- Email: [email protected]
Readability of Patient Education Materials From the Web Sites of Orthopedic Implant Manufacturers
Accepted Manuscript Readability of Patient Education Materials From the Websites of Orthopaedic Implant Manufacturers Meghan M. Yi, BA, Paul H. Yi, MD, Khalil I. Hussein, MD, Michael B. Cross, MD, Craig J. Della Valle, MD PII:
S0883-5403(17)30586-7
DOI:
10.1016/j.arth.2017.07.003
Reference:
YARTH 55983
To appear in:
The Journal of Arthroplasty
Received Date: 27 December 2016 Revised Date:
29 June 2017
Accepted Date: 3 July 2017
Please cite this article as: Yi MM, Yi PH, Hussein KI, Cross MB, Della Valle CJ, Readability of Patient Education Materials From the Websites of Orthopaedic Implant Manufacturers, The Journal of Arthroplasty (2017), doi: 10.1016/j.arth.2017.07.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Readability of Patient Education Materials From the Websites of Orthopaedic Implant Manufacturers
Della Valle, MD5*
2
Albany Medical College, Albany, NY
The Johns Hopkins Hospital, Baltimore, MD
4
Greenwich Hospital, Greenwich, CT
M AN U
3
Hospital for Special Surgery, New York, NY
Rush University Medical Center, Chicago, IL
TE D
5
SC
1
RI PT
Meghan M Yi, BA,1 Paul H Yi, MD,2 Khalil I Hussein, MD,3 Michael B Cross, MD,4 Craig J
*Address correspondence to:
EP
Craig J. Della Valle, MD
Rush University Medical Center
AC C
1611 West Harrison Street Suite 300
Chicago, IL 60612, USA
email: [email protected]
ACCEPTED MANUSCRIPT 1
Readability of Patient Education Materials From the Websites of Orthopaedic Implant
2
Manufacturers
AC C
EP
TE D
M AN U
SC
RI PT
1
ACCEPTED MANUSCRIPT 2
Abstract
4
Background
5
Prior studies indicate that orthopaedic patient education materials are written at a level that is too
6
high for the average patient. The purpose of this study was to assess the readability of online
7
patient education materials provided by orthopaedic implant manufacturers.
RI PT
3
8
Methods
SC
9
All patient education articles available in 2013 from the websites of the five largest orthopaedic
11
implant manufacturers were identified. Each article was evaluated with the Flesch-Kincaid (FK)
12
readability test. The number of articles with readability ≤ the 8th grade level (average reading
13
ability of US adults) and the 6th grade level (recommended level for patient education materials)
14
were determined. Mean readability levels of each company’s articles were compared using
15
ANOVA (significance set at p < 0.05).
16
Results
17
581 Articles were reviewed from the five largest implant manufacturers. The mean overall FK
18
grade level was 10.9 (range, 3.8-16.1). Only 58 articles (10%) were written ≤ the 8th grade level,
19
and only 13 (2.2%) were ≤ the 6th grade level. The mean FK grade level was significantly
20
different amongst groups (Smith-Newphew = 12.0, Stryker =11.6, Biomet = 11.3, Depuy =10.6,
21
Zimmer =10.1;; p < 0.0001).
23
TE D
EP
AC C
22
M AN U
10
Conclusions
ACCEPTED MANUSCRIPT 3
The majority of patient education materials from implant manufacturers are written at a level too
25
high to be comprehended by the average patient. Future efforts should be made to improve the
26
readability of orthopaedic patient education materials.
27 28
Keywords: Patient Education, Readability, Internet
AC C
EP
TE D
M AN U
SC
29
RI PT
24
ACCEPTED MANUSCRIPT 4
Introduction
31
The Internet has become an increasingly popular source of orthopaedic patient educational
32
materials in recent years.1–3 As patients seek to educate themselves about their orthopaedic
33
conditions by looking to the Internet, a growing awareness and evaluation of such online patient
34
educational materials has emerged in the literature.4–8 Despite the increasing accessibility of
35
online orthopaedic patient educational materials, the health information patients find on the
36
Internet have been shown to be of variable quality with materials that are difficult to read or
37
which may be misleading, trends that have been observed throughout the various subspecialties
38
of orthopaedic surgery.6,8–14
M AN U
SC
RI PT
30
Readability is the reading comprehension grade level a person must possess in order to
40
read and understand a given written text.6,9–11,15–19 While the average adult in the United States
41
can read at an eighth grade level, the National Institutes of Health20 and American Medical
42
Association21 recommend that health education material be written at a sixth grade level or
43
below to help facilitate comprehension due to the complicated nature of medical information.
44
Prior studies of orthopedic patient educational materials, however, have indicated that patient
45
education materials from the American Academy of Orthopaedic Surgeons (AAOS) and other
46
sources intended for patient use are written at a level that is too high for the average patient and
47
have overwhelmingly failed to meet these recommended reading level guidelines.4,6,9–11,15–18,22–27
EP
AC C
48
TE D
39
Although the readability of patient educational materials of the American Academy of
49
Orthopaedic Surgeons (AAOS) and the majority of the orthopaedic subspecialty societies has
50
been previously assessed4,9,10,15–18,22–25, no study has assessed patient educational materials
51
provided by the orthopaedic industry. The purpose of this study was to assess the readability of
52
online patient education materials provided by the five largest orthopaedic implant
ACCEPTED MANUSCRIPT 5
53
manufacturers.
54
Methods
56
We identified all articles available in 2013 from the online patient education libraries of the five
57
largest orthopaedic implant manufacturers (Biomet28, Depuy29, Smith-Nephew30, Stryker31,
58
Zimmer32). Articles that contained only figures and tables without text, patient testimonies,
59
product advertisements, and other like material that were not intended as patient education
60
material were excluded, as previously described.10,15,22
SC
The full text was extracted from each unique article and follow-up editing was performed
M AN U
61
RI PT
55
to prevent errors in readability analysis as previously described10,15,22. This editing included
63
omitting figures, tables, headers, and bullets, in addition to text unrelated to patient education,
64
such as HTML tags, navigation links, copyright notices, disclaimers, and author information. In
65
addition, in order to avoid the underestimation of readability difficulty, we removed headings of
66
lists and paragraphs, paragraph breaks, dashes, abbreviations, numbers, decimals, colons,
67
semicolons, parentheses, and slashes. For lists with complete sentences, the full sentences with
68
their written punctuation were maintained.10,15,22
EP
TE D
62
One observer then assessed each article with the Flesch-Kincaid readability test, which
70
evaluates the readability and comprehensibility of written text.15,23 The Flesch-Kincaid test has
71
been extensively used previously to evaluate the readability of orthopaedic and non-orthopaedic
72
patient education materials.6,9–11,15–18,22–27 The Flesch-Kincaid grade level assessment is included
73
in the Microsoft Office Word software and was enabled by clicking on the “Spelling and
74
Grammar” button, clicking “Options,” and then enabling the “Show readability statistics” option.
75
The program generates and presents the readability score after the user uses the “Spelling and
AC C
69
ACCEPTED MANUSCRIPT 6
Grammar” tool to review the document. This test considers all words and sentences in the given
77
text, and ascribes a grade level corresponding to the text’s difficulty level using the following
78
formula: (0.39 x total words per total sentences) + (11.8 x total syllables per total words) – 15.59.
79
A lower grade level score represents a more readable text, while a higher grade level score
80
represents a less readable text. For example, an article with a Flesch-Kincaid grade level score of
81
5, which indicates that a person who can fully read and understand the text must have the reading
82
level of a fifth grader or higher, is less difficult to read than an article with a Flesch-Kincaid
83
grade level score of 12, which indicates that the reading level of a person who can fully read and
84
understand the text must have the reading level of a high school graduate. A grade level of 13 to
85
15 represents a college-level education and a grade of greater than 16 represents a postgraduate-
86
level education.22,33
M AN U
SC
RI PT
76
87
Statistical analysis
89
The number of articles with readability less than or equal to the 8th grade level (average reading
90
ability of US adults) and the 6th grade reading level (recommended level for patient education
91
materials) were determined. Mean readability levels of each company’s articles were compared
92
using analysis of variance and t-tests, as appropriate (significance set at p < 0.05), as well as
93
between article topics (for example, articles addressing procedures/treatments versus those
94
addressing conditions/diseases). Intraobserver and interrater reliability of FK grade calculation
95
were determined by use of intraclass correlation coefficients; intraobserver reliability was
96
determined by having the same observer who calculated the FK scores calculate the scores of 15
97
randomly chosen articles a second time 1 week after the initial calculations, while interobserver
AC C
EP
TE D
88
ACCEPTED MANUSCRIPT 7
98
reliability was determined by having a second observer evaluating 30 randomly chosen
99
articles.10,22
100
Results
102
581 unique articles were reviewed from the five largest orthopaedic implant manufacturers in the
103
U.S.28–32 Of these, 296 (50.9%) addressed specific treatments or procedures while 285 (49.1%)
104
addressed conditions or disease. By extremity/body part, there were 163 articles (28%)
105
addressing the knee, 97 addressing the hip (16.7%), 10 addressing both the hip and knee (1.7%),
106
106 addressing the spine (18.2%), 85 addressing the shoulder (14.6%), 25 addressing the elbow
107
(4.3%), 11 addressing the hand and wrist (1.9%), 14 addressing the foot and ankle (2.4%), and
108
70 articles (12%) addressing multiple body parts (other than hip and knee) or orthopaedic
109
conditions, in general. Article distribution by specialty was as follows: 143 hip and knee
110
arthroplasty (24.6%), 98 sports hip and knee (16.9%), 106 spine (18.2%), 105 shoulder/elbow
111
(18.1%), 33 trauma (5.7%), 14 foot and ankle (2.4%), 11 hand and wrist (1.9%), and 71 general
112
orthopaedics and bone health (12.2%).
SC
M AN U
TE D
For all five companies’ articles, the overall mean Flesch-Kincaid grade level was 11.3
EP
113
RI PT
101
(range, 3.8-15.1; Table 1). This includes three companies (Depuy, Zimmer, and Biomet) with at
115
least one article written at the 8th grade and/or 6th grade level and two companies (Smith-Nephew
116
and Stryker) that had no articles written at either a 6th or 8th grade level on their websites.
117
Interestingly, articles that addressed orthopaedic conditions or diseases had lower average
118
readability levels than those that addressed specific treatments or procedures (10.5 vs. 11.2;
119
p=0.0004). There was no significant difference in readability levels between body
120
parts/extremities or between specialties.
AC C
114
ACCEPTED MANUSCRIPT 8
Out of all 581 articles evaluated from these five companies, only 13 articles (2.2%) were
122
written at a 6th grade level or below and only 56 articles (9.6%) were written at an 8th grade level
123
or below. In other words, 90.4 % of all articles were written at or above the national average 8th
124
grade reading level, while 97.8% of all articles were written at or above the recommended 6th
125
grade reading level. Thus, the majority of all articles analyzed from all five companies failed to
126
meet the 6th grade reading level standard.
The mean Flesch-Kincaid grade level was significantly different amongst the different
SC
127
RI PT
121
companies (Smith-Newphew = 12.0, Stryker =11.6, Biomet = 11.3, Depuy =10.6, Zimmer
129
=10.1; p < 0.0001)). Zimmer’s website had the greatest percentage of articles at or below the 8th
130
grade (21.1%) and 6th grade levels (12.6%), while two companies (Smith-Nephew and Stryker)
131
failed to provide any articles at the same grade levels. Intraobserver and interobserver reliability
132
of FK grade assessment were excellent (ICC of 0.996 and 0.9998, respectively).
M AN U
128
134 135
Discussion
TE D
133
Prior studies have shown that patients view online health literature as too confusing and overwhelming because of the breadth and content of health education websites.34 Most adults
137
read at an 8th grade level, but the American Medical Association21, the National Institutes of
138
Health20, and other health organizations recommend that patient education material be written at
139
less than a sixth grade reading level. Despite this recommendation, most, if not all, studies
140
focusing on the readability of patient education materials have demonstrated that the readability
141
of such resources is too high.4,6,9–11,15,16,18,22–24,26,27 Low health literacy has been associated with
142
poor health outcomes, more frequent and longer hospitalizations, more complications,
143
noncompliance, and increased healthcare costs. 9,37–39 The readability of patient education
AC C
EP
136
ACCEPTED MANUSCRIPT 9
materials from the American Academy of Orthopaedic Surgeons, American Orthopaedic Foot
145
and Ankle Society, Arthroscopy Association of North America, individual physicians, and many
146
other websites have been observed4,6,9–11,15,16,22,24,26, but no studies have focused on the websites
147
of the five biggest orthopaedic implant manufacturers in the U.S.: Biomet, Depuy, Smith-
148
Nephew, Stryker, and Zimmer.
RI PT
144
As a whole, the websites of the five largest orthopaedic companies in the U.S. may be too
150
sophisticated or wordy for the average patient to understand. In this study, we found that only 13
151
articles or 2.2% of all 581 articles analyzed measured up to the 6th grade recommended
152
guideline. When comparing the readability of these implant companies’ education materials to
153
that of other patient education materials in orthopaedics and other specialties, these resources
154
unfortunately continue the trend of high readability levels. 6,9, 10,15 It could be argued that in order
155
for a patient to initiate an Internet search of orthopaedic implant companies’ websites and
156
subsequently locate relevant patient education materials, he or she must have an above-average
157
level of health literacy, raising the possibility that these patient education materials could be
158
appropriately written for this self-motivated, potentially more-educated, population of patients.
159
However, it is difficult to assess the precise reading level of visitors to these websites.
M AN U
TE D
EP
160
SC
149
Still, noteworthy nuances exist among the articles of the five orthopaedic implant companies. Compared to the websites of the other four companies, Zimmer’s website had the
162
highest percentage of articles written at or below both the recommended 6th and 8th grade levels
163
(10% and 20%, respectively). Thus, Zimmer’s patient education materials appear to be the
164
easiest to read. Despite being the most easily readable, the average reading level of Zimmer’s
165
website was still 10.1, indicating that the average patient might still have difficulty
166
understanding the majority of its articles. On the other end of the spectrum, Smith-Nephew and
AC C
161
ACCEPTED MANUSCRIPT 10
167
Stryker’s websites seem to be the least reader-friendly of the five companies’ studied. In fact,
168
neither of these websites had any articles written at or below either the 6th or 8th grade levels and
169
their average, minimum, and maximum scores were among the highest of all five groups. Despite the high average readability level of these articles provided by implant
171
manufacturers, there is hope for the future of improving readability levels of patient education
172
materials. The fact that there were some articles that were written at an acceptable reading level
173
are proof that producing patient education materials at the recommended guidelines is feasible.
174
The first study of the readability of orthopaedic patient education materials 9 in 2008 concluded
175
that, in general, the orthopaedic community was unaware of the discrepancy between the
176
readability levels of patient education material and the average reading level of patients.
177
However, the results of numerous follow-up studies have suggest there is now a burgeoning
178
awareness and legitimate consideration of the issue. 4,6,9–11,15,16,22,24,26 Despite these efforts, there
179
are still major gaps between the readability of patient education materials and the average
180
patient’s reading level and much work remains. By continuing to evaluate and improve the
181
readability of online patient education materials, orthopaedic providers and companies will
182
improve the likelihood that patients will comprehend the educational materials provided, which
183
could potentially have a positive impact on their healthcare outcomes. 9,37–39
SC
M AN U
TE D
EP
Previous studies and literature on readability have suggested different methods of
AC C
184
RI PT
170
185
improving readability.10,22 Above all, considering the reading skills of the target population is
186
essential when preparing patient education materials, as is considering the reader’s point-of-
187
view. Replacing complex medical terms and jargon with simpler words (e.g., substituting the
188
commonly understood and one syllable word “scope” for the four syllable medical jargon
189
“arthroscopy”) and simplifying sentences to be more succinct and easier to understand are some
ACCEPTED MANUSCRIPT 11
techniques that may improve the readability of patient education materials. In addition, simpler
191
formatting of text and the inclusion of diagrams, charts, graphs, illustrations, and other non-
192
textual figures, may also help to decrease the written grade level of websites. 9,33,36 Finally,
193
screening education materials and revising them to meet readability guidelines before making
194
them available for patient use may also help improve readability.
195
RI PT
190
The results of this study should be viewed in light of several limitations. The FK
readability test, as previously described, has several inherent flaws, including its primary
197
consideration of the number of syllables per word and words per sentence, as well as its lack of
198
consideration of illustrations, and charts of patient education materials that may play a vital role
199
in improving the reader’s understanding of the website. In fact, these non-textual elements,
200
which may substantially enhance patients’ ability to understand complex medical information,
201
have even been considered a fundamental aspect of the overall understandability (but not
202
technically of the readability) of patient educational materials.1 Other readability assessments,
203
such as the Suitability Assessment of Materials which takes pictures, diagrams, and written text
204
into account, exist that improve upon the FK test’s weaknesses. However, this test, in particular
205
is relatively new, has not been as extensively validated as other assessments have been, is more
206
time consuming, and has been described as “inherently subjective.5,21” Thus, at this time, such
207
an analysis may not be practical or particularly helpful in understanding the readability of patient
208
education materials. The low cost, easy accessibility, and well-established use of the FK
209
readability test, which has also been shown to correlate well with other readability formulas, 22
210
may thus be the most logical analysis to evaluate readability at this time. Another limitation of
211
this study is that we only examined five orthopaedic companies’ websites; our results cannot be
212
extrapolated to the entire scope of patient education materials from all orthopaedic companies’
AC C
EP
TE D
M AN U
SC
196
ACCEPTED MANUSCRIPT 12
online patient education materials. However, because we did study the websites of the five
214
largest orthopaedic companies in the U.S., it is probable that these materials are more likely to be
215
found by patients themselves or recommended by orthopaedic surgeons to patients looking for
216
more information on orthopaedic procedures. Finally, only articles written in English were
217
included in this study, which excludes the articles that may be read by the large population of
218
Spanish-speakers who may also be seeking information on these manufacturers’ websites. As it
219
turns out, the readability of online health education materials written in Spanish has been studied,
220
although the websites of implant manufacturers have not been a specific area of focus.18
SC
Finally, it is important to acknowledge that written patient education materials, whether
M AN U
221
RI PT
213
in the form of a physical copy or on the Internet, play only a small role in a patient’s health care
223
decision making and granting their informed consent. In 1999, Braddock found that only 1.5% of
224
patients were assessed for their understanding after giving informed consent for interventions,
225
including various orthopaedic surgeries.41 Theoretically, easy to understand and patient-friendly
226
written materials will aid in patients’ decision making, especially in light of the fact that much
227
information discussed between the patient and doctor may be lost the moment patients leave the
228
office. However, because 9 out of 10 adults do not have proficient health literacy according to
229
the National Assessment of Adult Literacy 40 and it is highly likely that patients may hide their
230
illiteracy, and accept printed materials they cannot comprehend to an optimal capacity, there is
231
danger in relying heavily on published patient education materials to guide patients in making
232
informed decisions about their health. Creating patient education materials written at the
233
appropriate reading level is only a single element of the solution in the grand scheme of the
234
conundrum of improving patient understanding of their medical conditions and health.
AC C
EP
TE D
222
235 236
Conclusions
ACCEPTED MANUSCRIPT 13
The Internet has become an increasingly popular resource for health information. Patients may
238
turn to the websites of orthopaedic implant companies for more information about their
239
orthopaedic procedures, but our study suggests that most of its documents may be written at a
240
more sophisticated level than what the typical patient may be able to comprehend, which may
241
have negative implications on health outcomes and the healthcare system. Efforts to improve the
242
readability of patient education materials on these websites as well as others would be helpful to
243
optimize each patient’s level of understanding of his or her health. The existing precedence of
244
education materials written at the recommended guidelines and the ongoing discussion and
245
evaluation of such texts provide encouragement that widespread easily-read patient education
246
materials may be a legitimate possibility in the future. To best treat our patients, we must strive
247
to continue the discussion of and to evaluate existing online patient education materials,
248
remaining aware of and working to produce new, readable patient education materials, and
249
continuing to strive for more readable materials rather than settling for the status quo.
SC
M AN U
TE D EP AC C
250
RI PT
237
ACCEPTED MANUSCRIPT 14
References
252 253
1.
Krempec J, Hall J, Biermann JS. Internet use by patients in orthopaedic surgery. Iowa Orthop J. 2003;23:80-82.
254 255
2.
Beall MS, Golladay GJ, Greenfield MLVH, Hensinger RN, Biermann JS. Use of the Internet by pediatric orthopaedic outpatients. J Pediatr Orthop. 2002;22(2):261-264.
256
3.
Brooks BA. Using the Internet for patient education. Orthop Nurs. 2001;20(5):69-77.
257 258
4.
Feghhi DP, Komlos D, Agarwal N, Sabharwal S. Quality of online pediatric orthopaedic education materials. J Bone Joint Surg Am. 2014;96(23):e194. doi:10.2106/JBJS.N.00043.
259 260 261
5.
Butler L, Foster NE. Back pain online: a cross-sectional survey of the quality of web-based information on low back pain. Spine. 2003;28(4):395-401. doi:10.1097/01.BRS.0000048497.38319.D3.
262 263 264
6.
Polishchuk DL, Hashem J, Sabharwal S. Readability of online patient education materials on adult reconstruction Web sites. J Arthroplasty. 2012;27(5):716-719. doi:10.1016/j.arth.2011.08.020.
265 266 267
7.
Sabharwal S, Badarudeen S, Unes Kunju S. Readability of online patient education materials from the AAOS web site. Clin Orthop. 2008;466(5):1245-1250. doi:10.1007/s11999-008-0193-8.
268 269 270
8.
Beredjiklian PK, Bozentka DJ, Steinberg DR, Bernstein J. Evaluating the source and content of orthopaedic information on the Internet. The case of carpal tunnel syndrome. J Bone Joint Surg Am. 2000;82-A(11):1540-1543.
271 272 273
9.
Badarudeen S, Sabharwal S. Readability of patient education materials from the American Academy of Orthopaedic Surgeons and Pediatric Orthopaedic Society of North America web sites. J Bone Joint Surg Am. 2008;90(1):199-204. doi:10.2106ok/JBJS.G.00347.
274 275 276 277 278
10. Yi PH, Ganta A, Hussein KI, Frank RM, Jawa A. Readability of arthroscopy-related patient education materials from the American Academy of Orthopaedic Surgeons and Arthroscopy Association of North America Web sites. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2013;29(6):1108-1112. doi:10.1016/j.arthro.2013.03.003.
279 280 281
11. Wang SW, Capo JT, Orillaza N. Readability and comprehensibility of patient education material in hand-related web sites. J Hand Surg. 2009;34(7):1308-1315. doi:10.1016/j.jhsa.2009.04.008.
282 283
12. Moshirfar A, Campbell JT, Khasraghi FA, Wenz JF Sr. Evaluating the quality of Internetderived information on plantar fasciitis. Clin Orthop. 2004;(421):60-63.
AC C
EP
TE D
M AN U
SC
RI PT
251
ACCEPTED MANUSCRIPT 15
13. Dy CJ, Taylor SA, Patel RM, Kitay A, Roberts TR, Daluiski A. The effect of search term on the quality and accuracy of online information regarding distal radius fractures. J Hand Surg. 2012;37(9):1881-1887. doi:10.1016/j.jhsa.2012.05.021.
287 288 289
14. Mohan R, Yi PH, Hansen EN. Evaluating Online Information Regarding the Direct Anterior Approach for Total Hip Arthroplasty. J Arthroplasty. 2015. doi:10.1016/j.arth.2014.12.022.
290 291 292
15. Sabharwal S, Badarudeen S, Unes Kunju S. Readability of online patient education materials from the AAOS web site. Clin Orthop. 2008;466(5):1245-1250. doi:10.1007/s11999-008-0193-8.
293 294 295
16. Vives M, Young L, Sabharwal S. Readability of spine-related patient education materials from subspecialty organization and spine practitioner websites. Spine. 2009;34(25):28262831. doi:10.1097/BRS.0b013e3181b4bb0c.
296 297 298
17. Hansberry DR, Agarwal N, Shah R, et al. Analysis of the readability of patient education materials from surgical subspecialties. The Laryngoscope. 2014;124(2):405-412. doi:10.1002/lary.24261.
299 300 301
18. Berland GK, Elliott MN, Morales LS, et al. Health information on the Internet: accessibility, quality, and readability in English and Spanish. JAMA J Am Med Assoc. 2001;285(20):2612-2621.
302 303
19. Cotugna N, Vickery CE, Carpenter-Haefele KM. Evaluation of literacy level of patient education pages in health-related journals. J Community Health. 2005;30(3):213-219.
304 305
20. How to Write Easy-to-Read Health Materials. http://www.nlm.nih.gov/medlineplus/etr.html. Accessed June 27, 2014.
306 307 308
21. Weiss BD. Health Literacy: A Manual for Clinicians. 2nd ed. American Medical Association Foundation and American Medical Association; 2007. http://med.fsu.edu/userFiles/file/ahec_health_clinicians_manual.pdf.
309 310 311
22. Badarudeen S, Sabharwal S. Assessing readability of patient education materials: current role in orthopaedics. Clin Orthop. 2010;468(10):2572-2580. doi:10.1007/s11999-010-1380y.
312 313 314
23. Friedman DB, Hoffman-Goetz L. A systematic review of readability and comprehension instruments used for print and web-based cancer information. Health Educ Behav Off Publ Soc Public Health Educ. 2006;33(3):352-373. doi:10.1177/1090198105277329.
315 316 317
24. Feghhi DP, Agarwal N, Hansberry DR, Berberian WS, Sabharwal S. Critical review of patient education materials from the American Academy of Orthopaedic Surgeons. Am J Orthop Belle Mead NJ. 2014;43(8):E168-E174.
318 319
25. Graber MA, Roller CM, Kaeble B. Readability levels of patient education material on the World Wide Web. J Fam Pract. 1999;48(1):58-61.
AC C
EP
TE D
M AN U
SC
RI PT
284 285 286
ACCEPTED MANUSCRIPT 16
26. Bluman EM, Foley RP, Chiodo CP. Readability of the Patient Education Section of the AOFAS Website. Foot Ankle Int. 2009;30(4):287-291. doi:10.3113/FAI.2009.0287.
322 323 324
27. Wallace LS, Turner LW, Ballard JE, Keenum AJ, Weiss BD. Evaluation of web-based osteoporosis educational materials. J Womens Health 2002. 2005;14(10):936-945. doi:10.1089/jwh.2005.14.936.
325 326
28. Biomet Information for Patients and Caregivers. http://www.biomet.com/patients/. Accessed April 7, 2015.
327 328
29. DePuy Synthes Patients & Caregivers. http://www.depuysynthes.com/patients. Accessed April 7, 2015.
329 330
30. Smith & Nephew Patient. http://www.smith-nephew.com/us/patient/. Accessed April 7, 2015.
331
31. Stryker Patient. http://www.stryker.com/en-us/patients/index.htm. Accessed April 7, 2015.
332 333
32. Zimmer Patients and Caregivers. http://www.zimmer.com/patients-caregivers.html. Accessed April 7, 2015.
334 335
33. William DuBay. The Principles of Readability. http://www.impactinformation.com/impactinfo/readability02.pdf. Accessed June 27, 2014.
336 337 338 339 340
34. Street 1615 L., NW, Washington S 700, Inquiries D 20036 202 419 4300 | M 202 419 4349 | F 202 419 4372 | M. Most internet users start at a search engine when looking for health information online. Pew Res Cent Internet Am Life Proj. http://www.pewinternet.org/2006/10/29/most-internet-users-start-at-a-search-engine-whenlooking-for-health-information-online/. Accessed April 7, 2015.
341
35. Andrus MR, Roth MT. Health literacy: a review. Pharmacotherapy. 2002;22(3):282-302.
342 343 344
36. Doak C, Doak L, Root J. Teaching Patients with Low Literacy Skills. 2nd ed. J.B. Lippincott; 1996. http://www.hsph.harvard.edu/healthliteracy/resources/teaching-patientswith-low-literacy-skills/. Accessed June 27, 2014.
345 346 347
37. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107. doi:10.7326/0003-4819-155-2-201107190-00005.
348 349 350
38. Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19(12):1228-1239. doi:10.1111/j.1525-1497.2004.40153.x.
351 352 353
39. Serper M, Patzer RE, Curtis LM, et al. Health literacy, cognitive ability, and functional health status among older adults. Health Serv Res. 2014;49(4):1249-1267. doi:10.1111/1475-6773.12154.
AC C
EP
TE D
M AN U
SC
RI PT
320 321
ACCEPTED MANUSCRIPT 17
354 355 356 357
40. Berkman ND, DeWalt DA, Pignone MP, Sheridan SL, Lohr KN, Lux L, Sutton SF, Swinson T, Bonito AJ. Literacy and Health Outcomes. Evidence Report/Technology Assessment No. 87. AHRQ Publication No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality. January 2004.
359 360 361
RI PT
358
41. Braddock III CH, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed Decision Making in Outpatient PracticeTime to Get Back to Basics. JAMA. 1999;282(24):2313-2320. doi:10.1001/jama.282.24.2313
362
SC
363
AC C
EP
TE D
M AN U
364 365
ACCEPTED MANUSCRIPT 18
Table 1. Flesh-Kincaid grade level for five orthopaedic implant companies.
Overall
Number of Articles
Mean* (Range)
# of articles at or below 8th grade level (%)
# of articles at or below 6th grade level (%)
581
10.9
56 (9.6%)
13 (2.2%)
RI PT
366
368
ANOVA).
M AN U
SC
367
(3.8-19.9) 30 (11.1%) 270 10.6 0 (0%) Depuy (6.0-13.9) 74 12 0 (0%) 0 (0%) Smith(8.1-19.9) Nephew 0 (0%) 55 11.6 0 (0%) Stryker (8.4-15.3) 95 10.1 21 (21.1%) 12 (12.6%) Zimmer (3.8-15.1) 87 11.3 6 (6.9%) 1 (1.1%) Biomet (5.8-15.7) *Mean readability levels were significantly different between the 5 companies (p <0.0001 by
AC C
EP
TE D
369
S0883-5403(17)30586-7
DOI:
10.1016/j.arth.2017.07.003
Reference:
YARTH 55983
To appear in:
The Journal of Arthroplasty
Received Date: 27 December 2016 Revised Date:
29 June 2017
Accepted Date: 3 July 2017
Please cite this article as: Yi MM, Yi PH, Hussein KI, Cross MB, Della Valle CJ, Readability of Patient Education Materials From the Websites of Orthopaedic Implant Manufacturers, The Journal of Arthroplasty (2017), doi: 10.1016/j.arth.2017.07.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Readability of Patient Education Materials From the Websites of Orthopaedic Implant Manufacturers
Della Valle, MD5*
2
Albany Medical College, Albany, NY
The Johns Hopkins Hospital, Baltimore, MD
4
Greenwich Hospital, Greenwich, CT
M AN U
3
Hospital for Special Surgery, New York, NY
Rush University Medical Center, Chicago, IL
TE D
5
SC
1
RI PT
Meghan M Yi, BA,1 Paul H Yi, MD,2 Khalil I Hussein, MD,3 Michael B Cross, MD,4 Craig J
*Address correspondence to:
EP
Craig J. Della Valle, MD
Rush University Medical Center
AC C
1611 West Harrison Street Suite 300
Chicago, IL 60612, USA
email: [email protected]
ACCEPTED MANUSCRIPT 1
Readability of Patient Education Materials From the Websites of Orthopaedic Implant
2
Manufacturers
AC C
EP
TE D
M AN U
SC
RI PT
1
ACCEPTED MANUSCRIPT 2
Abstract
4
Background
5
Prior studies indicate that orthopaedic patient education materials are written at a level that is too
6
high for the average patient. The purpose of this study was to assess the readability of online
7
patient education materials provided by orthopaedic implant manufacturers.
RI PT
3
8
Methods
SC
9
All patient education articles available in 2013 from the websites of the five largest orthopaedic
11
implant manufacturers were identified. Each article was evaluated with the Flesch-Kincaid (FK)
12
readability test. The number of articles with readability ≤ the 8th grade level (average reading
13
ability of US adults) and the 6th grade level (recommended level for patient education materials)
14
were determined. Mean readability levels of each company’s articles were compared using
15
ANOVA (significance set at p < 0.05).
16
Results
17
581 Articles were reviewed from the five largest implant manufacturers. The mean overall FK
18
grade level was 10.9 (range, 3.8-16.1). Only 58 articles (10%) were written ≤ the 8th grade level,
19
and only 13 (2.2%) were ≤ the 6th grade level. The mean FK grade level was significantly
20
different amongst groups (Smith-Newphew = 12.0, Stryker =11.6, Biomet = 11.3, Depuy =10.6,
21
Zimmer =10.1;; p < 0.0001).
23
TE D
EP
AC C
22
M AN U
10
Conclusions
ACCEPTED MANUSCRIPT 3
The majority of patient education materials from implant manufacturers are written at a level too
25
high to be comprehended by the average patient. Future efforts should be made to improve the
26
readability of orthopaedic patient education materials.
27 28
Keywords: Patient Education, Readability, Internet
AC C
EP
TE D
M AN U
SC
29
RI PT
24
ACCEPTED MANUSCRIPT 4
Introduction
31
The Internet has become an increasingly popular source of orthopaedic patient educational
32
materials in recent years.1–3 As patients seek to educate themselves about their orthopaedic
33
conditions by looking to the Internet, a growing awareness and evaluation of such online patient
34
educational materials has emerged in the literature.4–8 Despite the increasing accessibility of
35
online orthopaedic patient educational materials, the health information patients find on the
36
Internet have been shown to be of variable quality with materials that are difficult to read or
37
which may be misleading, trends that have been observed throughout the various subspecialties
38
of orthopaedic surgery.6,8–14
M AN U
SC
RI PT
30
Readability is the reading comprehension grade level a person must possess in order to
40
read and understand a given written text.6,9–11,15–19 While the average adult in the United States
41
can read at an eighth grade level, the National Institutes of Health20 and American Medical
42
Association21 recommend that health education material be written at a sixth grade level or
43
below to help facilitate comprehension due to the complicated nature of medical information.
44
Prior studies of orthopedic patient educational materials, however, have indicated that patient
45
education materials from the American Academy of Orthopaedic Surgeons (AAOS) and other
46
sources intended for patient use are written at a level that is too high for the average patient and
47
have overwhelmingly failed to meet these recommended reading level guidelines.4,6,9–11,15–18,22–27
EP
AC C
48
TE D
39
Although the readability of patient educational materials of the American Academy of
49
Orthopaedic Surgeons (AAOS) and the majority of the orthopaedic subspecialty societies has
50
been previously assessed4,9,10,15–18,22–25, no study has assessed patient educational materials
51
provided by the orthopaedic industry. The purpose of this study was to assess the readability of
52
online patient education materials provided by the five largest orthopaedic implant
ACCEPTED MANUSCRIPT 5
53
manufacturers.
54
Methods
56
We identified all articles available in 2013 from the online patient education libraries of the five
57
largest orthopaedic implant manufacturers (Biomet28, Depuy29, Smith-Nephew30, Stryker31,
58
Zimmer32). Articles that contained only figures and tables without text, patient testimonies,
59
product advertisements, and other like material that were not intended as patient education
60
material were excluded, as previously described.10,15,22
SC
The full text was extracted from each unique article and follow-up editing was performed
M AN U
61
RI PT
55
to prevent errors in readability analysis as previously described10,15,22. This editing included
63
omitting figures, tables, headers, and bullets, in addition to text unrelated to patient education,
64
such as HTML tags, navigation links, copyright notices, disclaimers, and author information. In
65
addition, in order to avoid the underestimation of readability difficulty, we removed headings of
66
lists and paragraphs, paragraph breaks, dashes, abbreviations, numbers, decimals, colons,
67
semicolons, parentheses, and slashes. For lists with complete sentences, the full sentences with
68
their written punctuation were maintained.10,15,22
EP
TE D
62
One observer then assessed each article with the Flesch-Kincaid readability test, which
70
evaluates the readability and comprehensibility of written text.15,23 The Flesch-Kincaid test has
71
been extensively used previously to evaluate the readability of orthopaedic and non-orthopaedic
72
patient education materials.6,9–11,15–18,22–27 The Flesch-Kincaid grade level assessment is included
73
in the Microsoft Office Word software and was enabled by clicking on the “Spelling and
74
Grammar” button, clicking “Options,” and then enabling the “Show readability statistics” option.
75
The program generates and presents the readability score after the user uses the “Spelling and
AC C
69
ACCEPTED MANUSCRIPT 6
Grammar” tool to review the document. This test considers all words and sentences in the given
77
text, and ascribes a grade level corresponding to the text’s difficulty level using the following
78
formula: (0.39 x total words per total sentences) + (11.8 x total syllables per total words) – 15.59.
79
A lower grade level score represents a more readable text, while a higher grade level score
80
represents a less readable text. For example, an article with a Flesch-Kincaid grade level score of
81
5, which indicates that a person who can fully read and understand the text must have the reading
82
level of a fifth grader or higher, is less difficult to read than an article with a Flesch-Kincaid
83
grade level score of 12, which indicates that the reading level of a person who can fully read and
84
understand the text must have the reading level of a high school graduate. A grade level of 13 to
85
15 represents a college-level education and a grade of greater than 16 represents a postgraduate-
86
level education.22,33
M AN U
SC
RI PT
76
87
Statistical analysis
89
The number of articles with readability less than or equal to the 8th grade level (average reading
90
ability of US adults) and the 6th grade reading level (recommended level for patient education
91
materials) were determined. Mean readability levels of each company’s articles were compared
92
using analysis of variance and t-tests, as appropriate (significance set at p < 0.05), as well as
93
between article topics (for example, articles addressing procedures/treatments versus those
94
addressing conditions/diseases). Intraobserver and interrater reliability of FK grade calculation
95
were determined by use of intraclass correlation coefficients; intraobserver reliability was
96
determined by having the same observer who calculated the FK scores calculate the scores of 15
97
randomly chosen articles a second time 1 week after the initial calculations, while interobserver
AC C
EP
TE D
88
ACCEPTED MANUSCRIPT 7
98
reliability was determined by having a second observer evaluating 30 randomly chosen
99
articles.10,22
100
Results
102
581 unique articles were reviewed from the five largest orthopaedic implant manufacturers in the
103
U.S.28–32 Of these, 296 (50.9%) addressed specific treatments or procedures while 285 (49.1%)
104
addressed conditions or disease. By extremity/body part, there were 163 articles (28%)
105
addressing the knee, 97 addressing the hip (16.7%), 10 addressing both the hip and knee (1.7%),
106
106 addressing the spine (18.2%), 85 addressing the shoulder (14.6%), 25 addressing the elbow
107
(4.3%), 11 addressing the hand and wrist (1.9%), 14 addressing the foot and ankle (2.4%), and
108
70 articles (12%) addressing multiple body parts (other than hip and knee) or orthopaedic
109
conditions, in general. Article distribution by specialty was as follows: 143 hip and knee
110
arthroplasty (24.6%), 98 sports hip and knee (16.9%), 106 spine (18.2%), 105 shoulder/elbow
111
(18.1%), 33 trauma (5.7%), 14 foot and ankle (2.4%), 11 hand and wrist (1.9%), and 71 general
112
orthopaedics and bone health (12.2%).
SC
M AN U
TE D
For all five companies’ articles, the overall mean Flesch-Kincaid grade level was 11.3
EP
113
RI PT
101
(range, 3.8-15.1; Table 1). This includes three companies (Depuy, Zimmer, and Biomet) with at
115
least one article written at the 8th grade and/or 6th grade level and two companies (Smith-Nephew
116
and Stryker) that had no articles written at either a 6th or 8th grade level on their websites.
117
Interestingly, articles that addressed orthopaedic conditions or diseases had lower average
118
readability levels than those that addressed specific treatments or procedures (10.5 vs. 11.2;
119
p=0.0004). There was no significant difference in readability levels between body
120
parts/extremities or between specialties.
AC C
114
ACCEPTED MANUSCRIPT 8
Out of all 581 articles evaluated from these five companies, only 13 articles (2.2%) were
122
written at a 6th grade level or below and only 56 articles (9.6%) were written at an 8th grade level
123
or below. In other words, 90.4 % of all articles were written at or above the national average 8th
124
grade reading level, while 97.8% of all articles were written at or above the recommended 6th
125
grade reading level. Thus, the majority of all articles analyzed from all five companies failed to
126
meet the 6th grade reading level standard.
The mean Flesch-Kincaid grade level was significantly different amongst the different
SC
127
RI PT
121
companies (Smith-Newphew = 12.0, Stryker =11.6, Biomet = 11.3, Depuy =10.6, Zimmer
129
=10.1; p < 0.0001)). Zimmer’s website had the greatest percentage of articles at or below the 8th
130
grade (21.1%) and 6th grade levels (12.6%), while two companies (Smith-Nephew and Stryker)
131
failed to provide any articles at the same grade levels. Intraobserver and interobserver reliability
132
of FK grade assessment were excellent (ICC of 0.996 and 0.9998, respectively).
M AN U
128
134 135
Discussion
TE D
133
Prior studies have shown that patients view online health literature as too confusing and overwhelming because of the breadth and content of health education websites.34 Most adults
137
read at an 8th grade level, but the American Medical Association21, the National Institutes of
138
Health20, and other health organizations recommend that patient education material be written at
139
less than a sixth grade reading level. Despite this recommendation, most, if not all, studies
140
focusing on the readability of patient education materials have demonstrated that the readability
141
of such resources is too high.4,6,9–11,15,16,18,22–24,26,27 Low health literacy has been associated with
142
poor health outcomes, more frequent and longer hospitalizations, more complications,
143
noncompliance, and increased healthcare costs. 9,37–39 The readability of patient education
AC C
EP
136
ACCEPTED MANUSCRIPT 9
materials from the American Academy of Orthopaedic Surgeons, American Orthopaedic Foot
145
and Ankle Society, Arthroscopy Association of North America, individual physicians, and many
146
other websites have been observed4,6,9–11,15,16,22,24,26, but no studies have focused on the websites
147
of the five biggest orthopaedic implant manufacturers in the U.S.: Biomet, Depuy, Smith-
148
Nephew, Stryker, and Zimmer.
RI PT
144
As a whole, the websites of the five largest orthopaedic companies in the U.S. may be too
150
sophisticated or wordy for the average patient to understand. In this study, we found that only 13
151
articles or 2.2% of all 581 articles analyzed measured up to the 6th grade recommended
152
guideline. When comparing the readability of these implant companies’ education materials to
153
that of other patient education materials in orthopaedics and other specialties, these resources
154
unfortunately continue the trend of high readability levels. 6,9, 10,15 It could be argued that in order
155
for a patient to initiate an Internet search of orthopaedic implant companies’ websites and
156
subsequently locate relevant patient education materials, he or she must have an above-average
157
level of health literacy, raising the possibility that these patient education materials could be
158
appropriately written for this self-motivated, potentially more-educated, population of patients.
159
However, it is difficult to assess the precise reading level of visitors to these websites.
M AN U
TE D
EP
160
SC
149
Still, noteworthy nuances exist among the articles of the five orthopaedic implant companies. Compared to the websites of the other four companies, Zimmer’s website had the
162
highest percentage of articles written at or below both the recommended 6th and 8th grade levels
163
(10% and 20%, respectively). Thus, Zimmer’s patient education materials appear to be the
164
easiest to read. Despite being the most easily readable, the average reading level of Zimmer’s
165
website was still 10.1, indicating that the average patient might still have difficulty
166
understanding the majority of its articles. On the other end of the spectrum, Smith-Nephew and
AC C
161
ACCEPTED MANUSCRIPT 10
167
Stryker’s websites seem to be the least reader-friendly of the five companies’ studied. In fact,
168
neither of these websites had any articles written at or below either the 6th or 8th grade levels and
169
their average, minimum, and maximum scores were among the highest of all five groups. Despite the high average readability level of these articles provided by implant
171
manufacturers, there is hope for the future of improving readability levels of patient education
172
materials. The fact that there were some articles that were written at an acceptable reading level
173
are proof that producing patient education materials at the recommended guidelines is feasible.
174
The first study of the readability of orthopaedic patient education materials 9 in 2008 concluded
175
that, in general, the orthopaedic community was unaware of the discrepancy between the
176
readability levels of patient education material and the average reading level of patients.
177
However, the results of numerous follow-up studies have suggest there is now a burgeoning
178
awareness and legitimate consideration of the issue. 4,6,9–11,15,16,22,24,26 Despite these efforts, there
179
are still major gaps between the readability of patient education materials and the average
180
patient’s reading level and much work remains. By continuing to evaluate and improve the
181
readability of online patient education materials, orthopaedic providers and companies will
182
improve the likelihood that patients will comprehend the educational materials provided, which
183
could potentially have a positive impact on their healthcare outcomes. 9,37–39
SC
M AN U
TE D
EP
Previous studies and literature on readability have suggested different methods of
AC C
184
RI PT
170
185
improving readability.10,22 Above all, considering the reading skills of the target population is
186
essential when preparing patient education materials, as is considering the reader’s point-of-
187
view. Replacing complex medical terms and jargon with simpler words (e.g., substituting the
188
commonly understood and one syllable word “scope” for the four syllable medical jargon
189
“arthroscopy”) and simplifying sentences to be more succinct and easier to understand are some
ACCEPTED MANUSCRIPT 11
techniques that may improve the readability of patient education materials. In addition, simpler
191
formatting of text and the inclusion of diagrams, charts, graphs, illustrations, and other non-
192
textual figures, may also help to decrease the written grade level of websites. 9,33,36 Finally,
193
screening education materials and revising them to meet readability guidelines before making
194
them available for patient use may also help improve readability.
195
RI PT
190
The results of this study should be viewed in light of several limitations. The FK
readability test, as previously described, has several inherent flaws, including its primary
197
consideration of the number of syllables per word and words per sentence, as well as its lack of
198
consideration of illustrations, and charts of patient education materials that may play a vital role
199
in improving the reader’s understanding of the website. In fact, these non-textual elements,
200
which may substantially enhance patients’ ability to understand complex medical information,
201
have even been considered a fundamental aspect of the overall understandability (but not
202
technically of the readability) of patient educational materials.1 Other readability assessments,
203
such as the Suitability Assessment of Materials which takes pictures, diagrams, and written text
204
into account, exist that improve upon the FK test’s weaknesses. However, this test, in particular
205
is relatively new, has not been as extensively validated as other assessments have been, is more
206
time consuming, and has been described as “inherently subjective.5,21” Thus, at this time, such
207
an analysis may not be practical or particularly helpful in understanding the readability of patient
208
education materials. The low cost, easy accessibility, and well-established use of the FK
209
readability test, which has also been shown to correlate well with other readability formulas, 22
210
may thus be the most logical analysis to evaluate readability at this time. Another limitation of
211
this study is that we only examined five orthopaedic companies’ websites; our results cannot be
212
extrapolated to the entire scope of patient education materials from all orthopaedic companies’
AC C
EP
TE D
M AN U
SC
196
ACCEPTED MANUSCRIPT 12
online patient education materials. However, because we did study the websites of the five
214
largest orthopaedic companies in the U.S., it is probable that these materials are more likely to be
215
found by patients themselves or recommended by orthopaedic surgeons to patients looking for
216
more information on orthopaedic procedures. Finally, only articles written in English were
217
included in this study, which excludes the articles that may be read by the large population of
218
Spanish-speakers who may also be seeking information on these manufacturers’ websites. As it
219
turns out, the readability of online health education materials written in Spanish has been studied,
220
although the websites of implant manufacturers have not been a specific area of focus.18
SC
Finally, it is important to acknowledge that written patient education materials, whether
M AN U
221
RI PT
213
in the form of a physical copy or on the Internet, play only a small role in a patient’s health care
223
decision making and granting their informed consent. In 1999, Braddock found that only 1.5% of
224
patients were assessed for their understanding after giving informed consent for interventions,
225
including various orthopaedic surgeries.41 Theoretically, easy to understand and patient-friendly
226
written materials will aid in patients’ decision making, especially in light of the fact that much
227
information discussed between the patient and doctor may be lost the moment patients leave the
228
office. However, because 9 out of 10 adults do not have proficient health literacy according to
229
the National Assessment of Adult Literacy 40 and it is highly likely that patients may hide their
230
illiteracy, and accept printed materials they cannot comprehend to an optimal capacity, there is
231
danger in relying heavily on published patient education materials to guide patients in making
232
informed decisions about their health. Creating patient education materials written at the
233
appropriate reading level is only a single element of the solution in the grand scheme of the
234
conundrum of improving patient understanding of their medical conditions and health.
AC C
EP
TE D
222
235 236
Conclusions
ACCEPTED MANUSCRIPT 13
The Internet has become an increasingly popular resource for health information. Patients may
238
turn to the websites of orthopaedic implant companies for more information about their
239
orthopaedic procedures, but our study suggests that most of its documents may be written at a
240
more sophisticated level than what the typical patient may be able to comprehend, which may
241
have negative implications on health outcomes and the healthcare system. Efforts to improve the
242
readability of patient education materials on these websites as well as others would be helpful to
243
optimize each patient’s level of understanding of his or her health. The existing precedence of
244
education materials written at the recommended guidelines and the ongoing discussion and
245
evaluation of such texts provide encouragement that widespread easily-read patient education
246
materials may be a legitimate possibility in the future. To best treat our patients, we must strive
247
to continue the discussion of and to evaluate existing online patient education materials,
248
remaining aware of and working to produce new, readable patient education materials, and
249
continuing to strive for more readable materials rather than settling for the status quo.
SC
M AN U
TE D EP AC C
250
RI PT
237
ACCEPTED MANUSCRIPT 14
References
252 253
1.
Krempec J, Hall J, Biermann JS. Internet use by patients in orthopaedic surgery. Iowa Orthop J. 2003;23:80-82.
254 255
2.
Beall MS, Golladay GJ, Greenfield MLVH, Hensinger RN, Biermann JS. Use of the Internet by pediatric orthopaedic outpatients. J Pediatr Orthop. 2002;22(2):261-264.
256
3.
Brooks BA. Using the Internet for patient education. Orthop Nurs. 2001;20(5):69-77.
257 258
4.
Feghhi DP, Komlos D, Agarwal N, Sabharwal S. Quality of online pediatric orthopaedic education materials. J Bone Joint Surg Am. 2014;96(23):e194. doi:10.2106/JBJS.N.00043.
259 260 261
5.
Butler L, Foster NE. Back pain online: a cross-sectional survey of the quality of web-based information on low back pain. Spine. 2003;28(4):395-401. doi:10.1097/01.BRS.0000048497.38319.D3.
262 263 264
6.
Polishchuk DL, Hashem J, Sabharwal S. Readability of online patient education materials on adult reconstruction Web sites. J Arthroplasty. 2012;27(5):716-719. doi:10.1016/j.arth.2011.08.020.
265 266 267
7.
Sabharwal S, Badarudeen S, Unes Kunju S. Readability of online patient education materials from the AAOS web site. Clin Orthop. 2008;466(5):1245-1250. doi:10.1007/s11999-008-0193-8.
268 269 270
8.
Beredjiklian PK, Bozentka DJ, Steinberg DR, Bernstein J. Evaluating the source and content of orthopaedic information on the Internet. The case of carpal tunnel syndrome. J Bone Joint Surg Am. 2000;82-A(11):1540-1543.
271 272 273
9.
Badarudeen S, Sabharwal S. Readability of patient education materials from the American Academy of Orthopaedic Surgeons and Pediatric Orthopaedic Society of North America web sites. J Bone Joint Surg Am. 2008;90(1):199-204. doi:10.2106ok/JBJS.G.00347.
274 275 276 277 278
10. Yi PH, Ganta A, Hussein KI, Frank RM, Jawa A. Readability of arthroscopy-related patient education materials from the American Academy of Orthopaedic Surgeons and Arthroscopy Association of North America Web sites. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2013;29(6):1108-1112. doi:10.1016/j.arthro.2013.03.003.
279 280 281
11. Wang SW, Capo JT, Orillaza N. Readability and comprehensibility of patient education material in hand-related web sites. J Hand Surg. 2009;34(7):1308-1315. doi:10.1016/j.jhsa.2009.04.008.
282 283
12. Moshirfar A, Campbell JT, Khasraghi FA, Wenz JF Sr. Evaluating the quality of Internetderived information on plantar fasciitis. Clin Orthop. 2004;(421):60-63.
AC C
EP
TE D
M AN U
SC
RI PT
251
ACCEPTED MANUSCRIPT 15
13. Dy CJ, Taylor SA, Patel RM, Kitay A, Roberts TR, Daluiski A. The effect of search term on the quality and accuracy of online information regarding distal radius fractures. J Hand Surg. 2012;37(9):1881-1887. doi:10.1016/j.jhsa.2012.05.021.
287 288 289
14. Mohan R, Yi PH, Hansen EN. Evaluating Online Information Regarding the Direct Anterior Approach for Total Hip Arthroplasty. J Arthroplasty. 2015. doi:10.1016/j.arth.2014.12.022.
290 291 292
15. Sabharwal S, Badarudeen S, Unes Kunju S. Readability of online patient education materials from the AAOS web site. Clin Orthop. 2008;466(5):1245-1250. doi:10.1007/s11999-008-0193-8.
293 294 295
16. Vives M, Young L, Sabharwal S. Readability of spine-related patient education materials from subspecialty organization and spine practitioner websites. Spine. 2009;34(25):28262831. doi:10.1097/BRS.0b013e3181b4bb0c.
296 297 298
17. Hansberry DR, Agarwal N, Shah R, et al. Analysis of the readability of patient education materials from surgical subspecialties. The Laryngoscope. 2014;124(2):405-412. doi:10.1002/lary.24261.
299 300 301
18. Berland GK, Elliott MN, Morales LS, et al. Health information on the Internet: accessibility, quality, and readability in English and Spanish. JAMA J Am Med Assoc. 2001;285(20):2612-2621.
302 303
19. Cotugna N, Vickery CE, Carpenter-Haefele KM. Evaluation of literacy level of patient education pages in health-related journals. J Community Health. 2005;30(3):213-219.
304 305
20. How to Write Easy-to-Read Health Materials. http://www.nlm.nih.gov/medlineplus/etr.html. Accessed June 27, 2014.
306 307 308
21. Weiss BD. Health Literacy: A Manual for Clinicians. 2nd ed. American Medical Association Foundation and American Medical Association; 2007. http://med.fsu.edu/userFiles/file/ahec_health_clinicians_manual.pdf.
309 310 311
22. Badarudeen S, Sabharwal S. Assessing readability of patient education materials: current role in orthopaedics. Clin Orthop. 2010;468(10):2572-2580. doi:10.1007/s11999-010-1380y.
312 313 314
23. Friedman DB, Hoffman-Goetz L. A systematic review of readability and comprehension instruments used for print and web-based cancer information. Health Educ Behav Off Publ Soc Public Health Educ. 2006;33(3):352-373. doi:10.1177/1090198105277329.
315 316 317
24. Feghhi DP, Agarwal N, Hansberry DR, Berberian WS, Sabharwal S. Critical review of patient education materials from the American Academy of Orthopaedic Surgeons. Am J Orthop Belle Mead NJ. 2014;43(8):E168-E174.
318 319
25. Graber MA, Roller CM, Kaeble B. Readability levels of patient education material on the World Wide Web. J Fam Pract. 1999;48(1):58-61.
AC C
EP
TE D
M AN U
SC
RI PT
284 285 286
ACCEPTED MANUSCRIPT 16
26. Bluman EM, Foley RP, Chiodo CP. Readability of the Patient Education Section of the AOFAS Website. Foot Ankle Int. 2009;30(4):287-291. doi:10.3113/FAI.2009.0287.
322 323 324
27. Wallace LS, Turner LW, Ballard JE, Keenum AJ, Weiss BD. Evaluation of web-based osteoporosis educational materials. J Womens Health 2002. 2005;14(10):936-945. doi:10.1089/jwh.2005.14.936.
325 326
28. Biomet Information for Patients and Caregivers. http://www.biomet.com/patients/. Accessed April 7, 2015.
327 328
29. DePuy Synthes Patients & Caregivers. http://www.depuysynthes.com/patients. Accessed April 7, 2015.
329 330
30. Smith & Nephew Patient. http://www.smith-nephew.com/us/patient/. Accessed April 7, 2015.
331
31. Stryker Patient. http://www.stryker.com/en-us/patients/index.htm. Accessed April 7, 2015.
332 333
32. Zimmer Patients and Caregivers. http://www.zimmer.com/patients-caregivers.html. Accessed April 7, 2015.
334 335
33. William DuBay. The Principles of Readability. http://www.impactinformation.com/impactinfo/readability02.pdf. Accessed June 27, 2014.
336 337 338 339 340
34. Street 1615 L., NW, Washington S 700, Inquiries D 20036 202 419 4300 | M 202 419 4349 | F 202 419 4372 | M. Most internet users start at a search engine when looking for health information online. Pew Res Cent Internet Am Life Proj. http://www.pewinternet.org/2006/10/29/most-internet-users-start-at-a-search-engine-whenlooking-for-health-information-online/. Accessed April 7, 2015.
341
35. Andrus MR, Roth MT. Health literacy: a review. Pharmacotherapy. 2002;22(3):282-302.
342 343 344
36. Doak C, Doak L, Root J. Teaching Patients with Low Literacy Skills. 2nd ed. J.B. Lippincott; 1996. http://www.hsph.harvard.edu/healthliteracy/resources/teaching-patientswith-low-literacy-skills/. Accessed June 27, 2014.
345 346 347
37. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107. doi:10.7326/0003-4819-155-2-201107190-00005.
348 349 350
38. Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19(12):1228-1239. doi:10.1111/j.1525-1497.2004.40153.x.
351 352 353
39. Serper M, Patzer RE, Curtis LM, et al. Health literacy, cognitive ability, and functional health status among older adults. Health Serv Res. 2014;49(4):1249-1267. doi:10.1111/1475-6773.12154.
AC C
EP
TE D
M AN U
SC
RI PT
320 321
ACCEPTED MANUSCRIPT 17
354 355 356 357
40. Berkman ND, DeWalt DA, Pignone MP, Sheridan SL, Lohr KN, Lux L, Sutton SF, Swinson T, Bonito AJ. Literacy and Health Outcomes. Evidence Report/Technology Assessment No. 87. AHRQ Publication No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality. January 2004.
359 360 361
RI PT
358
41. Braddock III CH, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed Decision Making in Outpatient PracticeTime to Get Back to Basics. JAMA. 1999;282(24):2313-2320. doi:10.1001/jama.282.24.2313
362
SC
363
AC C
EP
TE D
M AN U
364 365
ACCEPTED MANUSCRIPT 18
Table 1. Flesh-Kincaid grade level for five orthopaedic implant companies.
Overall
Number of Articles
Mean* (Range)
# of articles at or below 8th grade level (%)
# of articles at or below 6th grade level (%)
581
10.9
56 (9.6%)
13 (2.2%)
RI PT
366
368
ANOVA).
M AN U
SC
367
(3.8-19.9) 30 (11.1%) 270 10.6 0 (0%) Depuy (6.0-13.9) 74 12 0 (0%) 0 (0%) Smith(8.1-19.9) Nephew 0 (0%) 55 11.6 0 (0%) Stryker (8.4-15.3) 95 10.1 21 (21.1%) 12 (12.6%) Zimmer (3.8-15.1) 87 11.3 6 (6.9%) 1 (1.1%) Biomet (5.8-15.7) *Mean readability levels were significantly different between the 5 companies (p <0.0001 by
AC C
EP
TE D
369