Contemporary hernia smartphone applications (apps)
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- Connor, K., Brady, R.R.W., de Beaux, A. et al. Hernia (2014) 18: 557. doi:10.1007/s10029-013-1130-7
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Smartphone technology and downloadable applications (apps) have created an unprecedented opportunity for access to medical information and healthcare-related tools by clinicians and their patients. Here, we review the current smartphone apps in relation to hernias, one of the most common operations worldwide. This article presents an overview of apps relating to hernias and discusses content, the presence of medical professional involvement and commercial interests.
The most widely used smartphone app online stores (Google Play, Apple, Nokia, Blackberry, Samsung and Windows) were searched for the following hernia-related terms: hernia, inguinal, femoral, umbilical, incisional and totally extraperitoneal. Those with no reference to hernia or hernia surgery were excluded.
26 smartphone apps were identified. Only 9 (35 %) had named medical professional involvement in their design/content and only 10 (38 %) were reviewed by consumers. Commercial interests/links were evident in 96 % of the apps. One app used a validated mathematical algorithm to help counsel patients about post-operative pain.
Conclusions and opportunities
There were a relatively small number of apps related to hernias in view of the worldwide frequency of hernia repair. This search identified many opportunities for the development of informative and validated evidence-based patient apps which can be recommended to patients by physicians. Greater regulation, transparency of commercial interests and involvement of medical professionals in the content and peer-review of healthcare-related apps is required.
KeywordsHernia Smartphone Apps Education Technology
Smartphones combine the communication capability of mobile phones with advanced operating system (OS) software which facilitates an increasing processing power, rapid internet access, cameras and the ability to download software applications (apps). Worldwide, it is estimated that 30 million apps are downloaded each day and growth in this field is projected to overtake the PC software market .
In 2011, $150 million was spent on medical apps and it is thought that there are currently in excess of 7,000 health-related smartphone apps , covering a wide variety of specialties. Although this represents just 2 % of the App market at present, medical app downloads are projected to rise by 25 % per annum over the next 5 years . In one US study of orthopaedic students and practitioners, 84 % had a smartphone and 53 % of them used their smartphone in clinical practice . Within the UK, 27 % of adults and 47 % of teenagers own a smartphone and approximately 47 % of these adults have downloaded an app according to OFCOM’s Communications 2011 Market Report . Based on current growth, it is estimated that 80–90 % of the UK population will own a smartphone within 10 years .
More than 20 million hernia repair operations are thought to occur worldwide each year  and whilst the range of available apps has been described in a large variety of specialities [4, 8, 9], little is known of the contemporary provision of apps for those living with or working with hernias. In addition to a lack of knowledge about the current field, there are emerging concerns from studies in many other specialities ranging from orthopaedic surgery  to dermatology , regarding the quality of information provided in health-related apps, level of peer-review, confidentiality issues, undeclared commercial interests and authorship of many apps . Misleading information identified in apps may directly be harmful to patients in some cases, such as the variability found between dose calculator apps for opioids . This has led to calls for tighter regulation and peer-review, transparency of authorship and funding and for increased clinical trials to provide evidence for the effectiveness of apps [4, 8, 11].
In this study, we aimed to review the contemporary smartphone apps available in relation to the field of hernias and to describe level of medical professional involvement in their content, any commercial links and customer reviews, in to identify both weaknesses and opportunities for development within this field.
The search was performed on the 24 October 2012. The major smartphone application online stores (Google Play, Apple, Blackberry, Samsung, Windows, Nokia Symbian) were individually explored for applications relating to hernias. The terms used in the search included ‘hernia’, ‘inguinal’ ‘umbilical’, ‘incisional’, ‘femoral’ and ‘totally extraperitoneal’. Apps without implied or explicit reference to hernia or hernia surgery in humans on the overview page were excluded (i.e. brainstem herniation, veterinary hernias).
Data were generated from the overview of the apps content provided by the developer. The data recorded for each app included the category of the application, implied target audience, documentation of medical professional involvement, evidence base reference, ratings, cost, and commercial content. All links to publisher pages were examined to establish authorship, referenced evidence and links to commercial products.
Some apps were found on a number of different smartphone store platforms, or appeared in an almost identical version/format within the same smartphone store. Only one version of the app was taken as representative, even if it appeared on multiple platforms. Data were tabulated and results were calculated using Microsoft Excel 2007 (Microsoft, Redmond, WA, USA).
Educational apps designed for patients
Three apps implied that their content was suited for the education of patients. The ‘CeQoL’ app (Carolinas Equation for Quality of Life), is designed to predict the likely occurrence of post-operative pain 1 year following inguinal hernia repair in males before surgery. The app stated clear medical professional involvement and the mathematical algorithm is based on data from the International Hernia Mesh Registry . There are disclaimers in place stating that questionnaire outcomes should be discussed with a medical practitioner. There was additional general education about hernias. An associated website had links to private hernia repair [14, 15].
The ‘Baby & Kid First Aid and Healthcare’ app was available on multiple platforms and had a free incentivising app with a link to the full priced app. As the multiple versions were almost identical, they were grouped under one app title within this study count. This app was designed as an aid for parents in diagnosing a wide variety of paediatric problems, including recognising the signs of hernia. There was no stated medical professional involvement or disclaimers in the overview content of this app. There were 15-peer reviews spread over the six versions of this app with an average rating of 5 stars out of 5.
The final app in this category was the ‘Hernia Treatment’ app, which provided the bulk of its education via a link to the Wikipedia page on hernias. It also had a link to an Amazon page selling hernia trusses.
Educational apps designed for medical professionals
This represented the largest group of apps in this study [16/26 apps (61.5 %)]. Cost ranged from £0 to £50.46. Of these, ten apps were ‘exam flashcards’ published by one company (Mometrix) aimed at medical professionals sitting examinations. Five of these apps discussed ‘hiatus hernia’.
The remaining six applications in this category are related to operative technique in hernia repair and related anatomy. Of these, two free informative apps were produced by a pharmaceutical and devices company (Ethicon) and were educational apps concerning mesh repair with their product. Overall, named medical professional involvement was rare in this category, occurring in just five of the 16 apps (31 %).
Symptom control apps designed for patients
There were four similar apps available which claimed to provide symptomatic relief from hernias in general. Notably, all were created by the same publisher ‘Vital Acts’. They suggested acupressure points in the feet and hands, and yoga points which would help with discomfort from hernia. There were no disclaimers on the overview page. None of these apps had stated involvement from a named medical professional. These apps appeared in a number of almost identical versions on different platforms. Of the limited peer-reviews (five) which these apps had had, the ratings were 1–1.5 out of 5.
Apps in this category included one personal promotion page, an autobiography by a doctor and one medical recruitment site. The personal promotion site was generated by a surgeon who had created an app which facilitated patients requesting a private consultation.
Cost and commercial aspects
Overall, 25/26 (96 %) of the apps in this study had an advertised commercial interest or outlet. Seven (27 %) of the full applications were free. For applications which required purchase, prices ranged from 60p to £50.46 for an examination textbook. The median cost (taken from the full priced versions where applicable) of all apps was £2. Commercial interests identified included links to other apps requiring a purchase (16 apps; 62 %), cost of app alone (four apps; 15 %), product promotion (two apps; 8 %), link to private surgery (two apps; 8 %) and links to online shops (one app; 4 %).
Of the seven apps that were free to download (27 %), three were aimed at patients. Within this group, two had links to private surgery through a related website and one, as discussed, had a link to buy hernia trusses. Four free apps were aimed at medical professionals, one was a free incentivising app, two were backed by a pharmaceutical company and one was designed to recruit medics to volunteer across the world.
Apps were occasionally reviewed by app users, but only 10 (38 %) of the apps had any customer review noted. There were a total of 47 votes for the ten ‘reviewed’ apps, with just three apps having more than five reviewers (range 1–15). The average rating was 3.31 (range 1–5).
Smartphone applications are increasingly becoming a major point of health-related information provision for clinicians and patients and demand for healthcare-related apps is reflected in the rapid expansion of this market. This review is the first study to specifically investigate the field of hernia smartphone applications. A number of notable findings emerged from this study. First, that the number of hernia apps available is relatively small compared with other reports in alternative specialities, which is surprising given the both the variety of hernia which can develop the chronic nature of the problem and the large number of hernia procedures performed each year.
Second, we found that although hernia apps provide a wide variety of medical information targeted at medical and lay audiences, involvement of medical professionals in their design was infrequently stated. In addition there was a lack of customer review, leaving little information for the average consumer to judge the quality of the app prior to download. Finally, the majority of apps had an obvious commercial interest, which could provide some concerns as to the quality and impartiality of the content.
One of the most notable apps in this field was the CeQoL app . Chronic groin discomfort affects 7–30 % of patients following either laparoscopic or open inguinal hernia repair [16, 17] and is considered to be the leading cause of malpractice suits relating to hernia operations in the UK . The CeQoL app has a user friendly mathematical algorithm based on data from the International Hernia Mesh Registry to predict the likelihood of post-operative pain following inguinal hernia repair in males. Although there are limitations to this app (there was insufficient data for the algorithm to be validated in women, it does not consider either different approaches or different types of hernia, and it remains to be validated prospectively), it provides a good example of the translation of evidence-based research into a clinically relevant and useful medical app solution. There is certainly great scope for similar apps of a high quality to be developed for different types of hernia, disease process and a wider audience.
Just 35 % of the apps in this study had named medical involvement and none had consumer reviews of more than 15 people. Those which are aimed at patients are particularly concerning, as this group is less likely to have the medical training required to reliably discern the quality and reliability of the medical information within an app. The lack of regulation in this field has been highlighted by a number of other authors [4, 8, 10]. In particular, Rosser et al.  highlighted concerns regarding the validity of content of apps concerned with pain management, and this may be a group of apps that hernia patients may also download.
This is the first paper to our knowledge to review commercial interests of healthcare-related apps in a specific field. The rapid growth expected within the app sector , combined with little regulation, raise the risk of financial interests overshadowing impartial content. In our study, 96 % of the apps identified had a clear commercial aim. However, the interpretation of this information is limited by the subjective nature of this study.
There are some limitations to this study. Information gathered from apps was taken from the overview pages, publishers’ websites and in downloading some of the free apps. Apps which required purchase, such as textbooks were not purchased as fully downloading all apps was not feasible for the authors in this unfunded study. Therefore, some information which may not be evident in the overview pages may have been available in the full price version. However, the basic overview information page is usually the only information available to the consumer prior to commitment of purchase or download and this should provide author credentials, content source and peer-review so that consumers are provided with information to support their choice of app.
Healthcare-related smartphone applications are a rapidly expanding market and the opportunities relating to hernia education, diagnosis and research are endless. However, as a point of information for the patient, there are concerns as to the unregulated nature of these apps, the majority of which have clear commercial links.
Conflict of interest
RB has previously published within the field of medical apps and is founder of www.researchactive.com, a company which provides mobile technology health solutions for clients in the public and private health sectors. ADB and BT are owners of a medical app for patients of bariatric surgery.