Total Ankle Arthroplasty: Can Patients Read, Understand, and Act on Online Educational Resources?
Authors: Shamrock Alan G. , Gao Burke , Gulbrandsen Trevor , Femino John E. , Netto Cesar de Cesar , Duchman Kyle R. 
Published: November 2020

Category: Ankle Arthritis; Ankle Introduction/Purpose: Patients often access online resources to learn about orthopedic procedures prior to undergoing elective surgery. In order to be fully understood by the average English-speaking adult, online health information must be written at an elementary school reading level. To be helpful to patients, educational resources should also be generally understandable and have actionable direction that positively affects their healthcare interactions. There are several previously validated indices for accessing the reading level of written materials. The Patient Education Materials Assessment Tool (PEMAT) provides a reliable and validated method to measure the understandability and actionability of education materials. The purpose of this study was to utilize PEMAT and readability algorithms to quantify readability, understandability and actionability of online patient education materials related to total ankle arthroplasty (TAA). Methods: Online patient education materials were identified using two independently conducted Google engine searches with the term ‘ankle replacement’. Using the top 50 search results, articles were included if they specifically served to educate patients regarding TAA. Exclusion criteria included news articles, non-text materials (video), research manuscripts, industry websites, and articles not related to TAA. The readability of included articles was quantified using the validated Flesch-Kincaid Grade Level index. The PEMAT form (Figure 1) for printed materials was used to assess understandability and actionability using a 0-100 scale for both measures of interest. Spearman’s correlation coefficient was utilized to examine the relationship between a website’s average rank on Google (from first to last) and its readability, understandability, and actionability. P-values of less than 0.05 were considered significant. Results: Forty-one websites met inclusion criteria. The mean Flesch Kincaid reading grade level was 13.7+-15.3 (range: 6.3-16.8), with no website written at an elementary school level. Article readability scores were not associated with Google search rank (p>0.301). Mean understandability and actionability scores were 70.4+-15.3 and 24.4+-24.3, respectively. Among understandability categories, only 9.8% (n=4) included summaries and only 46.3% (n=19) included visual aids. Among actionability categories, 58.5% (n=24) of websites identified at least one action for readers, but only 16.7% (n=4) of these studies broke down actions into explicit, easy to understand steps. Higher actionability scores were significantly associated with earlier Google search rank (rho:- 0.44, p=0.004), while higher understandability scores were associated with later Google search rank (rho: 0.53, p<0.001). Conclusion: No website describing TAA was written at or below the nationally recommended 6th grade reading level. Overall, TAA online educational materials scored poorly with respect to readability, understandability, and actionability. Article actionability but not understandability correlated with an earlier Google search rank. In the era of shared decision making, it is vital that patients understand procedures, as well as the risks and benefits prior to undergoing elective surgery. These results suggest that current publicly available resources for TAA remain inadequate for patient education.