# Written Comments on Docket: 2005N-0394 -- FDA's Communication of Drug Safety Information Public Hearing

Submitted by Susan Kleimann, Ph.D., Executive Director, Center for Plain
Language, 1321 Rhode Island Avenue, NW, Washington, DC 20005

## What is clarity for a FDA Patient Information Sheet?

For this presentation, I am going to focus on a rewrite of the Patient
Information Sheet for Adderall from a communication perspective, a focus
on how we say it, not merely on what we say. Using the FDA Alert, I will
identify some basic techniques to use in the rewriting of documents and
will introduce the importance of testing.

### What's on the information sheet?

The Adderall Patient Information Sheet includes the usual FDA
information, such as FDA Alerts about side effects and warnings about
abuse. The site also has information in a Q&A format:

-   What is Adderall XR?

-   Who should not take Adderall?

-   What are the risks?

-   Are there any interactions?

-   How do I take Adderall?

### What about the language of the Adderall alert? 

Let's look at the current language of the Adderall alert:

> Health Canada has suspended marketing of Adderall XR products from the
> Canadian market due to concern about reports of sudden unexplained
> death (SUD) in children taking Adderall and Adderall XR. SUD has been
> associated with amphetamine abuse and reported in children with
> underlying cardiac abnormalities taking recommended doses of
> amphetamines, including Adderall and Adderall XR. In addition, a very
> small number of cases of SUD have been reported in children without
> cardiac abnormalities taking Adderall. At this time, FDA cannot
> conclude that recommended doses of Adderall can cause SUD, but is
> continuing to carefully evaluate these data.

Can consumers understand this? Flesch-Kincaid shows a reading grade
level of 16.7. Take out the word Adderall and the level is the same.
Readability formulas consider basically the length of the words and the
length of the sentences. Such a simplistic way of looking at readability
will give us a crude diagnostic measure of readability. However, it
doesn't help us very much because readability is a function of so much
more than words and sentence length. In the following sample rewrite, I
reduced the reading level on Flesch-Kincaid to 13.3, but let's consider
the other changes that make a more significant difference in the
readability of the alert.

### Sample Rewrite

### What?

> Health Canada no longer allows marketing in Canada of Adderall XR
> products.

### Why?

> Some children taking Adderall XR have died suddenly and without
> apparent cause. A sudden unexplained death (SUD) has occurred with
> three types of medical conditions:

1.  in children with an abuse of amphetamines

2.  in children with underlying cardiac abnormalities and who are taking
    recommended doses of Adderall and Adderall XR, and

3.  in a very small number of children without underlying cardiac
    abnormalities

### What's Next?

> FDA is looking at these data, but cannot conclude that recommended
> doses of Adderall can cause SUD. FDA will update this information when
> we learn more.

### What did we do in rewriting this document?

To improve the clarity of the Adderall alert, we used a number of
document design techniques that help to improve the readability of the
text. These techniques include creating a predictable structure,
simplifying words, breaking up long sentences, emphasizing key
information, and stating implied information directly.

-   Creating a predictable structure

> As a first step, we identified the type of information that was
> currently in the alert. Some of the information explained the action
> that had caused the alert, then the reason that an alert was being
> issued, and statement of what FDA was doing, in this case, "continuing
> to carefully evaluate these data."
>
> As a second step, we returned to the idea of what questions a consumer
> would want answered and decided that they would have three questions:
> what is the status, what is the reason for the alert, and what will
> happen in the future? To further simplify the structure, I changed the
> questions to reflect a familiar pattern of a newspaper story: What?
> Why? What's next? If FDA used these three questions for all alerts,
> they would provide a predictable structure and would help to build a
> cognitive map for consumers based on familiar questions.

-   Simplifying words

> To simplify words requires both replacing one word with another and
> sometimes replacing a word with a phrase. In this rewrite, we replaced
> "has suspended marketing" with no longer allows marketing." In another
> instance, we replaced the technical phrase of "sudden unexplained
> death (SUD)" with the more humane phrasing of "Some children have died
> suddenly and without apparent cause." Using these two principles
> allows most of the word choice to be simplified.

-   Breaking up long sentences

> The original passage has four sentences, consisting of 30, 25, 20, and
> 22 words. In the rewrite, I increased the number of sentences to five.
> First, I broke up the first sentence to separate the "what" and "why"
> of the original. Second, to make it seem that there are more
> sentences, I used three bullets to break out key information in the
> third sentence. The reader's eye sees eight sentences because of the
> bullets. Thus the combination of headings and bullets breakup what had
> previously looked like an impenetrable block of text.

-   Emphasizing key information

> Both the headings and the bullets help identify key information. The
> headings group the information as mentioned above to emphasize the
> three types of information included in the alert. The bullets pull out
> the three conditions in which children have died. This key information
> had been buried previously in the text. Not only is this a readability
> issue, but of all the information in the alert, the three conditions
> are the most important for consumers.

-   Stating implied information directly

> In the original, the last sentence states that FDA "is continuing to
> carefully update these data." Although this sentence implies that FDA
> will share their future analysis, the sentence does not state it
> directly. We changed the phrasing to "FDA will update this information
> when we learn more." This sentence is direct and doesn't make the
> consumer work as hard to figure out the implication.

**What's Next?**

Rewrites of text are a first step in providing consumers with more
usable and readable information. However, the effort needs to continue
with testing of the documents with consumers. After all, the ultimate
judge of a document's success is the consumer. In testing sessions,
designers are able to work one-on-one with consumers to ask them about
their questions, observe how the structure of the document affects their
understanding, and observe consumers' reactions to the language of the
document.

Testing doesn't need to be expensive. In qualitative testing, a small
sample size is the norm. Diagnostic usability testing uncovers usability
problems quickly and test sessions begin to get repetitive after about
five participants are interviewed. According to Virzi, 80% of usability
problems are uncovered with about five participants and 90% after ten
participants[^1]. Testing is not the focus of these comments, but
testing is key to ensuring document clarity.

[^1]: Dumas, Joesph S. (2003). Chapter 56: User-Based Evaluations. In J.
    A. Jacko & A. Sears (Eds.), *The Human Computer Interaction
    Handbook: Fundamentals, Evolving Technologies and Emerging
    Applications.* Mahwah, New Jersey: Lawrence Erlbaum Associates,
    Publishers