To the Editor:
Patient-reported outcome measures are important standardized survey tools in medicine. In anesthesiology, patient-reported outcome measures are used perioperatively to collect information about patients’ health status, quality of life, and healthcare experiences.1 As health care evolves, patient-reported outcome measures have the ability to enhance patient engagement and shared decision making, which could improve the safety and efficacy of anesthesia.2
Although there are many benefits of patient-reported outcome measures, low health literacy is a significant barrier to their effective use. The National Institutes of Health (Bethesda, Maryland) and other healthcare organizations recommend healthcare-related materials to be published at or below a sixth-grade reading level.3 Recent studies in other fields have calculated many specialty-specific patient-reported outcome measures to be above the recommended complexity.3 We examined patient-reported outcome measures commonly used in the perioperative setting in relation to health equity.
Eighteen patient-reported outcome measures were selected from those in a systematic review.1 Three additional patient-reported outcome measures highly cited in anesthesia literature were also included.4 The 21 patient-reported outcome measures evaluated are listed in table 1. Readability was assessed by a linguistics software (readable.com; Added Bytes, United Kingdom) using the Gunning Fog Index, Simple Measure of Gobbledygook (SMOG) Index, FORCAST Grade Level, and Flesch Reading Ease Score, indices used in previous readability studies and applicable to healthcare materials.3 Each numerical score computed per index correlates to a reading grade level. Consequently, an average readability score of six denotes a reading grade level of sixth grade.
All 21 anesthesia patient-reported outcome measures analyzed had average readability scores above the sixth-grade level. The overall average readability was nine, corresponding to a ninth-grade reading level. The Hospital Anxiety and Depression Scale had the easiest readability at six, whereas the Bauer questionnaire had the most difficult at twelve. The average readability levels by patient-reported outcome measure are reported in table 1. Table 1 also shows the readability scores of each individual patient-reported outcome measure and the mean readability score and SD by index.
Patient-reported outcome measures have become an important tool to measure not only vital outcomes such as mortality and postoperative complications but also postoperative symptoms that affect length of hospital stay, chronic health conditions, and cost of care.5 Measuring these outcomes allows for better patient engagement and shared decision making, thus enhancing overall medical care.2
Recent readability studies in specialties such as otolaryngology have also reported the majority of their patient-reported outcome measures to be higher than recommended by healthcare organizations.3 Furthermore, several readability studies found online patient education materials in anesthesia to be even less readable.6,7 De Oliveira et al.6,7 determined a 13th-grade reading level is required to understand most patient education materials in anesthesia. Other studies reported the reading level of patient-reported experience measures in regional anesthesia and neuraxial labor analgesia to be well above the sixth grade.
The complexity of healthcare reading materials poses a significant challenge for patients with lower health literacy, particularly in their ability to accurately complete patient-reported outcome measure questionnaires. Low health literacy disproportionately affects underserved populations, including minority groups, immigrants, and adults with lower education levels, further contributing to health disparities.8 Low health literacy is also associated with poor health outcomes, including delayed diagnoses, inadequate self-management skills, and higher rates of chronic conditions.9 Similarly, perioperative outcomes may be negatively affected.10
This study has several limitations. First, the Gunning Fog and SMOG indices were developed to analyze running narratives, rather than questionnaires, which may have affected readability scores.3 Second, the algorithms are not designed to analyze complex medical terms, which may have also affected the readability scores.3 Last, although a comprehensive literature search was conducted by the authors, it is possible that some validated anesthesia patient-reported outcome measures were not included in this study. However, inclusion of more would likely not have altered data enough to affect conclusions, because the average readability of patient-reported outcome measures in this study is at a ninth-grade level.
Developers of patient-reported outcome measure should consider performing readability analysis of text when designing questionnaires. And although these tools undergo a rigorous vetting before implementation, the authors would like to raise awareness of imperfections that exist. Improving the readability of these reporting tools could aid in improving data accuracy and health outcomes.
The authors declare no competing interests.