Introduction
Patients often access online resources to learn about orthopedic procedures prior to undergoing elective surgery. The American Medical Association (AMA) and National Institutes of Health (NIH) recommend online health information to be written at a 6th grade or lower reading level in order to be fully understood by the average adult in the United States. Previous studies have examined the syntax reading grade level of educational materials in multiple orthopedic procedures, however reading grade level does not measure whether text is written such that readers can process key information (understandability) or identify available actions to take (actionability). The Patient Education Materials Assessment Tool (PEMAT-P) is a valid and reliable method to measure the understandability and actionability of online patient education materials. The purpose of the current study was to utilize PEMAT and readability algorithms to quantify readability, understandability and actionability of online patient education materials related to the surgical repair of acute ruptures of the Achilles tendon.
Methods
Online patient education materials were identified using two independent Google searches with the term “Achilles Tendon Repair.” Using the top 50 search results, articles were included if they specifically served to educate patients regarding the surgical repair of acute ruptures of the Achilles tendon. Exclusion criteria included news articles, non-text material (video), research manuscripts, industry websites, and articles not related to Achilles tendon repair procedures. The readability of included articles was quantified using a total of five objective algorithms: Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook (SMOG) grade, Coleman-Liau Index, and Gunning-Fog Index. The PEMAT-P form was used to assess actionability and understandability using a 0-100% scale for both measures of interest. A PEMAT score of 70% or below is considered poorly understandable or poorly actionable. Spearman’s correlation coefficient was utilized to examine the relationship between a website’s average rank on Google and its readability, understandability, and actionability. P-values of less than 0.05 were considered significant.
Results
Thirty-one websites (54.4%) met inclusion criteria. The mean reading grade level (Flesch-Kincaid) was 10.8±2.9. Higher Flesch-Kincaid Grade Level (p=0.010), SMOG grade (p=0.005), and Gunning-Fog Index (p=0.045) scores were associated with later Google search rank. Only Flesch reading ease scores were positively associated with earlier Google search rank (p=0.013). The mean understandability and actionability scores were 67.1±16.4% and 38.3±28.4%, respectively, falling below the 70% PEMAT score threshold for both scales. The most frequently missed understandability criteria included absent summaries (12.9%), followed by absent visual aids (38.7%), and lack of clear titles (42%). Among actionability categories, 74% of websites identified at least one action which could be taken by the reader, but only 45% of studies broke down actions into explicit, easy to understand steps. Higher actionability scores were not significantly associated with Google search rank (p=0.888), while higher understandability scores were associated with later Google search rank (p=0.017).
Conclusion
Only one website describing Achilles tendon repair procedures was written at or below the 6th grade reading level. Overall, the online educational materials assessed scored poorly with respect to readability, understandability, and actionability. Interestingly, higher readability and understandability scores were associated with later Google search rank. In the era of shared decision-making, future efforts should be made to improve the readability of online patient resources.