The Internet, HINARI, The Ptolemy Project

Global Access to Research Information on Trauma

Andrew Howard BA MD MSc FRCSCAssociate Professor of Surgery

Director, Office of International SurgeryUniversity of Toronto

Division of Orthopaedics, Hospital for Sick Children

Overview

• Part 1 - Global Access to Journals– Access improving

• HINARI, Ptolemy, Open Access

• Part 2 - Global Relevance of Journals– Musculoskeletal Trauma vastly underrepresented in

Journals– Prevention ignored in orthopaedic journals

• Part 3 - Action Plan– Support access– Research and publish on prevention and treatment

relevant to low income countries

Access to Journals

• To 1990 - Paper product, from medical publishing houses to personal/institutional libraries

• 1990 Onward - Internet based access eventually taking over

• Many models for electronic subscriptions– With paper journal– Institutional (University, Medical Society)– Pay per Use

• None of these helps low income countries

Low Income Country Access

• HINARI– WHO Initiative, Institutional Libraries

• Ptolemy– University of Toronto Initiative, Individual Access

• ‘Open Access’ Journals– New Publishing Model (Pay to publish, free to

read)– PLoS Medicine, Biomed Central

HINARI

HINARI Outcomes

• Major Journals On-Side

• Millions of Downloads

• 3000 Institutions

• Not always reaching users

Ptolemy Project College of Surgeons of East, Central, and Southern Africa

(COSECSA)

University of Toronto

Andrew Howard, Massey Beveridge, Brian Ostrow, Pankaj Jani www.ptolemy.ca

Ptolemy.info@utoronto.ca

The Ptolemy Project

Cooperative COSECSA and University of Toronto project since 2003

Provides full text access to 44,000 journals and 146,000 textbooks

Free of charge to surgeons in East Africa

Free training, African trainers

Reading course ‘Surgery in Africa’ online

Purpose of Project

• Provide world medical literature directly to the surgeon to enhance– Clinical care– Teaching– Research

• Negotiated for any country below 65 on WHO human development index

Evaluation of Project

• Log files of web accesses maintained by the University of Toronto Library

• Participant consent• Record:

– Time of access– Country of access– Material used

• Anonymous, aggregated data only

Results – Total use

• October 2007: 209 users• 250 to 300 web sessions / month where full

text articles are read or downloaded. • Another 111 users trained November and

December 2007• The Surgery in Africa Review Course 2700

visitors per month, 300 visits to top reviews

Results - Actual Journals

2047 distinct journal titles were accessed40,457 Full Text Downloads50% of access is to 26 highest use journals50% is to remaining 2021 journals75% of all users used at least some of the top twenty

journals. Popularity of access via Ptolemy bore no relation to the

published impact factors of the journals. The list of journals people actually read is far broader

than the list generated from a previous self report user survey.

Internet ‘Long Tail’

• 50% in top 26 journals

• 50% in remaining 2021 journals

• Need the whole library!!!

Current Orthopaedics 1099Survey of Ophthalmology 754The American Journal of Surgery 610British Journal of Plastic Surgery 584Burns 550Cornea 536Surgical Endoscopy 517Current Opinion in Ophthalmology 511American Journal of Ophthalmology 509British Journal of Surgery 488Veterinary Parasitology 427Operative Techniques in General Surgery 426Journal of the American College of Surgeons 413Journal of Pediatric Surgery 400World Journal of Surgery 376Current Problems in Surgery 312Journal of American Association for Pediatric Ophthalmology and Strabismus 305Journal of AAPOS 291Surgery 289The Lancet 285Pediatric Surgery International 263Retina 256

Clinical Orthopaedics & Related Research 42

Journal of Bone & Joint Surgery - American Volume 43

Number of Articles from Identifiable* Journals

Results – Titles of Papers

Clinical care for acute surgical problems is the most popular reason for consulting Ptolemy

eg acute abdomen, compartment syndrome, trauma management, specific fractures

Education is next most popular. eg ‘surgical clinics’ and ‘orthopaedic clinics’

journals read in sequenceResearch is present

eg epidemiology, methods, reviews

Summary of Ptolemy

• Those who use Ptolemy, use it a lot

• Many registered users do not access– Difficulties (logging on, finding journals)– Preferred sources of information– Time for education and research– The ‘academic cycle’– Knowledge translation

Open Access Publishing

• All Open Access:– PLoS (Public Library of Science)– BMC (Biomed Central)

• Delayed Open Access– Commercial journals– 6 months or 12 months– Depends on title and changes frequently

• Public Library of Science• Pay $2750 to publish• Seven scientific and clinical journals• Flagship PLoS Medicine has an impact factor

of 15• Intent: Government Funded Research to fund

publication costs, free access to results• NIH and HHMI committed to pay author fees

• Earlier Entrant than PLoS

• Hundreds of clinical and scientific journals

• Many have small readership

• ? Economic Model

PubMed Central

• Free full text archive of journals providing content usually with 6 to 12 months delay

• 367 journals listed, 220 open access (with delay), 7 partial access, 140 no access

• Misses the biggest key clinical journals• Majority of Open Access is BMC and PLoS

But, Is The Medical Literature Relevant to the Real World of Trauma ?

Research Question

• Is the Global Burden of Disease due to Trauma properly represented in Orthopaedic and General Medical Journals?

Method - Global Burden of Disease (2003-2020)

• Group I (Communicable diseases) – Musculoskeletal infection

• Group II (noncommunicable diseases)– Congenital anomalies

• Down syndrome• Spina bifida

– Musculoskeletal diseases• Rheumatoid arthritis• Osteoarthritis• Osteoporosis and low trauma

fractures• Gout • Low back pain

• Group III (Injuries)– Unintentional injuries

• Road traffic accidents• Falls

– Intentional injuries• Self-inflicted injuries• Violence• War

Methods - Journals

• Clinical Orthopedics and Related Research, Journal of Bone and Joint Surgery, A and B, Journal of Pediatric Orthopedics,

• British Medical Journal, Journal of American Medical Association and The Lancet.

• January 2005 to December 2006. • Original clinical and basic science research papers,

editorials, symposia review articles as well as those in supplement issues were included.

Results - Journals

• 2005 and 2006

• 2677 articles from the four orthopedic journals

• 3937 articles from the three medical journals.

0%10%20%30%40%50%60%70%80%90%

100%

GBD GMJ OJ

Non MSK

MSK

Predominance of Musculoskeletal Conditions

Results - Morbidity:

0%10%20%30%40%50%60%70%80%90%

100%

GBD GMJ OJ

Injuries

NoncommunicablediseasesInfectious disease

Results - Mortality

0

20

40

60

80

100

GBD GMJ OJ

Injuries

NoncommunicablediseasesInfectious diseases

Results - Prevention or Treatment ?

0%

20%

40%

60%

80%

100%

GMJ OJ

Injury treatmentInjury prevention

Discussion

• Injury accounts for the vast bulk of musculoskeletal morbidity and mortality

• General medical journals underrepresent MSK, but concentrate on injury especially prevention

• Orthopaedic journals underrepresent injury; and almost totally ignore prevention

Premise(s)

• Access to relevant information is the sine qua non of solving a problem.

• If you can’t measure it, you can’t control it.

• You are what you read.

Overview

• Part 1 - Global Access to Journals– Access improving

• HINARI, Ptolemy, Open Access

• Part 2 - Global Relevance of Journals– Musculoskeletal Trauma vastly underrepresented in

Journals– Prevention ignored in orthopaedic journals

• Part 3 - Action Plan– Support open access– Research and publish on prevention and treatment relevant

to low income countries