title: Are patient-reported outcome measures in orthopaedics easily read by patients?
abstract: BACKGROUND
  Patient-reported outcome measures (PROMs) are commonly used by healthcare providers as means of assessing health-related quality of life and function at any given time. The complexity of PROMs can differ and when combined with varying degrees of adult literacy, error can be introduced if patients fail to understand questions. With an average adult literacy level of 11-year-old students in the United Kingdom, it is unclear to what degree PROMs can be read and understood by most patients (readability); to our knowledge, this has not been evaluated.
  
  
  OBJECTIVE
  We wished to determine the readability of commonly used PROMs in orthopaedic surgery, as assessed by a validated tool that measures the complexity of the language in these surveys.
  
  
  METHODS
  We performed a MEDLINE search to identify the most-commonly reported PROMs in orthopaedic research. One hundred twenty-one PROMs were identified and reviewed by 19 attending orthopaedic surgeons at our institution. Fifty-nine were selected as the most commonly used in our department. Of these, 52 (78%) were disease specific and included: 12 (20%) knee, 10 (17%) shoulder, seven (12%) spine, six (10%) hip, five (8%) foot and ankle, four (7%) elbow, three (5%) pelvis, three (5%) hand and wrist, and two (3%) lower limb. The remaining seven (12%) PROMs were general health questionnaires. The Flesch Reading Ease Score is a validated readability tool measuring average sentence length and syllables per word. It is expressed on a scale from 0 to 100 with higher scores indicating easier reading. We extracted the text from each PROM and inserted it in the same online Flesch Reading Ease Score calculator to generate a score.
  
  
  RESULTS
  The mean readability score was 55 (range, 0-93), corresponding to text best understood by 16- to 18-year-old students (11th-12th grades). Twenty-nine PROMs (49%) scored less than 60, classifying them as at least fairly difficult to read. Eight (14%) scored less than 30, best understood by university graduates. Only seven of 59 PROMs analyzed scored greater than 79, corresponding to text that can be understood by the average UK adult.
  
  
  CONCLUSIONS
  The majority of PROMs analyzed are written at a level that is incomprehensible to the average UK adult.
  
  
  CONCLUSIONS
  This issue needs to be addressed if we are to continue basing our research conclusions on outcome scores. The information obtained is useful for patients to understand their musculoskeletal health, governmental agencies allocating healthcare resources, provision of management guidelines, and as a link to other data sets, such as hospital episodes statistics. Accurate and reliable data can be obtained only if patients who complete these evaluations are able to read and understand the questions asked.
authors.affiliation: Department of Trauma and Orthopaedic Surgery, Basildon and Thurrock University Hospitals, Basildon, Essex, UK. Ibraheimel-daly@nhs.net
authors.forename: Ibraheim
authors.initials: I
authors.lastname: El-Daly
authors.forename: Hajir
authors.initials: H
authors.lastname: Ibraheim
authors.forename: Karthig
authors.initials: K
authors.lastname: Rajakulendran
authors.forename: Paul
authors.initials: P
authors.lastname: Culpan
authors.forename: Peter
authors.initials: P
authors.lastname: Bates
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D032882:Comprehension; D006304:Health Status; D006801:Humans; D000067010:Literacy; D008875:Middle Aged; D009140:Musculoskeletal Diseases / Q000601:surgery; D019637:Orthopedic Procedures; D063868:Patient Outcome Assessment; D011788:Quality of Life; D015203:Reproducibility of Results; D057566:Self Report; D011795:Surveys and Questionnaires; D006113:United Kingdom; D055815:Young Adult