“Am I Having A Stroke?” Connecting Physicians With Online Information Seekers To Prevent Disease

Five questions with UCSF neurologist and stroke researcher Anthony Kim about his latest study that explores how the Internet can potentially help to reach people who are searching for information online and reduce the number of preventable disease incidences.

Anthony S. Kim, MD, MAS, is assistant clinical professor of neurology at the University of California, San Francisco (UCSF) and Medical Director of the UCSF Stroke Center. His research focuses on improving the diagnosis and cost-effective management of stroke and transient ischemic attack (TIA, also called “mini-stroke”). 

 An estimated 800,000 new strokes occur each year in the U.S., making it the fourth leading cause of death in America. Anthony Kim believes that the Internet opens up new opportunities that will change the way we develop interventions and conduct research to improve health. 

Q: Millions of Americans search online for health information each year. Scientists are using this type of data to better understand flu outbreaks, the seasonal variance of kidney stones, the demographic prevalence of stroke, and even to demonstrate the online effectiveness of health awareness campaigns. What did you learn in your latest study?

We were surprised to see that tens of thousands of people were regularly ‘asking’ a search engine about stroke-related symptoms in many cases shortly after the onset of symptoms. In fact, every month, about 100 people were finding our study website by entering the query: “Am I having a stroke?” directly into their Google search box.

One of the challenges with mini-stroke is that most people do not seek urgent medical attention because the symptoms are transitory by definition. So people don’t realize that it is a medical emergency. Even though the symptoms may have resolved, the risk of a subsequent stroke is very high—upwards of 11% within the next 90 days—with most of this risk concentrated in the first hours and days after the mini-stroke. So getting the message out there about urgent medical attention is key.

We started this study because we thought that if people who have had a mini-stroke are looking online for information on their symptoms, then rather than just listing static health information about the disease on a website, maybe we can engage them by making the website more interactive and asking them to enter some of their symptoms online. And we wondered whether we could use this information to assess whether or not it was a true TIA or stroke and then encourage them to get the urgent medical as appropriate.

One third of the people we identified hadn’t had a medical evaluation for mini-stroke yet, which is critical, because it is a medical emergency. Instead of calling a doctor or going to the emergency room, many people were turning to the Internet as the first source for health information.

Q: How did your approach work exactly?

When a person searched on Google for stroke-related keywords, a paid text advertisement “Possible Mini-Stroke/TIA?” appeared with a link to the study website (Image). The ad appeared on the search results page and on related websites with existing content about the topic.

When users clicked on the text ad link, they were directed to the study website. Those visitors who met all of the study’s entry criteria were asked to provide informed consent online. They then reported their demographic information and symptoms based on a risk score developed for use by clinicians.

We were notified in real-time as soon as someone enrolled, and then we arranged for two vascular neurologists to follow up with the patient by telephone.

Q: You tested the approach for about four months. What’s your verdict?

We definitely think that there is a lot of potential here. About 60% of U.S. adults say that their real-life medical decisions have been influenced by information they read online. This changes the way we think about providing medical care and conducting research.

With a modest advertising budget, we were able to attract more than 200 people to our study website each day from all 50 states. About one percent of them (251 out of 25,000) completed the online questionnaire, which allowed us to contact them for follow up. Although this seems low at first, it is comparable to conversion rates in other domains of online advertising.

Also, even though the people who joined the study were a highly selected group, the incremental costs for reaching an additional person were low and the potential for applying a targeted and cost-effective public health intervention in this group would still be very interesting to evaluate in the future.

Before we started, we thought that we might lose people throughout the enrollment process since we confirmed eligibility and asked for consent online, but we didn’t. For the most part, if people were interested in participating, they completed the entire online enrollment process.

During follow up calls, we learned that 38% of enrollees actually had a mini-stroke or stroke. But fully a third of them had not seen a doctor yet. Our approach made it possible to connect with these people fairly efficiently and early on in order to influence their behavior acutely.

Despite these potential advantages, Internet-based public health interventions that target people who are looking for health information online are still underdeveloped and understudied. There’s a lot for us to learn in this space.

Q: What online tools did you use to carry out your project?

We used Google AdWords and Google’s Display Network to target English-speaking adults in the U.S. During the four-month enrollment period, the tool automatically displayed our ads more than 4.5 million times based on criteria such as location, demographics, and search terms.

Ideally, to minimize ongoing costs you would want to build and optimize a website so that it ranks highly among the non-paid (organic) search results. Non-profits can also take advantage of Google Grants, a program that supports in-kind donations of advertising resources to help selected organizations promote their websites on Google.

Q: Do you have any tips for others who want to develop similar projects?

We quickly realized that it helped to work closely with our Institutional Review Board (IRB) given that this is a new and evolving area of research, and to ensure data security and safety mechanisms are in place to protect participants. I definitely recommend that.

It’s also important to be realistic about the goals and metrics of success, and not to over-interpret numbers that seem to reflect low engagement. We saw that most visitors (86%) immediately exited the website within a few seconds of arriving at the home page. This probably reflected people who were looking for something else and clicked away immediately. But the beauty of the Internet is that it is very efficient to reach people across a wide geographic area very quickly. So it is not unexpected that we would also screen visitors who may not be qualified for the study or are not interested in enrolling.

Groups interested in using this approach should think about selection bias, authentication, validation, and the “digital divide”. Even though there is some evidence that disparities in access and adoption of Internet technologies are narrowing in the U.S., depending on the goals and target for your study or intervention the reach of the Internet is not uniform.

But selection bias issues aside, for a public health intervention you may be most interested in other metrics such as the number of people reached per dollar spent, or the burden of disease averted per dollar spent, which the Internet is particularly suited to help optimize.

And, it’s definitely beneficial to bring different subject matter and methods experts to the table. Knowledge of search engine optimization, online accessibility, website and user interface design is not necessarily part of the core expertise of a traditional clinical researcher, but developing these skills and interacting with experts in these areas could become very important for the new cadre of clinical researchers and public health professionals coming down the pipeline.

The original article was posted on the website of the Clinical and Translational Science Institute (CTSI) at UCSF.

Awareness Campaigns Drive More People To Search For Health Information Online

October is National Breast Cancer Awareness Month. If you’re wondering whether health awareness campaigns are worth your time and should be considered for your editorial planning, take a look at this study in the journal BMC Cancer Journal. It shows that “the annual breast cancer awareness campaign is proving effective in stimulating online activity” and increasing the searches about breast cancer.

Ronan Glynn from the National University of Ireland Galway and colleagues looked at six years of search trend data collected by Google Trends. They found that in August the search traffic for terms about breast cancer begins to rise. They peak in October and begin to decrease to normal levels in November/December.

In times where 80% of internet users, or 59% of U.S. adults, look online for health information these results may not seem surprising. However, the team did not see the same effect associated with lung and prostate cancer. The authors discuss a few likely explanations:

• Breast cancer has been repeatedly shown to receive more attention than any other malignancy in both the print and television media.
• Breast cancer (number affected United States 2006, 2,605,000) has a greater prevalence than either prostate ( 2,320,000) or lung cancer (426,000).
• American women have been shown to overestimate their breast cancer risk, and thus may have a lower threshold for searching out information and advice on breast cancer.

It is not possible to say what groups are responsible for the search activity on Google (i.e. advocates, patients, health professionals, etc.) and whether those people necessarily show an increased awareness of breast cancer or health seeking behavior offline.

Nonetheless, this study provides a new perspective and is interesting to groups beyond the medical field.

“From Twitter To Tenure”: MD Shares How Twitter Can Be A Valuable Tool For Academics

There is still considerable resistance to embracing social media tools for academic purposes, but if you are reading this blog post on FutureDocs by Vineet Arora, MD,  you are probably willing to consider their positive effects.

Credit: Jason Archer, http://www.academictechnology.org

Vineet shares the various ways social media has impacted her academic career including finding grant opportunities, disseminating research results, and being found as an expert for media interviews and lectures. Here is her list:

Media interviews – I was interviewed by Dr Pauline Chen through the New York Times who located me through – you guessed it Twitter!  She actually approached me for the interview by direct messaging me through Twitter.  She was following me and noticed my interests in handoffs on my Google profile which is linked to my Twitter account.  She was also very encouraging when I started the blog which was exciting!

Workshop presentations– I presented a workshop on social media in medical education (#SMIME as we like to call it), at 2 major medical meetings with 3 others (including @MotherInMed who encouraged me to start a blog and also is my copresenter at SGIM).  The idea was borne on Twitter…and the first time I actually met one of the workshop presenters (who I knew on Twitter) was at the workshop.

Acquired new skills  – My workshop co-presenter who I only knew through Twitter ended up being Carrie Saarinen, an instructional technologist (a very cool job and every school needs one!).  She is an amazing resource and taught me how to do a wiki.  After my period of ‘lurking’, I started my own ‘course’ wiki  dedicated to helping students do research and scholarly work which we are launching in a week.

Lecture invitations – Several of my lecture invitations come through social media.  Most notably, I was invited to speak for an AMSA webinar on handoffs and also speak to the Committee of Interns and Residents on teaching trainees about cost conscious medicine.  Both invitations started with a reference to finding me through Twitter or the blog.

Committee invitations – I am now on the SGIM communications task force as a result of my interest in social media.  Our most recent effort was a piece about ‘tweeting the meeting’ with @medrants and an older piece focused on the top Twitter Myths and Tips.

Grant opportunities – I recently submitted a grant with an organization that I learned of on Twitter – Initially, I had contacted Neel Shah from Costs of Care asking him if they had a curriculum on healthcare costs.  They did not, but were interested in writing a grant to develop a curriculum so they brought my team on board and we submitted together (fingers crossed).

Dissemination – One of the defining features of scholarship (the currency of promotion in academic medical centers) is that it has to be shared.   Well, social media is one of the most powerful ways to share information.   In a recent example, we entered a social media contest media video contest on the media sharing site Slideshare.  Using social media, we were able to obtain the most number of ‘shares’ on Facebook on Twitter which led to the most number of views and ultimately won ‘Best Professional Video.’  To date, this video, has received over 13,000 views, which I was able to highlight as a form of ‘dissemination’ in a recent meeting with our Chairman about medical education scholarship.    While digital scholarship is still under investigation with vocal critics and enthusiastic proponents debating the value of digital scholarship in academia, digital scholarship does appear to have a place for spreading nontraditional media that cannot be shared via peer review.

Further reading:

• Guide to using Twitter in university research, teaching, and impact activities

The original post was published on BioMed2.0 blog