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��ࡱ�>��	46����123������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	��ˑbjbj���	4�������,���������11111����EEE8}�Y�Em,f333*$N�2 t,,,,,,,�-�u0B,1� **� � ,1133�',"""� �1313N#�"� ,"""3�����S~*Ώ�Ep!^":#=,0m,"�0�!4�0"�01"8� � "� � � � � ,,"� � � m,� � � � ���������������������������������������������������������������������0� � � � � � � � � �	�:	Readability Assessment of Internet-Based Patient Education Materials Related to Parathyroid Surgery


1Chirag R. Patel, MD
1Saurin Sanghvi, MD
1Deepa V. Cherla, MD
1Soly Baredes, MD, FACS
1,2,3Jean Anderson Eloy, MD, FACS

1Department of Otolaryngology � Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ

2Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ

3Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, NJ

Running Title:  Readability of Parathyroid Surgery Education Materials

Key Words: Parathyroid surgery, readability, Flesch-Kincaid Grade Level, Flesch Reading Ease, Gobbledygook, patient education material, parathyroidectomy, Internet patient education material, health information, patient literacy.

Financial Disclosures:  None
Conflicts of Interest:  None
Word Count: 1642


Corresponding Author: 
Jean Anderson Eloy, MD, FACS
Associate Professor and Vice Chairman
Director of Rhinology, Sinus Surgery, and Endoscopic Skull Base Surgery
Department of Otolaryngology � Head and Neck Surgery
Rutgers New Jersey Medical School
90 Bergen St., Suite 8100
Newark, NJ 07103
Phone: (973) 972-4588
FAX: (973) 972-3767
E-mail: HYPERLINK "mailto:jean.anderson.eloy@gmail.com"jean.anderson.eloy@gmail.com
ABSTRACT
Objective:  Patient education is critical in obtaining informed consent and reducing preoperative anxiety.  Written PEM can supplement verbal communication to improve understanding and satisfaction.  Published guidelines recommend that health information be presented at or below a sixth-grade reading level to facilitate comprehension.  We investigate the grade level of online PEMs regarding parathyroid surgery.

Methods: A popular internet search engine was used to identify PEM discussing parathyroid surgery.  Four formulas were used to calculate readability scores: Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade Level (FKGL), Gunning Frequency of Gobbledygook (GFOG), and Simple Measure of Gobbledygook (SMOG).

Results:  Thirty web-based articles discussing parathyroid surgery were identified.  The average FRES was 42.8 (�1 SD 16.3, 95%CI 36.6 to 48.8, range 6.1 to 71.3).  The average FKGL score was 11.7 (�1 SD 3.3, 95%CI 10.5 to 12.9, range 6.1 to 19.0).  The SMOG scores averaged 14.2 (�1 SD 2.6, 95%CI 13.2 to 15.2, range 10.7 to 21.9) and the GFOG scores averaged 15.0 (�1 SD 3.5, 95%CI 13.7 to 16.3, range 10.6 to 24.8).

Conclusion: Online patient education material (PEM) on parathyroid surgery is written above the recommended sixth-grade reading level.  Improving readability of PEM may promote better health education and compliance.INTRODUCTION
Most patients awaiting elective surgery experience preoperative anxiety.  A recent study reviewed concerns of patients awaiting thyroidectomy and found that patients most worried about surgery related concerns such as experiencing a complication, postoperative pain, aesthetics, unfavorable diagnosis, and the need for further surgery. HYPERLINK \l "_ENREF_1" \o "Abdul-Sater, 2011 #998"  ADDIN EN.CITE  ADDIN EN.CITE.DATA 1  The provision of information has been shown to reduce preoperative anxiety and improve satisfaction with treatment. HYPERLINK \l "_ENREF_2" \o "Chan, 2002 #999"  ADDIN EN.CITE  ADDIN EN.CITE.DATA 2 In addition to helping reduce anxiety, patient education is a critical component to obtaining informed consent.  Educating the patient and obtaining adequate informed consent prior to administering treatment is the standard of care in modern medical practice.  As such, a thorough discussion of the nature and purpose of the treatment, its risks and benefits, the potential complications, alternative therapies, and consequences of not receiving the proposed treatment is necessary.  Unfortunately, many patients do not understand much of the information disclosed to them and the ability to recall this information decays with time. HYPERLINK \l "_ENREF_2" \o "Chan, 2002 #999"  ADDIN EN.CITE  ADDIN EN.CITE.DATA 2
Written information can be a cost-effective way of increasing a patient�s knowledge and allaying fears or anxiety about a condition or surgical procedure. HYPERLINK \l "_ENREF_3" \o "Blanck, 2011 #8"  ADDIN EN.CITE  ADDIN EN.CITE.DATA 3  It allows patients to read and explore the details of their procedure at their own pace.  It also allows them to review that information as needed. This has been shown to improve recall and reduce preoperative anxiety. HYPERLINK \l "_ENREF_2" \o "Chan, 2002 #999"  ADDIN EN.CITE  ADDIN EN.CITE.DATA 2
Self exposure to information is a well identified coping mechanism for dealing with stress and anxiety of the unknown. HYPERLINK \l "_ENREF_4" \o "Kain, 1999 #38"  ADDIN EN.CITE <EndNote><Cite><Author>Kain</Author><Year>1999</Year><RecNum>38</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>38</rec-number><foreign-keys><key app="EN" db-id="ea2wx0ffhrfefkep5zgvrts00fxv2evxevre">38</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kain, Z. N.</author></authors></contributors><titles><title>Perioperative information and parental anxiety: the next generation</title><secondary-title>Anesth Analg</secondary-title><alt-title>Anesthesia and analgesia</alt-title></titles><periodical><full-title>Anesth Analg</full-title><abbr-1>Anesthesia and analgesia</abbr-1></periodical><alt-periodical><full-title>Anesth Analg</full-title><abbr-1>Anesthesia and analgesia</abbr-1></alt-periodical><pages>237-9</pages><volume>88</volume><number>2</number><edition>1999/02/11</edition><keywords><keyword>Adaptation, Psychological</keyword><keyword>Adult</keyword><keyword>Anesthesia, General/psychology</keyword><keyword>Anxiety/*etiology/prevention &amp; control</keyword><keyword>Child</keyword><keyword>*Health Education</keyword><keyword>Humans</keyword><keyword>Outcome Assessment (Health Care)</keyword><keyword>Parent-Child Relations</keyword><keyword>*Parents/education</keyword><keyword>Reproducibility of Results</keyword><keyword>Surgical Procedures, Operative/adverse effects/*psychology</keyword><keyword>Teaching/methods</keyword><keyword>Videotape Recording</keyword></keywords><dates><year>1999</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0003-2999 (Print)&#xD;0003-2999 (Linking)</isbn><accession-num>9972732</accession-num><work-type>Comment&#xD;Editorial</work-type><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/9972732</url></related-urls></urls><language>eng</language></record></Cite></EndNote>4  The acquisition of information provides patient with a sense of predictability and autonomy over their condition. HYPERLINK \l "_ENREF_5" \o "Durling, 2007 #39"  ADDIN EN.CITE <EndNote><Cite><Author>Durling</Author><Year>2007</Year><RecNum>39</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>39</rec-number><foreign-keys><key app="EN" db-id="ea2wx0ffhrfefkep5zgvrts00fxv2evxevre">39</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Durling, M.</author><author>Milne, D.</author><author>Hutton, N.</author><author>Ryan, S.</author></authors></contributors><titles><title>Decreasing patient&apos;s preoperative anxiety: a literature review</title><secondary-title>Aust Nurs J</secondary-title></titles><periodical><full-title>Aust Nurs J</full-title></periodical><pages>35</pages><volume>14</volume><number>11</number><edition>2007/06/23</edition><keywords><keyword>Anxiety/etiology/*prevention &amp; control/psychology</keyword><keyword>Evidence-Based Medicine</keyword><keyword>Humans</keyword><keyword>Nurse Anesthetists/*organization &amp; administration</keyword><keyword>Nurse&apos;s Role</keyword><keyword>Nursing Evaluation Research</keyword><keyword>Preoperative Care/methods/*nursing/psychology</keyword></keywords><dates><year>2007</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1320-3185 (Print)&#xD;1320-3185 (Linking)</isbn><accession-num>17583023</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/17583023</url></related-urls></urls><language>eng</language></record></Cite></EndNote>5  The availability of health information on the internet has made this a simpler task.  Nearly 75% of U.S. adults use the internet, and 80% of those users look for health information. HYPERLINK \l "_ENREF_6" \o "Fox, 2011 #989"  ADDIN EN.CITE <EndNote><Cite><Author>Fox</Author><Year>2011</Year><RecNum>989</RecNum><DisplayText><style face="superscript">6</style></DisplayText><record><rec-number>989</rec-number><foreign-keys><key app="EN" db-id="tr52f05zqezf0lezdf3xeff00ds0er2pvpep">989</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Fox, Susannah</author></authors></contributors><titles><title>Social Life of Health Information, 2011</title><secondary-title>Pew Research Center�s Internet &amp; American Life Project</secondary-title></titles><periodical><full-title>Pew Research Center�s Internet &amp; American Life Project</full-title></periodical><dates><year>2011</year><pub-dates><date>May 12, 2011</date></pub-dates></dates><urls></urls></record></Cite></EndNote>6  In order for this online information to be valuable, it must be comprehensible.
Readability refers to the comprehension level a person must have to understand the information they are reading. HYPERLINK \l "_ENREF_7" \o "Albright, 1996 #990"  ADDIN EN.CITE <EndNote><Cite><Author>Albright</Author><Year>1996</Year><RecNum>990</RecNum><DisplayText><style face="superscript">7</style></DisplayText><record><rec-number>990</rec-number><foreign-keys><key app="EN" db-id="tr52f05zqezf0lezdf3xeff00ds0er2pvpep">990</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Albright, J.</author><author>de Guzman, C.</author><author>Acebo, P.</author><author>Paiva, D.</author><author>Faulkner, M.</author><author>Swanson, J.</author></authors></contributors><auth-address>Summit Medical Center, Samuel Merritt College, Oakland, CA 94609, USA.</auth-address><titles><title>Readability of patient education materials: implications for clinical practice</title><secondary-title>Appl Nurs Res</secondary-title><alt-title>Applied nursing research : ANR</alt-title></titles><periodical><full-title>Applied nursing research : ANR</full-title><abbr-1>Appl Nurs Res</abbr-1></periodical><alt-periodical><full-title>Applied nursing research : ANR</full-title><abbr-1>Appl Nurs Res</abbr-1></alt-periodical><pages>139-43</pages><volume>9</volume><number>3</number><edition>1996/08/01</edition><keywords><keyword>*Educational Status</keyword><keyword>Humans</keyword><keyword>Nursing Evaluation Research</keyword><keyword>*Patient Education as Topic</keyword><keyword>*Reading</keyword><keyword>Teaching Materials/*standards</keyword></keywords><dates><year>1996</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0897-1897 (Print)&#xD;0897-1897 (Linking)</isbn><accession-num>8771859</accession-num><work-type>Review</work-type><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/8771859</url></related-urls></urls><language>eng</language></record></Cite></EndNote>7  There are several different measures of readability that take into account different components of sentence length and word difficulty. HYPERLINK \l "_ENREF_8" \o "Wilson, 2009 #687"  ADDIN EN.CITE <EndNote><Cite><Author>Wilson</Author><Year>2009</Year><RecNum>687</RecNum><DisplayText><style face="superscript">8</style></DisplayText><record><rec-number>687</rec-number><foreign-keys><key app="EN" db-id="tr52f05zqezf0lezdf3xeff00ds0er2pvpep">687</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wilson, M.</author></authors></contributors><auth-address>Department of Nursing, School of Health Sciences, University of Saint Francis, Fort Wayne, IN, USA.</auth-address><titles><title>Readability and patient education materials used for low-income populations</title><secondary-title>Clin Nurse Spec</secondary-title><alt-title>Clinical nurse specialist CNS</alt-title></titles><periodical><full-title>Clinical nurse specialist CNS</full-title><abbr-1>Clin Nurse Spec</abbr-1></periodical><alt-periodical><full-title>Clinical nurse specialist CNS</full-title><abbr-1>Clin Nurse Spec</abbr-1></alt-periodical><pages>33-40; quiz 41-2</pages><volume>23</volume><number>1</number><edition>2008/12/23</edition><keywords><keyword>Humans</keyword><keyword>Midwestern United States</keyword><keyword>Patient Education as Topic/*methods</keyword><keyword>*Poverty</keyword><keyword>*Reading</keyword></keywords><dates><year>2009</year><pub-dates><date>Jan-Feb</date></pub-dates></dates><isbn>1538-9782 (Electronic)&#xD;0887-6274 (Linking)</isbn><accession-num>19098513</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/19098513</url></related-urls></urls><electronic-resource-num>10.1097/01.NUR.0000343079.50214.31</electronic-resource-num><language>eng</language></record></Cite></EndNote>8  There is no consensus on which readability formula is best suited for evaluating health information. HYPERLINK \l "_ENREF_9" \o "Badarudeen, 2010 #995"  ADDIN EN.CITE  ADDIN EN.CITE.DATA 9  The Flesch-Kincaid Grade Level (FKGL) and Gunning Frequency of Gobbledygook (GFOG) are two of the more commonly used indices. HYPERLINK \l "_ENREF_10" \o "Walsh, 2008 #672"  ADDIN EN.CITE <EndNote><Cite><Author>Walsh</Author><Year>2008</Year><RecNum>672</RecNum><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>672</rec-number><foreign-keys><key app="EN" db-id="tr52f05zqezf0lezdf3xeff00ds0er2pvpep">672</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Walsh, T. M.</author><author>Volsko, T. A.</author></authors></contributors><auth-address>Department of Health Professions, Youngstown State University, One University Plaza, Youngstown, OH 44555, USA. tmwalsh01@student.ysu.edu</auth-address><titles><title>Readability assessment of internet-based consumer health information</title><secondary-title>Respir Care</secondary-title><alt-title>Respiratory care</alt-title></titles><periodical><full-title>Respiratory care</full-title><abbr-1>Respir Care</abbr-1></periodical><alt-periodical><full-title>Respiratory care</full-title><abbr-1>Respir Care</abbr-1></alt-periodical><pages>1310-5</pages><volume>53</volume><number>10</number><edition>2008/09/25</edition><keywords><keyword>Consumer Health Information/methods/*standards</keyword><keyword>Health Education/*standards</keyword><keyword>Humans</keyword><keyword>*Internet</keyword><keyword>Reproducibility of Results</keyword><keyword>United States</keyword></keywords><dates><year>2008</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0020-1324 (Print)&#xD;0020-1324 (Linking)</isbn><accession-num>18811992</accession-num><work-type>Comparative Study</work-type><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/18811992</url></related-urls></urls><language>eng</language></record></Cite></EndNote>10  The Simple Measure of Gobbledygook (SMOG) was developed by Harry McLaughlin in the 1960s as a simpler and reportedly more accurate measure of readability. HYPERLINK \l "_ENREF_11" \o "McLaughlin, 1969 #40"  ADDIN EN.CITE <EndNote><Cite><Author>McLaughlin</Author><Year>1969</Year><RecNum>40</RecNum><DisplayText><style face="superscript">11</style></DisplayText><record><rec-number>40</rec-number><foreign-keys><key app="EN" db-id="ea2wx0ffhrfefkep5zgvrts00fxv2evxevre">40</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McLaughlin, G. Harry</author></authors></contributors><titles><title>SMOG Grading - A New Readability Formula</title><secondary-title>Journal of Reading</secondary-title></titles><periodical><full-title>Journal of Reading</full-title></periodical><pages>639-646</pages><dates><year>1969</year><pub-dates><date>May 1969</date></pub-dates></dates><urls></urls></record></Cite></EndNote>11  All three of these formulas provide a score which indicates the years of education necessary to read and comprehend the material.  Alternatively, Flesch Reading Ease (FRE) score rates text on a 100-point scale; the higher the score, the easier it is to read the document (Table 1).
	The United States Department of Health and Human Services (USDHHS) categorizes materials as �Easy to Read� if they are written at a 6th grade reading level or less.  Materials between 7th and 9th grade reading level is considered �Average Difficulty,� and material above the 9th grade reading level is considered �Difficult� (Table 1). HYPERLINK \l "_ENREF_10" \o "Walsh, 2008 #672"  ADDIN EN.CITE <EndNote><Cite><Author>Walsh</Author><Year>2008</Year><RecNum>672</RecNum><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>672</rec-number><foreign-keys><key app="EN" db-id="tr52f05zqezf0lezdf3xeff00ds0er2pvpep">672</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Walsh, T. M.</author><author>Volsko, T. A.</author></authors></contributors><auth-address>Department of Health Professions, Youngstown State University, One University Plaza, Youngstown, OH 44555, USA. tmwalsh01@student.ysu.edu</auth-address><titles><title>Readability assessment of internet-based consumer health information</title><secondary-title>Respir Care</secondary-title><alt-title>Respiratory care</alt-title></titles><periodical><full-title>Respiratory care</full-title><abbr-1>Respir Care</abbr-1></periodical><alt-periodical><full-title>Respiratory care</full-title><abbr-1>Respir Care</abbr-1></alt-periodical><pages>1310-5</pages><volume>53</volume><number>10</number><edition>2008/09/25</edition><keywords><keyword>Consumer Health Information/methods/*standards</keyword><keyword>Health Education/*standards</keyword><keyword>Humans</keyword><keyword>*Internet</keyword><keyword>Reproducibility of Results</keyword><keyword>United States</keyword></keywords><dates><year>2008</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0020-1324 (Print)&#xD;0020-1324 (Linking)</isbn><accession-num>18811992</accession-num><work-type>Comparative Study</work-type><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/18811992</url></related-urls></urls><language>eng</language></record></Cite></EndNote>10 The average adult in the United States reads at a seventh grade level. HYPERLINK \l "_ENREF_12" \o "Patel, 2011 #991"  ADDIN EN.CITE <EndNote><Cite><Author>Patel</Author><Year>2011</Year><RecNum>991</RecNum><DisplayText><style face="superscript">12</style></DisplayText><record><rec-number>991</rec-number><foreign-keys><key app="EN" db-id="tr52f05zqezf0lezdf3xeff00ds0er2pvpep">991</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Patel, P. P.</author><author>Hoppe, I. C.</author><author>Ahuja, N. K.</author><author>Ciminello, F. S.</author></authors></contributors><titles><title>Analysis of comprehensibility of patient information regarding complex craniofacial conditions</title><secondary-title>J Craniofac Surg</secondary-title><alt-title>The Journal of craniofacial surgery</alt-title></titles><periodical><full-title>The Journal of craniofacial surgery</full-title><abbr-1>J Craniofac Surg</abbr-1></periodical><alt-periodical><full-title>The Journal of craniofacial surgery</full-title><abbr-1>J Craniofac Surg</abbr-1></alt-periodical><pages>1179-82</pages><volume>22</volume><number>4</number><edition>2011/07/23</edition><keywords><keyword>*Comprehension</keyword><keyword>Consumer Health Information/classification</keyword><keyword>Craniofacial Abnormalities/*surgery</keyword><keyword>*Health Literacy</keyword><keyword>Humans</keyword><keyword>*Internet</keyword><keyword>Patient Care Planning</keyword><keyword>Patient Education as Topic/classification</keyword><keyword>Reconstructive Surgical Procedures</keyword><keyword>Terminology as Topic</keyword><keyword>Vocabulary</keyword></keywords><dates><year>2011</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1536-3732 (Electronic)&#xD;1049-2275 (Linking)</isbn><accession-num>21778840</accession-num><work-type>Editorial</work-type><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/21778840</url></related-urls></urls><electronic-resource-num>10.1097/SCS.0b013e31821c00e4</electronic-resource-num><language>eng</language></record></Cite></EndNote>12  Multiple professional health care organizations recommend that patient education materials be written in the �Easy to Read� USDHHS category to facilitate comprehension. ADDIN EN.CITE  ADDIN EN.CITE.DATA  HYPERLINK \l "_ENREF_12" \o "Patel, 2011 #991" 12, HYPERLINK \l "_ENREF_13" \o "Polishchuk, 2011 #994" 13  The purpose of this study was to evaluate the readability of patient education material on the internet regarding parathyroid surgery.  We hypothesized that the readability of most online material would be above the recommended 6th grade reading level.



MATERIALS AND METHODS
In February 2012, the search engine �Google� (Google, Inc. Mountain View, CA) was used to perform an internet search for patient education material related to parathyroid surgery.  The terms �parathyroid surgery� and �parathyroidectomy� were used to perform the search.  The first 50 results for each term were searched for information relating to parathyroidectomy that was intended for patients or the general public.  Articles were excluded if information was presented in languages other than English or primarily in list, table, or graphic form.  Included materials were converted to plain text and saved as Microsoft Word documents.  Information unrelated to the topic such as copyright notice, disclaimers, date stamps, author or website information, and hyperlinks were removed.  Tables, photographs, citations, decimals, colons, semicolons and dashes within sentences were also removed to avoid skewing readability scores. HYPERLINK \l "_ENREF_14" \o "Schmitt, 2011 #675" 
Readability scores were calculated using FRES, FKGL, GFOG, and SMOG formulas.  They were then categorized by USDHHS category.  FKGL and FRES scores were calculated using Microsoft Word 2007 in Microsoft Windows XP (Microsoft Corp, Redman, WA).  GFOG and SMOG scores were calculated using a free online utility accessible at �http://www.online-utility.org/english/readability_test_and_improve.jsp�.  Alternatively, these scores can be calculated manually using the formulas provided in Table 2.  Data was analyzed using statistical software available through Microsoft Excel 2007 (Microsoft Corp, Redman, WA).  Mean values, standard deviation, and 95% confidence intervals of all four indices were calculated.

RESULTS
Thirty Web-based articles related to parathyroid surgery from 26 independent sources were assessed by FRES, FKGL, SMOG, and GFOG readability formulas.  Sources included clinical practices (Austin Surgeons; C/V ENT Surgical Group;  Northwest ENT and Allergy Center; New York Center for Advanced Parathyroid Surgery; Norman Parathyroid Center; North Atlanta Surgical Associates; Texas Ear Nose and Throat Specialists; Center for Advanced Head and Neck Surgery in Beverly Hills, CA), individual physicians (Dr. Komisar, Dr. Speyer), academic centers (Baylor, Cleveland Clinic, Columbia, Johns Hopkins University, Ohio State, Stanford, University of California Los Angeles, University of Pittsburgh Medical Center, University of Texas Southwestern, University of Virginia), hospitals (Aria Health, Cedars-Sinai), professional societies (American Association of Endocrine Surgeons, National Institutes of Health) and miscellaneous informational sites (Drugs.com, EndocrineWeb.com).   
The average FRES was 42.8 (� 1 SD 16.3, 95% CI 36.6 to 48.8, range 6.1 to 71.3), which is rated as a "difficult" writing style (Table 1).  The average FKGL score was 11.7 (�1 SD 3.3, 95% CI 10.5 to 12.9, range 6.1 to 19.0).  The SMOG scores had an average of 14.2 (�1 SD 2.6, 95% CI 13.2 to 15.2, range 10.7 to 21.9) and the GFOG scores averaged 15.0 (�1 SD 3.5, 95% CI 13.7 to 16.3, range 10.6 to 24.8).  These were all statistically higher than the recommended 6th grade reading level (p < 0.0001, single sample one-tailed t test for all 3 readability indices).

DISCUSSION
Effective communication of health information requires that it be presented at a level that is comprehensible to the target audience.  This is particularly important for patients undergoing surgery as it is part of obtaining informed consent.  Open dialogue between patient and physician is the most effective and most trusted form of communication. HYPERLINK \l "_ENREF_14" \o "Schmitt, 2011 #675"   It allows the patient to ask questions and allows the provider to tailor the information on an individual basis.  However, verbal communication is limited by the time constraints of the physician-patient encounter and is often forgotten over time. ADDIN EN.CITE  ADDIN EN.CITE.DATA  HYPERLINK \l "_ENREF_2" \o "Chan, 2002 #999" 2, HYPERLINK \l "_ENREF_14" \o "Dugdale, 1999 #19" 14
Written information is a valuable adjunct to verbal communication.  It can reinforce topics discussed during a face-to-face visit and improve both understanding and recall of the proposed surgery.  This in turn reduces anxiety and improves satisfaction. HYPERLINK \l "_ENREF_2" \o "Chan, 2002 #999"  ADDIN EN.CITE  ADDIN EN.CITE.DATA 2  Providing patients with appropriately written educational materials is central in achieving this goal.  National Adult Literacy Surveys identified nearly 20% of adults in the U.S. reads at or below a fifth grade reading level, and the average adult reads at a seventh grade reading level.  Accordingly, the general recommendation is that patient education material be written at or below a 6th grade reading level. ADDIN EN.CITE  ADDIN EN.CITE.DATA  HYPERLINK \l "_ENREF_12" \o "Patel, 2011 #991" 12, HYPERLINK \l "_ENREF_13" \o "Polishchuk, 2011 #994" 13
In our study, we identified 30 patient education materials on the internet discussing parathyroid surgery.  Readability scores varied greatly between articles and between indices for individual articles.  SMOG and GFOG scores were consistently higher than FKGL scores.  This is a common occurrence due to the different philosophies behind their formulas.  No article was found to be in the �Easy to Read� category by any readability formula.  SMOG and GFOG scored all documents as �Difficult�, meaning they were considered complex enough to require the reader to have graduated high school.  Sixteen documents by FKGL, and only 5 documents by FRE, were rated as being of �Average Difficulty.�
There is no gold standard for determining readability.  Different formulas take different factors into account.  SMOG and GFOG rely heavily on the number of polysyllabic words.  As this study reviewed documents related to parathyroidectomy, is it is likely that the number of polysyllabic words was inordinately high due to the repetitive use of �parathyroid� or �parathyroidectomy.�  Alternatively, the use of scientific jargon or other anatomic terms which are short in length may also skew readability scores.  Finally, while we can calculate readability, assessing for comprehensibility is a far more difficult task.  Readability formulas do not account for diagrams, pictures, illustrations, information layout, or interactive presentations.  These undoubtedly enhance the educational nature of these documents which cannot be easily measured.
This study has demonstrated that the readability of patient education materials available online discussing parathyroid surgery is well above the recommended sixth grade reading level.  This is not only true with parathyroid surgery.  Many other studies reviewing a wide range of topics have similarly found that publically available patient-oriented health information is written at a higher-than-recommended reading level. ADDIN EN.CITE  ADDIN EN.CITE.DATA  HYPERLINK \l "_ENREF_13" \o "Polishchuk, 2011 #994" 13, HYPERLINK \l "_ENREF_15" \o "D'Alessandro, 2001 #676" 15-28  Improving readability of these materials should be a common goal, but we must be careful not to over-simplify information.  Careful use of illustrations and diagrams, substituting complex medical terms with simpler ones, using shorter sentences, and applying different fonts and layouts can help improve the quality of educational materials without undermining the importance of the information. HYPERLINK \l "_ENREF_9" \o "Badarudeen, 2010 #995"  ADDIN EN.CITE  ADDIN EN.CITE.DATA 9  By providing patients with information that is simpler and comprehensible, we can promote better health education and improve compliance, patient satisfaction, and quality of life.

CONCLUSION
Online patient education materials relating to parathyroid surgery are written above the recommended sixth grade reading level.  No single formula can accurately assess readability, and these scores alone do not fully represent comprehensibility.  Written information provided to patients should not only be written at a level that is readable by the majority of the U.S. population but also in a way that is meaningful and educational. 
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23.	Cherla DV, Sanghvi S, Choudhry OJ, Jyung RW, Eloy JA, Liu JK. Readability assessment of internet-based patient education materials related to acoustic neuromas. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2013; In press.
24.	Svider PF, Agarwal N, Choudhry OJet al. Readability assessment of online patient education materials from academic otolaryngology-head and neck surgery departments. Am J Otolaryngol 2013; 34:31-35.
25.	Patel CR, Cherla DV, Sanghvi S, Baredes S, Eloy JA. Readability assessment of online thyroid surgery patient education materials. Head Neck 2012; Sep 13; Epub ahead of print; doi: 10.1002/hed.23157.
26.	Colaco M, Svider PF, Agarwal N, Eloy JA, Jackson IM. Readability assessment of online urology patient education materials. J Urol 2013; 189:1048-1052.
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28.	Kasabwala K, Misra P, Hansberry DRet al. Readability assessment of the American Rhinologic Society patient education materials. Int Forum Allergy Rhinol 2013; 3:325-333.


TABLES
Table 1. FRE Score Interpretation
FRE ScoreLevel of DifficultyNumber of PEM (%)Estimated Grade LevelUSDHHS Readability Category0-29Very Difficult6 (20%)Above CollegeDifficult30-49Difficult14 (46.7 %)College50-59Fairly Difficult5 (16.7%)10th-12th60-69Standard4 (13.3%)8th-9thAverage Difficulty70-79Fairly Easy1 (3.3%)7th80-89Easy0 (0%)6thEasy to Read90-100Very Easy0 (0%)5thFRE = Flesch Reading Ease; USDHHS = United States Department of Health and Human Services

Table 2. Readability FormulasFREFKGLSMOGGFOG
FIGURE LEGENDS
Figure 1. Number of Articles per USDHHS Category for each Readability Index








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M.</author></authors></contributors><auth-address>Division of Urology, Department of Surgery, Neurological Institute of New Jersey, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, New Jersey.</auth-address><titles><title>Readability assessment of online urology patient education materials</title><secondary-title>The Journal of urology</secondary-title><alt-title>J Urol</alt-title></titles><periodical><full-title>The Journal of urology</full-title><abbr-1>J Urol</abbr-1></periodical><alt-periodical><full-title>The Journal of urology</full-title><abbr-1>J Urol</abbr-1></alt-periodical><pages>1048-52</pages><volume>189</volume><number>3</number><edition>2012/09/29</edition><dates><year>2013</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1527-3792 (Electronic)&#xD;0022-5347 (Linking)</isbn><accession-num>23017508</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/23017508</url></related-urls></urls><electronic-resource-num>10.1016/j.juro.2012.08.255</electronic-resource-num><language>eng</language></record></Cite><Cite><Author>Eloy</Author><Year>2012</Year><RecNum>2356</RecNum><record><rec-number>2356</rec-number><foreign-keys><key app="EN" db-id="tr52f05zqezf0lezdf3xeff00ds0er2pvpep">2356</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eloy, J. 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Jean.Anderson.Eloy@gmail.com</auth-address><titles><title>Readability assessment of patient education materials on major otolaryngology association websites</title><secondary-title>Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery</secondary-title><alt-title>Otolaryngol Head Neck Surg</alt-title></titles><periodical><full-title>Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery</full-title><abbr-1>Otolaryngol Head Neck Surg</abbr-1></periodical><alt-periodical><full-title>Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery</full-title><abbr-1>Otolaryngol Head Neck Surg</abbr-1></alt-periodical><pages>848-54</pages><volume>147</volume><number>5</number><edition>2012/08/07</edition><dates><year>2012</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1097-6817 (Electronic)&#xD;0194-5998 (Linking)</isbn><accession-num>22864405</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/22864405</url></related-urls></urls><electronic-resource-num>10.1177/0194599812456152</electronic-resource-num><language>eng</language></record></Cite><Cite><Author>Kasabwala</Author><Year>2013</Year><RecNum>2722</RecNum><record><rec-number>2722</rec-number><foreign-keys><key app="EN" db-id="tr52f05zqezf0lezdf3xeff00ds0er2pvpep">2722</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kasabwala, K.</author><author>Misra, P.</author><author>Hansberry, D. R.</author><author>Agarwal, N.</author><author>Baredes, S.</author><author>Setzen, M.</author><author>Eloy, J. A.</author></authors></contributors><auth-address>Department of Otolaryngology-Head and Neck Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ.</auth-address><titles><title>Readability assessment of the American Rhinologic Society patient education materials</title><secondary-title>Int Forum Allergy Rhinol</secondary-title><alt-title>Int Forum Allergy Rhinol</alt-title></titles><periodical><full-title>Int Forum of Allergy Rhinol</full-title><abbr-1>Int Forum Allergy Rhinol</abbr-1></periodical><alt-periodical><full-title>Int Forum of Allergy Rhinol</full-title><abbr-1>Int Forum Allergy Rhinol</abbr-1></alt-periodical><pages>325-33</pages><volume>3</volume><number>4</number><edition>2012/10/10</edition><dates><year>2013</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>2042-6984 (Electronic)</isbn><accession-num>23044857</accession-num><urls><related-urls><url>http://www.ncbi.nlm.nih.gov/pubmed/23044857</url></related-urls></urls><electronic-resource-num>10.1002/alr.21097</electronic-resource-num><language>eng</language></record></Cite></EndNote>uD���y������K�
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