Introduction

Patients undergoing elective procedures often utilize online educational materials to familiarize themselves with the surgical procedure and expected postoperative recovery. While the internet is easily accessible and ubiquitous today, the ability of patients to read, understand, and act on these materials is unknown. The purpose of the current study was to critically evaluate online resources regarding anterior cruciate ligament (ACL) surgery utilizing measures of readability, understandability, and actionability.

Methods

Using the term “ACL surgery,” two independent searches were performed utilizing a public search engine (Google.com). Patient education materials were identified from the top 50 results. Audio-visual materials, news articles, materials intended for advertising or medical professionals, and materials unrelated to ACL surgery were excluded. Readability was quantified using Flesch Reading Ease, Flesch-Kincaid Grade Level (FKGL), SMOG (Simple Measure of Gobbledygook) Grade, Coleman-Liau Index, and Gunning-Fog Index. The Patient Education Materials Assessment Tool (PEMAT) was utilized to assess actionability and understandability of materials. The relationship between an online resource’s Google search rank (from first to last) and its readability, understandability, and actionability were examined.

Results

68 unique websites were identified, of which 39 met inclusion criteria. The mean FKGL was 10.08±2.34 with no website scoring =6th grade level. Mean understandability and actionability were 59.18±10.86 (range: 33.64 to 79.17) and 34.41±22.31 (range: 0 to 81.67), respectively. Only 5 (12.82%) and 1 (2.56%) resources scored above the 70% adequate PEMAT-P threshold mark for understandability and actionability, respectively. Readability (lowest p-value: p = 0.103), understandability (rho= -0.13; p=0.441), and actionability (rho= 0.28; p=0.096) scores were not associated with Google rank. Interrater reliability demonstrated moderate agreement (kappa= 0.50±0.04; p<0.001).

Conclusion

Overall, ACL surgery patient education materials scored poorly with respect to readability, understandability, and actionability. No online resource scored at the AMA and NIH recommended reading level. Only 5 scored above the proven threshold for understandability and only one for actionability. Future efforts should be made to improve the readability, understandability and actionability of online resources to optimize patient knowledge and facilitate informed decision-making.