Readability and Suitability of Patient-Reported Outcome Measures in Foot and Ankle Surgery: A Health Literacy Assessment

Abstract

Category: Other; Ankle; Hindfoot; Midfoot/Forefoot; Trauma Introduction/Purpose: Health literacy is consistently reported as one of the best predictors of health status. This becomes even more important considering the complex medical information that is communicated to a patient during a clinical visit. Patient reported outcome measures (PROMs) are used on a standard of care basis in orthopedic surgery, and consistently included in research projects to elucidate meaningful clinical information. While there have been published assessments on the reading grade level of orthopedic PROMs in general, few address foot and ankle specific outcome measures. There have been no reports on aesthetic component of these PROMs, which have a major impact on readability. The purpose of this study is to report on the literacy, readability, and suitability of PROMs in foot and ankle surgery. Methods: A PubMed search was conducted to identify the most frequently utilized foot and ankle PROMs. Two recent systematic reviews identified 86 total PROMs in orthopedic surgery, 8 of which were foot and ankle specific. For the readability component, the Flesh-Kincaid reading grade level was assessed for each PROM. For the aesthetic component, the Suitability Assessment of Materials (SAM) was utilized to assess for content, literacy demand, graphics, layout, typography, learning stimulation, motivation and cultural appropriateness. SAM is a validated measure for analyzing print materials, and designate rankings of not suitable, adequate, or superior, based on results of the analysis. SAM scores were evaluated for all included PROMs by two investigators and averaged together for increased validity. Descriptive statistics were performed on all results. Statistical analysis was performed with SPSS Version 24.0. Results: The average Flesh-Kincaid grade for all PROMs was 6.12 (+-2.2, range 3.9-8.5). 5 of the 8 (62.5%) PROMs were at or below the AMA-recommended 6th grade reading level, with 6 of 8 (75.0%) below the NIH-recommended 8th grade reading level. The average SAM score for all included foot and ankle PROMs was ‘adequate,’ receiving a score of 1. 1 PROM was designated ‘not suitable,’ with the remaining 7 deemed ‘adequate.’ The area that scored the lowest on the SAM assessment was the ‘graphics’ section. Conclusion: The PROMs used in foot and ankle surgery perform well on the Flesh-Kincaid score in comparison to both the AMA and NIH reading grade level standards. The highest rating for the SAM score was average, indicating room for improvement in suitability. The inclusion of graphics and illustrations would make these scores more easily understood by patients, which can improve their healthcare experience and improve patient satisfaction and health outcomes.