Readability analysis of healthcare-oriented education resources from the American Academy of Facial Plastic and Reconstructive Surgery

Readability Assessment of Online Patient Abdominoplasty Resources

BACKGROUND

Limited functional health literacy is recognized as an important contributor to health disparities in the United States. As internet access becomes more universal, there is increasing concern about whether patients with poor or marginal literacy can access understandable healthcare information. As such, the National Institutes of Health and American Medical Association recommend that patient information be written at a sixth grade level. This study identifies the most popular online resources for patient information about abdominoplasty and evaluates their readability in the context of average American literacy.

METHODS

The two largest internet search engines were queried for "tummy tuck surgery" to simulate a patient search in lay terms. The ten most popular sites common to both search engines were identified, and all relevant articles from the main sites were downloaded. Sponsored results were excluded. Readability analysis of the articles was performed using ten established tests.

RESULTS

Online information about abdominoplasty from the ten most popular publically available websites had an overall average readability of 12th grade. Mean reading grade level scores among tests were: Coleman-Liau 11.9, Flesch-Kincaid 11.4, FORCAST 11.1, Fry 13, Gunning Fog 13.5, New Dale-Chall 11.8, New Fog Count 9.9, Raygor Estimate 12, and SMOG 13.4; Flesch Reading Ease index score was 46.

CONCLUSIONS

Online patient resources about abdominoplasty are uniformly above the recommended target readability level and are likely too difficult for many patients to understand. A range of readability identified among websites could allow surgeons to guide patients to more appropriate resources for their literacy skills.

Craniofacial Surgery and Adverse Outcomes

Objective:

This study aimed to evaluate factors contributing to medical negligence relevant to craniofacial surgery.

Methods:

Retrospective analysis of verdict and settlement reports on the Westlaw legal database for outcome, awards, physician defendants, and other specific factors raised in malpractice litigation.

Results:

Of 42 verdicts and settlement reports included, 52.4% were resolved with either an out-of-court settlement or plaintiff verdict, with aggregate payments totaling $50.1M (in 2013 dollars). Median settlements and jury-awarded damages were $988 000 and $555 000, respectively. Payments in pediatric cases ($1.2M) were significantly higher. Plastic surgeons, oral surgeons, and otolaryngologists were the most commonly named defendants. The most common alleged factors included intraoperative negligence (69.0%), permanent deficits (54.8%), requiring additional surgery (52.4%), missed/delayed diagnosis of a complication (42.9%), disfigurement/scarring (28.6%), postoperative negligence (28.6%), and inadequate informed consent (20.6% of surgical cases). Failure to diagnose a fracture (19.0%) and cleft-reparative procedures (14.3%) were the most frequently litigated entities.

Conclusion:

Medical negligence related to craniofacial surgery involves plaintiffs in a wide age range as well as physician defendants in numerous specialties, and proceedings resolved with settlement and plaintiff verdict involve substantial payments. Cases with death, allegedly permanent injuries, and pediatric plaintiffs had significantly higher payments.

Readability Assessment of Internet-Based Patient Education Materials Related to Parathyroid Surgery

Objectives:

Patient education is critical in obtaining informed consent and reducing preoperative anxiety. Written patient education material (PEM) can supplement verbal communication to improve understanding and satisfaction. Published guidelines recommend that health information be presented at or below a sixth-grade reading level to facilitate comprehension. We investigate the grade level of online PEMs regarding parathyroid surgery.

Methods:

A popular internet search engine was used to identify PEM discussing parathyroid surgery. Four formulas were used to calculate readability scores: Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), Gunning Frequency of Gobbledygook (GFOG), and Simple Measure of Gobbledygook (SMOG).

Results:

Thirty web-based articles discussing parathyroid surgery were identified. The average FRE score was 42.8 (± 1 standard deviation [SD] 16.3; 95% confidence interval [CI], 36.6-48.8; range, 6.1-71.3). The average FKGL score was 11.7 (± 1 SD 3.3; 95% CI, 10.5-12.9; range, 6.1-19.0). The SMOG scores averaged 14.2 (± 1 SD 2.6; 95% CI, 13.2-15.2; range, 10.7-21.9), and the GFOG scores averaged 15.0 (± 1 SD 3.5; 95% CI, 13.7-16.3; range, 10.6-24.8).

Conclusion:

Online PEM on parathyroid surgery is written above the recommended sixth-grade reading level. Improving readability of PEM may promote better health education and compliance.

Are we effectively informing patients? A quantitative analysis of on-line patient education resources from the American Society of Neuroradiology

BACKGROUND AND PURPOSE

The ubiquitous use of the Internet by the public in an attempt to better understand their health care requires the on-line resources written at an appropriate level to maximize comprehension for the average user. The National Institutes of Health and the American Medical Association recommend on-line patient education resources written at a third-to-seventh grade level. We evaluated the readability of the patient education resources provided on the Web site of the American Society of Neuroradiology (http://www.asnr.org/patientinfo/).

MATERIALS AND METHODS

All patient education material from the ASNR Web site and the Society of Neurointerventional Surgery Web site were downloaded and evaluated with the computer software, Readability Studio Professional Edition, by using 10 quantitative readability scales: the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, Coleman-Liau Index, Gunning Fog Index, New Dale-Chall, FORCAST Formula, Fry Graph, Raygor Reading Estimate, and New Fog Count. An unpaired t test was used to compare the readability level of resources available on the American Society of Neuroradiology and the Society of Neurointerventional Surgery Web sites.

RESULTS

The 20 individual patient education articles were written at a 13.9 ± 1.4 grade level with only 5% written at <11th grade level. There was no statistical difference between the level of readability of the resources on the American Society of Neuroradiology and Society of Neurointerventional Surgery Web sites.

CONCLUSIONS

The patient education resources on these Web sites fail to meet the guidelines of the National Institutes of Health and American Medical Association. Members of the public may fail to fully understand these resources and would benefit from revisions that result in more comprehensible information cast in simpler language.

Readability assessment of package inserts of biological medicinal products from the European medicines agency website

BACKGROUND

Package inserts that accompany medicines are a common source of information aimed at patients and should match patient abilities in terms of readability.

OBJECTIVE

Our objective was to determine the degree of readability of the package inserts for biological medicinal products commercially available in 2007 and compare them with the readability of the same package inserts in 2010.

METHODS

A total of 33 package inserts were selected and classified into five groups according to the type of medicine: monoclonal antibody-based products, cytokines, therapeutic enzymes, recombinant blood factors and other blood-related products, and recombinant hormones. The package inserts were downloaded from the European Medicines Agency website in 2007 and 2010. Readability was evaluated for the entire text of five of the six sections of the package inserts and for the 'Annex' when there was one. Three readability formulas were used: SMOG (Simple Measure of Gobbledygook) grade, Flesh-Kincaid grade level, and Szigriszt's perspicuity index.

RESULTS

No significant differences were found between the readability results for the 2007 package inserts and those from 2010 according to any of the three readability indices studied (p>0.05). However, there were significant differences (p<0.05) between the readability scores of the sections of the package inserts in both 2007 and 2010. The readability of the package inserts was above the recommended sixth grade reading level (ages 11-12) and may lead to difficulties of understanding for people with limited literacy.

CONCLUSIONS

All the sections should be easy to read and, therefore, the readability of the medicine package inserts studied should be improved.

Readability assessment of Internet-based patient education materials related to acoustic neuromas

OBJECTIVE

The objectives of this study were to assess the readability of Internet-based patient education materials related to acoustic neuromas (AN-IPEMs) by 4 widely validated readability indices, to evaluate scores against the existing sixth grade recommended reading level, and to compare the readability scores of patient education materials (PEMs) produced by professional organizations, clinical practices, hospitals, and miscellaneous sources.

MATERIALS AND METHODS

AN-IPEMs from 67 web sites (6 professional societies, 33 clinical practices, 19 hospitals, and 9 miscellaneous) were assessed using Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG), and Gunning Frequency of Gobbledygook (Gunning FOG). Scores were then evaluated against national recommendations by 1-tailed t tests and against each other using 1-way ANOVAs.

RESULTS

The average FKGL, SMOG, and Gunning FOG scores were all significantly higher than the recommended sixth grade reading level suggested by the USDHHS (p < 0.0001, single sample 1-tailed t test). Zero articles, by all indices, had a reading level equal to or below the sixth grade reading level. The FKGLs also varied between the various sources at a significant level (p = 0.01 one-way ANOVA independent samples). The average FKGLs of clinical practice and professional society AN-IPEMs were significantly higher than the average FKGLs of hospital AN-IPEMs (both p ≤ 0.05 one-tailed t-tests assuming unequal variances).

CONCLUSION

AN-IPEMs are written at a level significantly higher than that suggested by national recommendations. Current AN-IPEMs may need to be revised in order to enhance patient comprehension.

Meningitis and legal liability: an otolaryngology perspective

PURPOSE

Meningitis is a potential complication in otolaryngologic procedures and conditions. Severe sequelae make understanding factors involved in relevant malpractice litigation critical. We analyze pertinent litigation for awards, outcomes, patient demographic factors, and other alleged causes of malpractice.

METHODS

Pertinent jury verdict and settlement reports were examined using the Westlaw legal database (Thomson Reuters, New York, NY).

RESULTS

Twenty-three cases (60.5%) involved non-iatrogenic injuries, including inadequate treatment or failure to diagnose sinusitis or otitis media, while 15 (39.5%) involved iatrogenic cases, mostly rhinologic procedures. 36.8% of cases were resolved for the defendant, 28.9% with juries awarding damages, and 34.2% with settlements. Although not statistically significant, mean damages awarded were higher than settlements ($2.1 vs. 1.5M, p=0.056), and cases involving pediatric patients were more likely to be resolved with payment than those with adult litigants (80.0% vs. 52.2%, p=0.08 respectively). Other frequent alleged factors included permanent deficits (63.2%), requiring additional surgery (41.1%), death (34.2%), cognitive deficits (21.2%), deafness (15.8%), and inadequate informed consent (33.0% of iatrogenic cases).

CONCLUSIONS

Practitioners facing litigation related to meningitis may wish to consider these findings, notably for cases involving death or permanent functional deficits, as cases with out of court settlements tended to be resolved with lower payments. Cases involving misdiagnosis may be more likely to be resolved with payment compared with iatrogenic cases. By understanding the issues detailed in this analysis and including them in the informed consent process for patients undergoing rhinologic and otologic procedures, otolaryngologists may potentially improve patient safety and decrease liability.

Obstructive sleep apnea: strategies for minimizing liability and enhancing patient safety

OBJECTIVE

To characterize malpractice litigation regarding obstructive sleep apnea (OSA) and educate physicians on frequently cited factors.

STUDY DESIGN AND SETTING

Analysis of the Westlaw legal database.

METHODS

Jury verdict and settlement reports were examined for outcome, awards, patient demographic factors, defendant specialty, and alleged causes of malpractice.

RESULTS

Out of 54 identified cases, 33 (61.1%) cases were resolved in favor of defendants, 12 (22.2%) via settlement, and 9 (16.7%) through jury award. Median settlement and jury awards did not significantly differ ($750,000 vs $550,000, P > .50). Age and gender did not affect outcome. Otolaryngologists and anesthesiologists were the most frequently named defendants. Forty-seven cases (87.1%) stemmed from OSA patients who underwent procedures with resultant perioperative adverse events. Common alleged factors included death (48.1%), permanent deficits (42.6%), intraoperative complications (35.2%), requiring additional surgery (25.9%), anoxic brain injury (24.1%), inadequate informed consent (24.1%), inappropriate medication administration (22.2%), and inadequate monitoring (20.4%).

CONCLUSION

Litigation related to OSA is frequently associated with perioperative complications more than nonoperative issues such as a failure to diagnose this disorder. Nonetheless, OSA is considerably underdiagnosed, and special attention should be paid to at-risk patients, including close monitoring of their clinical status and the medications they receive. For patients with diagnosed or suspected OSA with planned operative intervention, whether for OSA or an unrelated issue, a comprehensive informed consent process detailing the factors outlined in this analysis is an effective strategy to increase communication and improve the physician-patient relationship, minimize liability, and ultimately improve patient safety.

Readability of arthroscopy-related patient education materials from the American Academy of Orthopaedic Surgeons and Arthroscopy Association of North America Web sites

We sought to assess the readability levels of arthroscopy-related patient education materials available on the Web sites of the American Academy of Orthopaedic Surgeons (AAOS) and the Arthroscopy Association of North America (AANA). We identified all articles related to arthroscopy available in 2012 from the online patient education libraries of AAOS and AANA. After performing follow-up editing, we assessed each article with the Flesch-Kincaid (FK) readability test. Mean readability levels of the articles from the AAOS Web site and the AANA Web site were compared. We also determined the number of articles with readability levels at or below the eighth-grade level (the average reading ability of the US adult population) and sixth-grade level (the widely recommended level for patient education materials). Intraobserver reliability and interobserver reliability of FK grade assessment were evaluated. A total of 62 articles were reviewed (43 from AAOS and 19 from AANA). The mean overall FK grade level was 10.2 (range, 5.2 to 12). The AAOS articles had a mean FK grade level of 9.6 (range, 5.2 to 12), whereas the AANA articles had a mean FK grade level of 11.4 (range, 8.7 to 12); the difference was significant (P < .0001). Only 3 articles had a readability level at or below the eighth-grade level and only 1 was at or below the sixth-grade level; all were from AAOS. Intraobserver reliability and interobserver reliability were excellent (intraclass correlation coefficient of 1 for both). Online patient education materials related to arthroscopy from AAOS and AANA may be written at a level too difficult for a large portion of the patient population to comprehend.