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Letters to the Editor to:

The Orthopaedic Forum:
Sameer Badarudeen and Sanjeev Sabharwal
Readability of Patient Education Materials from the American Academy of Orthopaedic Surgeons and Pediatric Orthopaedic Society of North America Web Sites
J Bone Joint Surg Am 2008; 90: 199-204 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Dr. Sabharwal et al. respond to Dr. Moseley, et al.
Sanjeev Sabharwal, M.D., Sameer Badarudeen, MB, BS   (19 March 2008)
[Read Letter to the Editor] Readability of Online Educational Material
Colin F. Moseley, M.D., Steven Richards, MD, Section Editor, Pediatric Orthopaedic Surgery, "Your Orthopaedic Connection". Frances A. Farley, MD, Chairman, Patient Education Committee   (7 February 2008)

Dr. Sabharwal et al. respond to Dr. Moseley, et al. 19 March 2008
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Sanjeev Sabharwal, M.D.
UMDNJ-New Jersey Medical School, Newark, NJ,
Sameer Badarudeen, MB, BS

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Re: Dr. Sabharwal et al. respond to Dr. Moseley, et al.

sabharsa{at}umdnj.edu Sanjeev Sabharwal, M.D., et al.

To The Editor:

We agree with Dr. Moseley and coauthors that selecting the reading level for patient education materials is a “balancing act with no perfect solution”. Apparently, the target reading level for the AAOS patient education website, "Your Orthopaedic Connection" (YOC), was the eighth grade. However, we did report(1) that 70 percent of the online articles pertaining to pediatric orthopaedic topics had readability scores that were higher than the eighth grade level.

As mentioned in our manuscript, recommendations from the National Work Group on Cancer and Health(2), the American Medical Association(3), and the National Institutes of Health(4), are to keep readability of patient information material less than a sixth grade level. In another recent study(5) assessing the readability of all available patient education articles at the AAOS website, we found that only ten of the 426 articles in English had readability level less than or equal to sixth grade.

We concur with the authors’ suggestion of stratifying the contents of the patient education materials to suite the needs and comprehensibility of a larger segment of the population, and have mentioned this in the discussion section of our manuscript(1). We do realize that making a comprehensive patient education handout to serve the entire adult population is a challenging task and the current tools for assessing readability such as the Flesch-Kinkaid formula have limitations(1,5). However, we hope that organizations such as the AAOS and POSNA will continue to provide validated and up-to-date information about various orthopaedic conditions in a way that is sensitive to the diversity and readability of the entire patient population.

Referemces:

1. Badarudeen, S, and Sabharwal S. Readability of patient education materials from the American Academy of Orthopaedic Surgeons and Pediatric Orthopaedic Society of North America web sites. J Bone Joint Surg Am. 2008;90(1):199-204.

2. Cotugna N, Vickery CE, Carpenter-Haefele KM. Evaluation of literacy level of patient education pages in health-related journals. J Community Health. 2005;30(3):213-9.

3. Weiss BD. Health literacy: a manual for clinicians. Chicago, IL: American Medical Association Foundation. 2003.

4. National Institutes of Health: How to write easy to read health materials. Updated 2007 Aug 22. http://www.nlm.nih.gov.mlprox.csmc.edu/medlineplus/etr.html. Accessed 2007 Nov 8.

5. Sabharwal S, Badarudeen S, Kunju SU. Readability of online patient education materials at the AAOS website. Clin. Orthop. (Published online March 7, 2008).
Readability of Online Educational Material 7 February 2008
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Colin F. Moseley, M.D.,
Orthopaedic Surgeon
Editor, AAOS's "Your Orthopaedic Connection",
Steven Richards, MD, Section Editor, Pediatric Orthopaedic Surgery, "Your Orthopaedic Connection". Frances A. Farley, MD, Chairman, Patient Education Committee

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Re: Readability of Online Educational Material

colinmoseley{at}mac.com Colin F. Moseley, M.D., et al.

To The Editor:

We read with great interest the article, “Readability of Patient Education Materials from the American Academy of Orthopaedic and Pediatric Orthopaedic Society of North America Web Sites"(1). The authors examined readability levels of the pediatric articles on the American Academy of Orthopaedic Surgeons (AAOS) web site, "Your Orthopaedic Connection" (YOC), and the articles on the Pediatric Orthopaedic Society of North America (POSNA) web site, and found that only 2 percent of the articles were at the desired sixth grade readability level. That result is consistent with the fact that we have recently been targeting YOC articles at the eighth grade level.

The reading level of individuals seeking health information on the internet is not documented and, although the authors cite cancer literature to set their optimal readability at the sixth grade level, it has not been established that there is a single optimal readability level of health information on the internet. Indeed, lowering the reading level by restricting vocabulary and grammar can make it impossible to express essential concepts. Selecting the reading level is, therefore, a balancing act with no perfect solution.

To deal with the varied reading abilities and varied pre-existing "medical" knowledge of its users, YOC has decided to present information and learning modules at two levels: a "basic" level aimed at grade six English and little or no pre-existing knowledge, and an "advanced" level aimed at the high school graduate with strong reading skills and some knowledge of human biology. In a sense, the AAOS's "Orthopaedic Knowledge Online" presents a third, even higher, level aimed at the orthopaedic resident and surgeon.

The authors' suggestions to use shorter sentences and simpler words and phrases and to include more illustrations are established principles for future YOC content.

We applaud the authors for their novel, timely research on an important topic in this emerging field. We encourage their further investigations in this fertile area.

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Reference:

1. Badarudeen S, Sabharwal S. Readability of patient education materials from the American Academy of Orthopaedic Surgeons and Pediatric Orthopaedic Society of North America web sites. J Bone Joint Surg Am. 2008;90:199-204.