Introduction

It is known that patients often turn to the internet to learn about orthopedic procedures. As more patients consider a total knee arthroplasty (TKA), there will likely be increased interest in relevant online education material. The American Medical Association (AMA) and National Institutes of Health (NIH) recommend that publicly available 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. Additionally, educational resources should be written such that readers can process key information (understandability) or identify available actions to take (actionability). The purpose of this study was to quantify the readability, understandability, and actionability of online patient educational materials (PEM) regarding total knee arthroplasty.

Methods

Using trend analysis software (trends.google.com), the most common searched term “knee replacement” was determined (Figure 1). Subsequently two independent online searches (Google.com) were performed. From the top 50 search results, websites were included if directed at educating patients regarding this subject. From the top 50 results, all PEM websites were included in the analysis. Non-text websites (audiovisual), articles (news/research/industry), and unrelated resources were excluded. Readability was quantified using valid objective algorithms: Flesch-Kincaid Grade-Level (FKGL), Simple Measure of Gobbledygook (SMOG) grade, Coleman-Liau Index (CLI), and Gunning-Fog Index (GFI). The Patient Education Materials Assessment Tool (PEMAT) was utilized to assess understandability and actionability (0-100%). The Patient Education Materials Assessment Tool (PEMAT) was utilized to assess actionability and understandability (0-100%). PEMAT uses a threshold score of 70% or higher as acceptable understandability and actionability. The relationship between Google search rank with FKGL and PEMAT scores was quantified.

Results

Thirty-four unique websites were included. The mean FKGL, SMOG, CLI, and GFI was 11.8±1.6, 11.1±1.2, 1186±1.4, and 14.7±1.6, respectively. None of the websites scored at or below the 6th grade level. Mean understandability and actionability scores were 54.9±12.1 and 30.3±22.0. Only 5.9% (n=2) and 2.9% (n=1) of websites met the >70% threshold for understandability and actionability, respectively. Only 29.4% (n=10) sources used common language and only 35.3% (n=12) defined complicated medical terms. Based on website type, the mean understandability scores for academic institution, private practice, and health information publisher websites was 57.2±8.8%, 52.6±11.1%, and 54.3±15.3% (p=0.67), respectively (Figure 3). Readability (rho:-0.07; p=0.69), understandability (rho:-0.02; p=0.93), and actionability (rho:-0.22; p=0.23) scores were not associated with Google search rank.

Conclusion

TKA materials scored poorly with respect to readability, understandability, and actionability with none of the resources scoring at or below the AMA/NIH recommended reading level. Only 5.9% scored adequately on understandability measures. Substantial efforts are needed to improve the readability, understandability and actionability of online resources in order to optimize patient knowledge and facilitate informed decision-making.