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Patient education materials (PEMs) in rheumatology and general medicine demanded greater literacy than is typically recommended, researchers found.

Handouts from the American College of Rheumatology (ACR) and the JAMA Network group required a 10th-grade reading level on average by one metric, and a college-sophomore level by another, according to Yazmin Rustomji, MD, and colleagues at Rush University in Chicago.

Those from JAMA were particularly difficult, with means of 121 "complex words" per piece and 21 words per sentence, the group .

Yet the and, ironically, the , which oversees the JAMA group, have recommended against PEMs requiring more than a 6th-grade reading level, Rustomji and colleagues observed. The CDC, meanwhile, calls for materials to be no more difficult than an 8th-grade level.

"As effective PEMs help educate patients about their health, promote shared decision making, increase medication compliance, lower healthcare costs, and improve health outcomes, it is essential that they are more patient-friendly," they wrote. "Therefore, current PEMs should be revised to the appropriate reading level, and new PEMs should be created in line with national recommendations."

The researchers analyzed 86 PEM products from the ACR and 89 posted by the JAMA group, covering a wide range of rheumatology and general medicine topics. (The two organizations' homepages for PEMs are located and .) Rustomji and colleagues then analyzed each of them with the following readability gauges:

• Flesch Kincaid Readability Ease (FKRE)
• Flesch Kincaid Grade Level (FKGL)
• Simple Measure of Gobbledygook Index (SMOG)
• Gunning Fog Score (GFS)
• Coleman Liau Index (CLI)
• Automated Readability Index (ARI)

"Each index provides insight into the complexity and comprehensibility of the text based on factors including sentence and word length, syllables per word, and the use of uncommon words," the investigators explained.

The FKGL, SMOG, and GFS instruments are particularly informative because they indicate the school-grade literacy level needed for adequate comprehension. Across both ACR and JAMA PEMs, more than 20% demanded a college-level reading level as graded by SMOG and more than one-third were that complex according to the FKGL. Some documents required college-graduate, even fellowship level literacy.

By the same token, only a handful met the 6th-to-8th grade literacy standards. The FKGL and GFS identified only one; 13 met the standard according to SMOG.

Under the GFS, the average score was 14.39, "denoting about 14 years of formal education required to comprehend the text on the first reading," Rustomji and colleagues reported; means for the FKGL and SMOG were 12.08 and 10.89, respectively.

In comparing ACR and JAMA PEMs' readability, the former were generally easier by about two grade levels. By the FKGL, for example, the averages were 11.07 versus 13.06, respectively (P<0.001).

It's not the first study to throw shade on PEMs for understandability. showed that, among nearly 2,600 PEMs appearing in "high-impact" journals, 8.2% were readable at an 8th-grade level; just 2.1% were readable at a 6th-grade level. (However, that study included materials published as far back as 1998, when readability was arguably less of a concern.)

Rustomji and colleagues also pointed to a in which patients were given PEMs about rheumatology drug therapies and then tested on their comprehension: materials about adalimumab (Humira) and nonsteroidal anti-inflammatory drugs clearly missed the mark, with fewer than half of patients answering all questions about them correctly, although most understood the PEMs for prednisone and methotrexate adequately.

In preparing PEMs, Rustomji and colleagues recommended a which "emphasizes the importance of conducting a needs analysis, setting learning objectives, composing appropriate content, and evaluating the effectiveness of the materials."

Limitations to the study included a semi-automated procedure for inputting materials into the readability instruments, which was unable to process graphical elements within the PEMs that might have improved patients' comprehension. Additionally, the study only examined English-language materials, and its focus on ACR and JAMA materials means it may not be generalizable to PEMs developed elsewhere.

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