Results
Of the 115 AAOS website articles included in the study and reviewed, 18 were coauthored by OTA, 10 by AOSSM, 14 by POSNA, 2 by ASSH, 2 by ASES, 1 by AAHKS, 3 by AOFAS, 1 by AOSSM and ASES, and 1 by AOFAS and AOSSM.
Mean FK grade level was 9.1 (range, 6.2-12; 95% CI, 8.9-9.3) for all articles reviewed and 9.1 (range, 6.2-12; 95% CI, 8.8-9.4) for articles exclusively written by AAOS. For coauthored articles, mean FK grade level was 9.3 (range, 7.6-11.3; 95% CI, 8.8-9.8) for AAOS-OTA; 8.9 (range, 7.4-10.4; 95% CI, 8.4-9.6) for AAOS-AOSSM; 9.4 (range, 7-11.8; 95% CI, 8.9-10.1) for AAOS-POSNA; 7.8 (range, 7.8-9.1; 95% CI, 7.2-9.8) for AAOS-ASSH; 9 (range, 8.2-9.6; 95% CI, 7.6-10.2) for AAOS-ASES; 9 (range, 7.9-9; 95% CI, 7.9-9.3) for AAOS-AOFAS; 8.1 for the 1 AAOS-AAHKS article; 8.5 for the 1 AAOS-AOSSM-ASES article; and 8 for the 1 AAOS-AOFAS-AOSSM article (Figure).
For FK readability calculations, interobserver reliability (ICC, 0.9982) and intraobserver reliability (ICC, 1) were both excellent.
Discussion
Although increasing numbers of patients are using information from the Internet to inform their healthcare decisions,12 studies have shown that online PEMs are written at a readability level above that of the average patient.1,9,13 In the present study, we also found that OT-PEMs from AAOS are written at a level considerably higher than the recommended sixth-grade reading level,16 potentially impairing patient comprehension and leading to poorer health outcomes.17
The pervasiveness of too-high PEM readability levels has been found across orthopedic subspecialties.2,9,12,13 Following this trend, the OT articles we reviewed had a ninth-grade reading level on average, and only 1 of 115 articles was below the recommended sixth-grade level.10 The issue of too-high PEM readability levels is thus a problem both in OT and in orthopedics in general. Accordingly, efforts to address this problem are warranted, especially as orthopedic PEM readability has not substantially improved over the past several years.18In this study, we also tried to identify any readability differences between articles coauthored by orthopedic societies and articles that were not coauthored by orthopedic societies. We hypothesized that multidisciplinary authorship could improve PEM readability; for example, orthopedic societies could collaborate with other medical specialties (eg, family medicine) that have produced appropriately readable PEMs. One study found that the majority of PEMs from the American Academy of Family Physicians (AAFP) were written below the sixth-grade reading level because of strict organizational regulation of the production of such materials.19 By noting and adopting successful PEM development methods used by groups such as AAFP,19,20 we might be able to improve OT-PEM readability. However, this was not the case in our study, though our observations may have been limited by the small sample of reviewable articles.
One factor contributing to the poor readability of orthopedic PEMs is that orthopedics terminology is complex and includes words that are often difficult to translate into simpler terms without losing their meaning.10 When PEMs are written at a level that is too complex, patients cannot fully comprehend them, which may lead to poor health literacy. This problem may be even more harmful when considering the poor literacy levels of patients at baseline. Kadakia and colleagues16 found that OT patients had poor health literacy; for example, fewer than half knew which bone they fractured. As health literacy is associated with poorer health outcomes and reduced use of healthcare services,21 optimizing patients’ health literacy is of crucial importance to both their education and their outcomes.
Our study should be viewed in light of some important limitations. As OTA does not publish its own PEMs, we assessed only OT-related articles that were available on the AAOS website and were exclusively written by AAOS, or coauthored by AAOS and by OTA and/or another orthopedic subspecialty organization. As these articles represent only a subset of the full spectrum of OT-PEMs available on the Internet, our results may not be generalizable to the entire scope of such materials. However, as AAOS and OTA represent the most authoritative OT organizations, we think these PEMs would be among those most likely to be recommended to patients by their surgeons. In addition, although we used a well-established tool for examining readability—the FK readability scale10-13—this tool has its own inherent limitations, as FK readability grade level is calculated purely on the basis of words per sentence and total syllables per word, and does not take into account other article elements, such as images, which also provide information.1,10 Nevertheless, the FK scale is an inexpensive, easily accessed readability tool that provides a reproducible readability value that is easily comparable to results from earlier studies.10 The final limitation is that we excluded from the study AAOS website articles written in a language other than English. Such articles, however, are important, as a large portion of the patient population speaks English as a second language. Indeed, the readability of Spanish PEMs has been investigated—albeit using a readability measure other than the FK scale—and may be a topic pertinent to orthopedic PEMs.22Most of the literature on the readability of orthopedic PEMs has found their reading levels too high for the average patient to comprehend.1,9-12 The trend continues with our study findings regarding OT-PEMs available online from AAOS. Although the literature on the inadequacies of orthopedic PEMs is vast,1,9-12 more work is needed to improve the quality, accuracy, and readability of these materials. There has been some success in improving PEM readability and producing appropriately readable materials within the medical profession,19,23 so we know that appropriately readable orthopedic PEMs are feasible.
Am J Orthop. 2017;46(3):E190-E194. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.