1. The Internet, HINARI, The Ptolemy Project Global Access to Research Information on Trauma Andrew Howard BA MD MSc FRCSC Associate Professor of Surgery Director, Office of International Surgery University of Toronto Division of Orthopaedics, Hospital for Sick Children

3. 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

4. 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

5. 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

6. HINARI

10. HINARI Outcomes Major Journals On-Side Millions of Downloads 3000 Institutions Not always reaching users

11. 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

12. 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

13. 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

14. 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

15. 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

16. Results - Actual Journals 2047 distinct journal titles were accessed 40,457 Full Text Downloads 50% of access is to 26 highest use journals 50% is to remaining 2021 journals 75% 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.

17. Internet ‘Long Tail’ 50% in top 26 journals 50% in remaining 2021 journals Need the whole library!!!

18. Number of Articles from Identifiable* Journals

19. 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 sequence Research is present eg epidemiology, methods, reviews

20. 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

21. 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

22. 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

23. Earlier Entrant than PLoS Hundreds of clinical and scientific journals Many have small readership ? Economic Model

24. 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

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

26. Research Question Is the Global Burden of Disease due to Trauma properly represented in Orthopaedic and General Medical Journals?

27. 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

28. 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.

29. Results - Journals 2005 and 2006 2677 articles from the four orthopedic journals 3937 articles from the three medical journals.

30. Predominance of Musculoskeletal Conditions

31. Results - Morbidity:

32. Results - Mortality

33. Results - Prevention or Treatment ?

34. 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

36. 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.

37. 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