Journal of Clinical Anesthesia (2015) 27, 401–405
Original Contribution
Readability evaluation of Internet-based patient education materials related to the anesthesiology field☆ Gildasio S. De Oliveira Jr. MD, MSCI (Assistant Professor)a,⁎, Michael Jung BS (Medical Student)b , Kirsten J. Mccaffery PhD (Associate Professor)c , Robert J. McCarthy PharmD (Research Professor)a , Michael S. Wolf PhD, MPH (Professor) d a
Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA c Faculty of Medicine, The University of Sydney, Chicago, IL 60611, USA d Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA b
Received 12 February 2014; accepted 17 February 2015
Keywords: Readability; Anesthesiology; Websites
Abstract Study Objective: The main objective of the current investigation was to assess the readability of Internet-based patient education materials related to the field of anesthesiology. We hypothesized that the majority of patient education materials would not be written according to current recommended readability grade level. Setting: Online patient education materials describing procedures, risks, and management of anesthesiarelated topics were identified using the search engine Google (available at www.google.com) using the terms anesthesia, anesthesiology, anesthesia risks, and anesthesia care. Design: Cross-sectional evaluation. Interventions: None. Measurements: Assessments of content readability were performed using validated instruments (Flesch-Kincaid Grade Formulae, the Gunning Frequency of Gobbledygook, the New Dale-Chall Test, the Fry graph, and the Flesch Reading Ease score). Main Results: Ninety-six Web sites containing Internet patient education materials (IPEMs) were evaluated. The median (interquartile range) readability grade level for all evaluated IPEMs was 13.5 (12.0-14.6). All the evaluated documents were classified at a greater readability level than the current recommended readability grade, P b .001. Readability grades were not significantly different among different IPEM sources. Assessment by the Flesch Reading Ease test classified all but 4 IPEMs as at least fairly difficult to read.
☆
Funding: Department of Anesthesiology, Northwestern University. ⁎ Corresponding author at: Department of Anesthesiology, Northwestern University, 241 East Huron St, F5-704, Chicago, IL, USA. Tel.: + 1 312 472 3573. E-mail address: [email protected] (G.S. De Oliveira).
http://dx.doi.org/10.1016/j.jclinane.2015.02.005 0952-8180/© 2015 Elsevier Inc. All rights reserved.
402
G.S. De Oliveira Jr. et al. Conclusions: Internet-based patient education materials related to the field of anesthesiology are currently written far above the recommended readability grade level. High complexity of written education materials likely limits access of information to millions of American patients. Redesign of online content of Web sites that provide patient education material regarding anesthesia could be an important step in improving access to information for patients with poor health literacy. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Healthy literacy is defined by the Institute of Medicine by “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate decisions” [1]. It has been estimated that approximately 40% of the US population have inadequate health literacy [2]. Because poor health literacy has been repeatedly associated with poor patient outcomes [3-5], strategies to improve access and understanding of medical information by patients with inadequate health literacy are largely needed. The Internet is currently the most used source of health-related information by surgical patients [6]. Because 50% of patients leave their doctor's office with a poor understanding of their diagnosis [7], Internet-based patient education materials are commonly used by patients in an effort to understand risks associated with medical and/or surgical interventions. In addition, optimal understanding of risk by patients is a necessary step to assure a valid informed consent process [8,9]. The National Institute of Health, US Department of Health and Human Services, and American Medical Association recommend that the readability level of patient education materials needs to be written at or below the sixth grade level to be effectively understood by the American public [10]. Other specialties have examined the readability of Internet-based patient education materials with varying results [11-13]. In contrast, the readability content of Internet-based patient education materials in the anesthesiology field has yet to be determined. Improvement in the readability of online education materials could provide better understandability of the risks and benefits of anesthesiology-related health information to millions of American patients. The main objective of the current investigation was to assess the readability of Internet-based patient education materials related to the field of anesthesiology. We hypothesized that the majority of patient education materials would not be written according to current recommended readability grade levels.
2. Materials and methods On October 3, 2013, online patient education materials describing procedures, risks, and management of anesthesiarelated topics were identified using the search engine Google
(available at www.google.com). The key word “anesthesia” was typed, and the first 200 Web pages from the generated list were examined for patient-related articles discussing anesthesia concepts. Articles were excluded if they were not patient education materials, if they were written in a language different from English, if they were described mainly in a graphic or table form, or if the article content had less than 30 sentences. The above procedure was then repeated for the terms anesthesiology, anesthesia care, and anesthesia risks. Additional articles meeting inclusion and exclusion criteria were added to the database. The available information from each Web site that met inclusion criteria was stored as single Microsoft Word (Microsoft, Redmond, WA) files. Following the same recommended methodology used previously to evaluate readability of medial information [14,11], additional text that was not pertinent to patient education such as information to guide Web site navigation, copyright notices, disclaimers, author contact, survey questionnaires, references, Web site resource locators (URLs), address, and telephone numbers was deleted to prevent them from altering the readability scores. In addition, editing of the sentences to remove colons and semicolons was performed as recommended by Flesch [15]. The readability of a text is determined as the education level a person completed to understand the written material. We used the Flesch-Kincaid Grade Formulae, Gunning Frequency of Gobbledygook, New Dale-Chall Test, and Fry graph to access the readability grade for included documents. These methods have been validated for assessment of readability and have been used as described in the literature [15]. The average readability grade of the 4 tests was obtained. A score from 0 to 12 reflects a precollege grade level; 13-16 corresponds to a college level; and scores greater than 16, to a graduate degree level. In addition, we also examined the texts using the Flesch Reading Ease, which generates a score from 0 to 100 corresponding to reading ease, with lower values corresponding to difficult text (0-30 for very difficult, 30-50 for difficult, 50-60 for fairly difficult, 60-70 for standard, 70-80 for fairly easy, 80-90 for easy, and 90-100 for very easy). Readability scores of the Flesch-Kincaid Grade Formulae, Gunning Frequency of Gobbledygook, and New Dale-Chall Test were analyzed using the software package Readability Studio Professional Version 2012.1 for Windows (Oleander Software Ltd, Vandalia, OH). Subgroup analysis was performed comparing the readability scores from different sources of Web site (academic and professional society,
Readability IPEM anesthesiology
403
clinical practice, and miscellaneous). A 1-sided t test was used to compare the mean readability level against the current recommended standards (sixth grade level). The source of the Web site was categorized to academic department, professional society organizations, clinical practices, or miscellaneous sources. The difference in readability levels among categories of Web sites was assessed using the Kruskal-Wallis 1-way analysis of variance. P b .05 was used to reject a type I error.
3. Results Ninety-six Web sites containing patient education materials were evaluated; the complete reference list of documents is presented as a supplementary material (Appendix 1). Twenty-three Internet patient education materials (IPEMs) originated from academic departments or society organizations; 32, from clinical practices; and 41, from miscellaneous sources (primarily Internet only). The median (interquartile range) readability grade level for all evaluated IPEMs was 13.5 (12.0-14.6). The readability grade assessment by the Fry graph is presented in Fig. 1. All the evaluated documents were classified at a greater readability level than the current recommended readability grade (sixth grade), P b .001. Readability grades were not significantly
Fig. 2 Box plot graphs demonstrating the required grade levels to comprehend the written online patient education material according to different Web site sources. The median (interquartile range) grade level for academic/society, clinical practices, and miscellaneous sources was not different among the study groups, 14 (12.3-15.5), 13.5 (12.6-14.5), and 12.8 (10.8-15.5), respectively, P = .18.
different among different IPEM sources (Fig. 2). Assessment by the Flesch Reading Ease test classified all but 4 IPEMs as at least fairly difficult to read (Fig. 3). Because several clinical practices did not contain their own information for patients and instead referred to the
Fig. 1 Fry graph chart demonstrating the school grades required to comprehend the written online patient education materials in the field of anesthesiology.
404
G.S. De Oliveira Jr. et al.
Fig. 3
Flesch readability ease test demonstrating that all but 4 Web sites content were classified at least as fairly difficult to read.
American Society of Anesthesiologists Web site Lifeline to Modern Medicine, we performed an additional analysis of the patient education material provided by the Web site. The lowest grade level obtained by the 4 readability tests was 13th, which was greater than the current recommendations (Table 1). The Flesch Reading Ease score was 26, which represents content that is very difficult to read.
4. Discussion The most important finding of the current investigation was that a 13th school grade is required to read most Table 1 Readability evaluation of the American Society of Anesthesiologists Web site Lifeline to Modern Medicine Test
Grade a
New Dale-Chall Flesh-Kincaid Fry Gunning Fog
13-15 14.4 17 17
a
School grade required to understand the material content. The National Institute of Health, US Department of Health and Human Services, and American Medical Association recommend that the readability level of patient education materials needs to be written at or below the sixth grade level to be effectively understood by the American public.
currently available patient education materials disseminated via easily searched Web sites related to anesthesia and anesthesiology. The difficulty in reading the patient education content was further confirmed by a classification of at least fairly difficult for the vast majority of evaluated sites. The readability of Internet-based patient education material related to the anesthesiology field far exceeds the current recommendation of the National Institute of Health, US Department of Health and Human Services, and American Medical Association [10]. Because of limited health literacy, it is likely that millions of patients in the United States are not able to understand patient education materials related to anesthesiology. Our findings are important because the Internet is currently the most common resource for patient education in the United States [16,17]. In addition, the use of Internet education material has been seen as important supplement to assure a proper informed consent process [18,19]. In contrast, misunderstanding of Internet content by patients can lead to significant confusion [20]. Our current results suggest that Internet-based patient education material related to the anesthesiology field should be redesigned and language content simplified to be assessable to patients with lower health literacy levels. Other specialties have also examined the readability of IPEM related to their respective fields. Similar to our findings, Edmunds et al [21] found that 83% of online
Readability IPEM anesthesiology ophthalmologic patient information was difficult to read. Other authors also found inadequate the online patient education material of surgical and medical subspecialty societies [22,16]. To the best of our knowledge, the current study is the first one to evaluate readability in the anesthesiology field. Although language simplification is a required initial step to improve information access to patients with limited health literacy, additional interventions are frequently required [16]. The use of visual pictorial aids has shown an additive effect on health-related content information [23]. One randomized controlled trial demonstrated that offering information to physicians regarding patients' health literacy increases completion of colorectal cancer screening test by patients [24]. Nevertheless, responsible parties that develop online patient education material to the anesthesiology field should test their content for readability [25]. Our current investigation should only be interpreted with respect to its limitations. We performed our search in the United States, and a same search using similar terms at a different country location would likely yield different results. In addition, we only examined online patient education material written in the English language. Different education levels among various countries require evaluations specific for each country and respective languages. Further studies to attest generalizability of our findings to different languages are, therefore, warranted. In summary, the content of online patient education material related to the anesthesiology field far exceeds current readability grade recommendations. The content is currently not accessible to millions of American patients who have limited health literacy. Because the Internet is currently the most common source of information of patients making medical decisions, redesign of online content of Web sites that provide patient education material in anesthesiology is likely the first step to enable health-illiterate patients to make informed decisions in regard to our field.
Appendix 1. Supplementary data Supplementary data to this article can be found online at http://dx.doi.org/10.1016/j.jclinane.2015.02.005.
References [1] Institute of Medicine. Health literacy: a prescription to end confusion. Washington DC: National Academy Press; 2004. [2] Kutner MA. National Center for Education Statistics. Literacy in everyday life: results from the 2003 national assessment of adult literacy. Washington, DC: National Center for Education Statistics; 2007. [3] Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional health status among older adults. Arch Intern Med 2005;165:1946-52.
405 [4] Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med 2007;167:1503-9. [5] Sudore RL, Yaffe K, Satterfield S, Harris TB, Mehta KM, Simonsick EM, et al. Limited literacy and mortality in the elderly: the health, aging, and body composition study. J Gen Intern Med 2006;21:806-12. [6] Azu MC, Lilley EJ, Kolli AH. Social media, surgeons, and the Internet: an era or an error? Am Surg 2012;78:555-8. [7] Bodenheimer T. The future of primary care: transforming practice. N Engl J Med 2008;359:2086-9. [8] Balajonda N, Bisanar TL, Mathew JP, Pang H, Voils CI. Determinants of a subject's decision to participate in clinical anesthesia research. Anesth Analg 2013;116:448-54. [9] Dennehy L, White S. Consent, assent, and the importance of risk stratification. Br J Anaesth 2012;109:40-6. [10] Finnie RK, Felder TM, Linder SK, Mullen PD. Beyond reading level: a systematic review of the suitability of cancer education print and Web-based materials. J Cancer Educ 2010;25:497-505. [11] Cherla DV, Sanghvi S, Choudhry OJ, Jyung RW, Eloy JA, Liu JK. Readability assessment of Internet-based patient education materials related to acoustic neuromas. Otol Neurotol 2013;34:1349-54. [12] 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. Arthroscopy 2013;29:1108-12. [13] Shukla P, Sanghvi SP, Lelkes VM, Kumar A, Contractor S. Readability assessment of internet-based patient education materials related to uterine artery embolization. J Vasc Interv Radiol 2013;24:469-74. [14] Sanghvi S, Cherla DV, Shukla PA, Eloy JA. Readability assessment of internet-based patient education materials related to facial fractures. Laryngoscope 2012;122:1943-8. [15] Friedman DB, Hoffman-Goetz L. A systematic review of readability and comprehension instruments used for print and web-based cancer information. Health Educ Behav 2006;33:352-73. [16] Agarwal N, Hansberry DR, Sabourin V, Tomei KL, Prestigiacomo CJ. A comparative analysis of the quality of patient education materials from medical specialties. JAMA Intern Med 2013;173:1257-9. [17] Farnan JM, Snyder Sulmasy L, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM. American College of Physicians Ethics, Professionalism and Human Rights Committee; American College of Physicians Council of Associates; Federation of State Medical Boards Special Committee on Ethics and Professionalism. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med 2013;158:620-7. [18] Mulsow JJ, Feeley TM, Tierney S. Beyond consent—improving understanding in surgical patients. Am J Surg 2012;203:112-20. [19] D'Ambrosia RD. Treating the Internet-informed patient. Orthopedics 2009;32:13. [20] Hungerford DS. Internet access produces misinformed patients: managing the confusion. Orthopedics 2009;32. [21] Edmunds MR, Barry RJ, Denniston AK. Readability assessment of online ophthalmic patient information. JAMA Ophthalmol 2013;131: 1610-6. [22] Hansberry DR, Agarwal N, Shah R, Schmitt PJ, Baredes S, Setzen M, et al. Analysis of the readability of patient education materials from surgical subspecialties. Laryngoscope 2013;124:405-12. [23] Sheridan SL, Halpern DJ, Viera AJ, Berkman ND, Donahue KE, Crotty K. Interventions for individuals with low health literacy: a systematic review. J Health Commun 2011;16:30-54. [24] Garcia-Retamero R, Okan Y, Cokely ET. Using visual aids to improve communication of risks about health: a review. Sci World J 2012;2012:562637. [25] Ferreira MR, Dolan NC, Fitzgibbon ML, Davis TC, Gorby N, Ladewski L, et al. Health care provider-directed intervention to increase colorectal cancer screening among veterans: results of a randomized controlled trial. J Clin Oncol 2005;23:1548-54.
©2015 Elsevier
Original Contribution
Readability evaluation of Internet-based patient education materials related to the anesthesiology field☆ Gildasio S. De Oliveira Jr. MD, MSCI (Assistant Professor)a,⁎, Michael Jung BS (Medical Student)b , Kirsten J. Mccaffery PhD (Associate Professor)c , Robert J. McCarthy PharmD (Research Professor)a , Michael S. Wolf PhD, MPH (Professor) d a
Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA c Faculty of Medicine, The University of Sydney, Chicago, IL 60611, USA d Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA b
Received 12 February 2014; accepted 17 February 2015
Keywords: Readability; Anesthesiology; Websites
Abstract Study Objective: The main objective of the current investigation was to assess the readability of Internet-based patient education materials related to the field of anesthesiology. We hypothesized that the majority of patient education materials would not be written according to current recommended readability grade level. Setting: Online patient education materials describing procedures, risks, and management of anesthesiarelated topics were identified using the search engine Google (available at www.google.com) using the terms anesthesia, anesthesiology, anesthesia risks, and anesthesia care. Design: Cross-sectional evaluation. Interventions: None. Measurements: Assessments of content readability were performed using validated instruments (Flesch-Kincaid Grade Formulae, the Gunning Frequency of Gobbledygook, the New Dale-Chall Test, the Fry graph, and the Flesch Reading Ease score). Main Results: Ninety-six Web sites containing Internet patient education materials (IPEMs) were evaluated. The median (interquartile range) readability grade level for all evaluated IPEMs was 13.5 (12.0-14.6). All the evaluated documents were classified at a greater readability level than the current recommended readability grade, P b .001. Readability grades were not significantly different among different IPEM sources. Assessment by the Flesch Reading Ease test classified all but 4 IPEMs as at least fairly difficult to read.
☆
Funding: Department of Anesthesiology, Northwestern University. ⁎ Corresponding author at: Department of Anesthesiology, Northwestern University, 241 East Huron St, F5-704, Chicago, IL, USA. Tel.: + 1 312 472 3573. E-mail address: [email protected] (G.S. De Oliveira).
http://dx.doi.org/10.1016/j.jclinane.2015.02.005 0952-8180/© 2015 Elsevier Inc. All rights reserved.
402
G.S. De Oliveira Jr. et al. Conclusions: Internet-based patient education materials related to the field of anesthesiology are currently written far above the recommended readability grade level. High complexity of written education materials likely limits access of information to millions of American patients. Redesign of online content of Web sites that provide patient education material regarding anesthesia could be an important step in improving access to information for patients with poor health literacy. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Healthy literacy is defined by the Institute of Medicine by “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate decisions” [1]. It has been estimated that approximately 40% of the US population have inadequate health literacy [2]. Because poor health literacy has been repeatedly associated with poor patient outcomes [3-5], strategies to improve access and understanding of medical information by patients with inadequate health literacy are largely needed. The Internet is currently the most used source of health-related information by surgical patients [6]. Because 50% of patients leave their doctor's office with a poor understanding of their diagnosis [7], Internet-based patient education materials are commonly used by patients in an effort to understand risks associated with medical and/or surgical interventions. In addition, optimal understanding of risk by patients is a necessary step to assure a valid informed consent process [8,9]. The National Institute of Health, US Department of Health and Human Services, and American Medical Association recommend that the readability level of patient education materials needs to be written at or below the sixth grade level to be effectively understood by the American public [10]. Other specialties have examined the readability of Internet-based patient education materials with varying results [11-13]. In contrast, the readability content of Internet-based patient education materials in the anesthesiology field has yet to be determined. Improvement in the readability of online education materials could provide better understandability of the risks and benefits of anesthesiology-related health information to millions of American patients. The main objective of the current investigation was to assess the readability of Internet-based patient education materials related to the field of anesthesiology. We hypothesized that the majority of patient education materials would not be written according to current recommended readability grade levels.
2. Materials and methods On October 3, 2013, online patient education materials describing procedures, risks, and management of anesthesiarelated topics were identified using the search engine Google
(available at www.google.com). The key word “anesthesia” was typed, and the first 200 Web pages from the generated list were examined for patient-related articles discussing anesthesia concepts. Articles were excluded if they were not patient education materials, if they were written in a language different from English, if they were described mainly in a graphic or table form, or if the article content had less than 30 sentences. The above procedure was then repeated for the terms anesthesiology, anesthesia care, and anesthesia risks. Additional articles meeting inclusion and exclusion criteria were added to the database. The available information from each Web site that met inclusion criteria was stored as single Microsoft Word (Microsoft, Redmond, WA) files. Following the same recommended methodology used previously to evaluate readability of medial information [14,11], additional text that was not pertinent to patient education such as information to guide Web site navigation, copyright notices, disclaimers, author contact, survey questionnaires, references, Web site resource locators (URLs), address, and telephone numbers was deleted to prevent them from altering the readability scores. In addition, editing of the sentences to remove colons and semicolons was performed as recommended by Flesch [15]. The readability of a text is determined as the education level a person completed to understand the written material. We used the Flesch-Kincaid Grade Formulae, Gunning Frequency of Gobbledygook, New Dale-Chall Test, and Fry graph to access the readability grade for included documents. These methods have been validated for assessment of readability and have been used as described in the literature [15]. The average readability grade of the 4 tests was obtained. A score from 0 to 12 reflects a precollege grade level; 13-16 corresponds to a college level; and scores greater than 16, to a graduate degree level. In addition, we also examined the texts using the Flesch Reading Ease, which generates a score from 0 to 100 corresponding to reading ease, with lower values corresponding to difficult text (0-30 for very difficult, 30-50 for difficult, 50-60 for fairly difficult, 60-70 for standard, 70-80 for fairly easy, 80-90 for easy, and 90-100 for very easy). Readability scores of the Flesch-Kincaid Grade Formulae, Gunning Frequency of Gobbledygook, and New Dale-Chall Test were analyzed using the software package Readability Studio Professional Version 2012.1 for Windows (Oleander Software Ltd, Vandalia, OH). Subgroup analysis was performed comparing the readability scores from different sources of Web site (academic and professional society,
Readability IPEM anesthesiology
403
clinical practice, and miscellaneous). A 1-sided t test was used to compare the mean readability level against the current recommended standards (sixth grade level). The source of the Web site was categorized to academic department, professional society organizations, clinical practices, or miscellaneous sources. The difference in readability levels among categories of Web sites was assessed using the Kruskal-Wallis 1-way analysis of variance. P b .05 was used to reject a type I error.
3. Results Ninety-six Web sites containing patient education materials were evaluated; the complete reference list of documents is presented as a supplementary material (Appendix 1). Twenty-three Internet patient education materials (IPEMs) originated from academic departments or society organizations; 32, from clinical practices; and 41, from miscellaneous sources (primarily Internet only). The median (interquartile range) readability grade level for all evaluated IPEMs was 13.5 (12.0-14.6). The readability grade assessment by the Fry graph is presented in Fig. 1. All the evaluated documents were classified at a greater readability level than the current recommended readability grade (sixth grade), P b .001. Readability grades were not significantly
Fig. 2 Box plot graphs demonstrating the required grade levels to comprehend the written online patient education material according to different Web site sources. The median (interquartile range) grade level for academic/society, clinical practices, and miscellaneous sources was not different among the study groups, 14 (12.3-15.5), 13.5 (12.6-14.5), and 12.8 (10.8-15.5), respectively, P = .18.
different among different IPEM sources (Fig. 2). Assessment by the Flesch Reading Ease test classified all but 4 IPEMs as at least fairly difficult to read (Fig. 3). Because several clinical practices did not contain their own information for patients and instead referred to the
Fig. 1 Fry graph chart demonstrating the school grades required to comprehend the written online patient education materials in the field of anesthesiology.
404
G.S. De Oliveira Jr. et al.
Fig. 3
Flesch readability ease test demonstrating that all but 4 Web sites content were classified at least as fairly difficult to read.
American Society of Anesthesiologists Web site Lifeline to Modern Medicine, we performed an additional analysis of the patient education material provided by the Web site. The lowest grade level obtained by the 4 readability tests was 13th, which was greater than the current recommendations (Table 1). The Flesch Reading Ease score was 26, which represents content that is very difficult to read.
4. Discussion The most important finding of the current investigation was that a 13th school grade is required to read most Table 1 Readability evaluation of the American Society of Anesthesiologists Web site Lifeline to Modern Medicine Test
Grade a
New Dale-Chall Flesh-Kincaid Fry Gunning Fog
13-15 14.4 17 17
a
School grade required to understand the material content. The National Institute of Health, US Department of Health and Human Services, and American Medical Association recommend that the readability level of patient education materials needs to be written at or below the sixth grade level to be effectively understood by the American public.
currently available patient education materials disseminated via easily searched Web sites related to anesthesia and anesthesiology. The difficulty in reading the patient education content was further confirmed by a classification of at least fairly difficult for the vast majority of evaluated sites. The readability of Internet-based patient education material related to the anesthesiology field far exceeds the current recommendation of the National Institute of Health, US Department of Health and Human Services, and American Medical Association [10]. Because of limited health literacy, it is likely that millions of patients in the United States are not able to understand patient education materials related to anesthesiology. Our findings are important because the Internet is currently the most common resource for patient education in the United States [16,17]. In addition, the use of Internet education material has been seen as important supplement to assure a proper informed consent process [18,19]. In contrast, misunderstanding of Internet content by patients can lead to significant confusion [20]. Our current results suggest that Internet-based patient education material related to the anesthesiology field should be redesigned and language content simplified to be assessable to patients with lower health literacy levels. Other specialties have also examined the readability of IPEM related to their respective fields. Similar to our findings, Edmunds et al [21] found that 83% of online
Readability IPEM anesthesiology ophthalmologic patient information was difficult to read. Other authors also found inadequate the online patient education material of surgical and medical subspecialty societies [22,16]. To the best of our knowledge, the current study is the first one to evaluate readability in the anesthesiology field. Although language simplification is a required initial step to improve information access to patients with limited health literacy, additional interventions are frequently required [16]. The use of visual pictorial aids has shown an additive effect on health-related content information [23]. One randomized controlled trial demonstrated that offering information to physicians regarding patients' health literacy increases completion of colorectal cancer screening test by patients [24]. Nevertheless, responsible parties that develop online patient education material to the anesthesiology field should test their content for readability [25]. Our current investigation should only be interpreted with respect to its limitations. We performed our search in the United States, and a same search using similar terms at a different country location would likely yield different results. In addition, we only examined online patient education material written in the English language. Different education levels among various countries require evaluations specific for each country and respective languages. Further studies to attest generalizability of our findings to different languages are, therefore, warranted. In summary, the content of online patient education material related to the anesthesiology field far exceeds current readability grade recommendations. The content is currently not accessible to millions of American patients who have limited health literacy. Because the Internet is currently the most common source of information of patients making medical decisions, redesign of online content of Web sites that provide patient education material in anesthesiology is likely the first step to enable health-illiterate patients to make informed decisions in regard to our field.
Appendix 1. Supplementary data Supplementary data to this article can be found online at http://dx.doi.org/10.1016/j.jclinane.2015.02.005.
References [1] Institute of Medicine. Health literacy: a prescription to end confusion. Washington DC: National Academy Press; 2004. [2] Kutner MA. National Center for Education Statistics. Literacy in everyday life: results from the 2003 national assessment of adult literacy. Washington, DC: National Center for Education Statistics; 2007. [3] Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional health status among older adults. Arch Intern Med 2005;165:1946-52.
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