relatively poor. Only a few of the Web
sites scored high but nevertheless they still did not fulfill
all the requirements. There is an urgent need of develop-
ing a Web site on this topic satisfying all EQIP items by a
multidisciplinary working group supported by an interna-
tional society with the use of the Delphi or Danish model
of consensus.
Adrian Fernando Palma, MD
Department of Plastic Surgery and Hand Surgery
University Hospital Zurich
Rämistrasse 100
8091 Zurich, Switzerland
E-mail: mail@adrianpalma.com
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