Editor's Spotlight/Take 5: Readability of Orthopaedic Patient-reported Outcome Measures: Is There a Fundamental Failure to Communicate?

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When the purpose of treatment is to help the patient by reducing symptoms and improve quality of life, there are some questions that only the patient can answer. As we seek each patient's answers, it turns out that the way we ask our questions may be as important as the questions themselves. How good are we at asking our patients these questions? Do our patients even understand them?
A recent study of orthopaedic patient-reported outcome measures (PROMs) reported that most such materials are written at a level that is incomprehensible to the average adult reader [2]. The problem of hard-to-understand content is, in fact, even more widespread than that. A total of 97% of the reading material on the American Academy of Orthopaedic Surgeons website was above the 6th grade reading level in one study [4]. Similar findings have been reported across disciplines and in other kinds of patient-education materials [3, 5-7, 10, 13]. With increasing emphasis on PROMs, the incomprehensibility of medical information written for our patients calls into question the reliability of the feedback we receive.
These concerns prompted Dr. Brent A. Ponce and his team at the University of Alabama at Birmingham to study the readability of PROMs used in orthopaedic surgery. They compared their results against both the Centers for Medicare & Medicaid Service's (CMS) and NIH's recommendations for reading grade levels. Given the reporting to the contrary [2, 4], Dr. Ponce's group offer a surprising finding—that the vast majority of PROMs are, in fact, written at an acceptable grade level. However, there are still a small number of PROMs that are beyond the grasp of most patient's reading comprehension.
Dr. Ponce and his coauthors went beyond analysis; they showed how deliberate editing can improve readability of medical information for patients. Editing improved all of the difficult-to-read PROMs. These suggestions are generalizable to printed information for patients. Using simple steps and available tools, we can apply the findings of Dr. Ponce's work to material we produce for our patients, from the development of future PROMs to printed discharge instructions.
Please join me for the Take-5 interview with Brent A. Ponce MD, as we explore the important topic of communication with patients.
Take-5 Interview with Brent A. Ponce MD, senior author of “Readability of Orthopaedic Patient-reported Outcome Measures: Is There a Fundamental Failure to Communicate?”
M. Daniel Wongworawat MD:You are familiar with previous reports [2, 4] showing that orthopaedic patient material often exceeds the reading level of those patients. Why do you think your findings are so different?
Brent A. Ponce MD: Assessing readability is challenging, especially in medicine. Physicians generally communicate as they would with peers instead of adopting the perspective of a patient who may not have the same education. Readability algorithms were specifically designed for use in the military, educational, or business sectors—not in medicine. Additionally, the currently used readability algorithms have been around for many years, and they each use different formulas that emphasize different items to assess text readability. To use a lone metric, as in prior orthopaedic studies, fails to consider numerous accepted, alternative ways to assess readability. For example, one algorithm may use the number of “complex words” in a text to determine grade level, while another may be based upon sentence length. Neither is wrong, but neither really considers all components of the text. To use a baseball analogy, Dave Kingman hit a lot of home runs, but he is not in the Hall of Fame. Many other players with fewer home runs are enshrined at Cooperstown.
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