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Most Patient Education Materials on Shoulder Conditions from the American Academy of Orthopaedic Surgeons Exceed Recommended Readability Levels

Open AccessPublished:September 28, 2022DOI:https://doi.org/10.1016/j.jseint.2022.09.004

      Abstract

      Introduction

      A growing number of patients use the internet to learn about their conditions and management options, but there may exist a disconnect between the readability of online education materials and a patient’s health literacy. This issue is of particular relevance for shoulder conditions, where even with traumatic injuries (e.g. clavicle fracture, shoulder dislocation), treatment is discretionary, directed primarily at quality of life, and therefore highly preference-sensitive.
      The purpose of this study was to utilize multiple readability algorithms to calculate the readability of the American Academy of Orthopedic Surgeons (AAOS) patient education materials pertaining to diseases and conditions of the shoulder.

      Methods

      Online patient education articles from the AAOS pertaining to diseases and conditions of the shoulder were reviewed. The articles were modified for analysis using Readability Pro and readability scores were computed using the following 9 algorithms: Flesch-Kincaid Grade Level, Flesch Reading Ease, Gunning Fog Index, Coleman-Liau Index, Simple Measure of the Gobbledygook Index (SMOG), Automated Readability Index, FORCAST, New Dale and Chall Index. A list of suggested word changes to improve the readability of included articles was compiled from Readable Pro. The average number of illustrations (images and/or videos) included per article was documented.

      Results

      Twenty eight articles were included for analysis. For each of the algorithms studied, the average scores were as follows: Flesch Kincaid Grade Level was 8.8±.8 [range 7.2-10.2]; recommended score: ≤ 8.0, Flesch Reading Ease 54.3±5.3 [range 45.3-64.1]; recommended score: ≥ 60, Gunning Fog 10.8±1.2 [range 8.3-13.1]; recommended score: ≤ 8.0, Coleman-Liau 11.2±.9 [range 9.2-12.9]; recommended score: ≤8.0, SMOG index 11.4±.8 [range 9.2-12.9]; recommended score: ≤ 8.0 , Automated Readability Index 8.4±.8 [range 6.9-10.0]; recommended score: ≤ 8.0, FORCAST 11.2±.4 [range 10.2-12.0]; recommended score: ≤ 9.0, and New Dale and Chall Index 5.8±.5 [range 4.9-7.2 recommended score: ≤ 6.0-6.9]. The average number of illustrations per article was 4.5±3.1 [range 1-14].

      Conclusion

      The readability of most patient education materials from the AAOS pertaining to diseases and conditions of the shoulder is higher than recommended across a variety of algorithms. Efforts to revise the readability of online education materials are important to facilitate shared-decision making, particularly in practice settings where most decisions are preference-sensitive.

      Keywords

      The internet has become an increasingly popular source of health information. According to recent data, more than 80% of orthopedic patients utilize the internet to learn about their conditions and treatment options prior to physician consultation
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      Internet use by patients in orthopaedic surgery.
      . Despite improved access to written education materials, there may exist a disconnect between the readability of these resources and a patient’s health literacy. This is especially problematic as low health literacy has been linked to poor patient outcomes, increased healthcare costs, and overutilization of emergency rooms
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      .
      The ability to understand written text is a critical component of health literacy. A patient’s reading skills are measured in terms of grade level, where “functional illiteracy” is equated to zero- to fifth-grade reading skills and “marginal literacy” is equated to sixth- to eight-grade reading skills
      • McCray A.T.
      Promoting health literacy.
      . According to a recent survey study, nearly 50% of the adult US population is functionally or marginally illiterate

      National Center for Education Statistics. A First Look at the Literacy of America’s Adults in the 21st Century. Washington, DC: U.S. Dept. of Education; 2006:28.

      ,

      National Center for Education Statistics. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: U.S. Dept. of Education; 1993

      . Moreover, substantial limitations in health literacy have been shown to exist among the elderly, unemployed, and those of lower socioeconomic status
      • Svendsen M.T.
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      • Sorensen K.
      • Pelikan J.
      • Riddersholm S.J.
      • Skals R.K.
      • et al.
      Associations of health literacy with socioeconomic position, health risk behavior, and health status: a large national population-based survey among Danish adults.
      . In 2010, the Plain Language Initiative was implemented in an attempt to equalize care. This initiative set forth guidelines to ensure agencies use clear communication in order to help their users find, understand, and apply the information to meet their health needs

      plainlanguage.gov; 2010. https://www.plainlanguage.gov/law/. [Accessed June 17 2022].

      . The guidelines are based upon writing for a specific audience, organization of information, word choice, brevity, and conversational voice.
      Numerous agencies including the National Institutes of Health (NIH), Centers for Disease Control (CDC), and American Medical Association (AMA) recommend that health materials be written at or below the fourth to eighth grade reading level

      Centers for Disease Control and Prevention Simply Put: a guide for creating easy-to-understand materials.; 2009. https://www.cdc.gov/healthliteracy/pdf/simply_put.pdf.

      ,

      National Cancer Institute Making health communication programs work; 2004. https://www.cancer.gov/publications/health-communication/pink-book.pdf.

      ,

      Weiss BD. Health literacy. 2003.

      ,
      • Weiss B.D.
      How to bridge the health literacy gap.
      . Despite this, multiple studies have shown that the readability level of online orthopedic education materials remains above these levels
      • Badarudeen S.
      • Sabharwal S.
      Readability of patient education materials from the American Academy of Orthopaedic Surgeons and Pediatric Orthopaedic Society of North America web sites.
      ,
      • Beutel B.G.
      • Danna N.R.
      • Melamed E.
      • Capo J.T.
      Comparative Readability of Shoulder and Elbow Patient Education Materials within Orthopaedic Websites.
      ,
      • Roberts H.
      • Zhang D.
      • Dyer G.S.
      The Readability of AAOS Patient Education Materials: Evaluating the Progress Since 2008.
      ,
      • Schumaier A.P.
      • Kakazu R.
      • Minoughan C.E.
      • Grawe B.M.
      Readability assessment of American Shoulder and Elbow Surgeons patient brochures with suggestions for improvement.
      ,
      • Wang S.W.
      • Capo J.T.
      • Orillaza N.
      Readability and comprehensibility of patient education material in hand-related web sites.
      .
      The purpose of this study was to utilize multiple readability algorithms to calculate the readability of the American Academy of Orthopedic Surgeons (AAOS) patient education materials pertaining to diseases and conditions of the shoulder. We hypothesize that the majority of these articles are written above the eighth grade reading level.

      Methods

      Online patient education articles from the AAOS pertaining to diseases and conditions of the shoulder were reviewed in June 2022

      Diseases & Conditions of The Shoulder; https://orthoinfo.aaos.org/en/diseases--conditions/?bodyPart=Shoulder. [Accessed June 11 2022].

      . The article topics included for analysis were:
      Arthritis of the Shoulder
      Biceps Tendinitis
      Biceps Tendon Tear at the Shoulder
      Brachial Plexus Injuries
      Burners and Stingers
      Chronic Shoulder Instability
      Clavicle Fracture (Broken Collarbone)
      Common Shoulder Injuries
      Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)
      Dislocated Shoulder
      Erb's Palsy (Brachial Plexus Birth Palsy)
      Frozen Shoulder
      Joint Replacement Infection
      Nerve Injuries
      Rotator Cuff Tears
      Rotator Cuff Tears: Frequently Asked Questions
      Scapula (Shoulder Blade) Fractures
      Scapula (Shoulder Blade) Disorders
      Shoulder Impingement/Rotator Cuff Tendinitis
      Shoulder Injuries in Throwing Athlete
      Shoulder Joint Tear (Glenoid Labrum Tear)
      Shoulder Pain and Common Shoulder Problems
      Shoulder Separation
      Shoulder Trauma (Fractures and Dislocations)
      SLAP Tears
      Sternoclavicular (SC) Joint Disorders
      Thoracic Outlet Syndrome
      Upper Extremity Limb Length Discrepancy
      The articles were modified to remove any images, figures, citations, references, copyright notices, disclaimers, or hyperlinks and converted to plain text in Microsoft Word as previously described
      • Badarudeen S.
      • Sabharwal S.
      Assessing readability of patient education materials: current role in orthopaedics.
      ,
      • Schumaier A.P.
      • Kakazu R.
      • Minoughan C.E.
      • Grawe B.M.
      Readability assessment of American Shoulder and Elbow Surgeons patient brochures with suggestions for improvement.
      ,
      • Stelzer J.W.
      • Wellington I.J.
      • Trudeau M.T.
      • Mancini M.R.
      • LeVasseur M.R.
      • Messina J.C.
      • et al.
      Readability assessment of patient educational materials for shoulder arthroplasty from top academic orthopedic institutions.
      . Analysis of the reformatted articles was performed using Readable Pro and the following readability scores were obtained (Table 2):
      Table 2Individual readability scores for each of the 28 AAOS articles pertaining to disease and conditions of the shoulder
      Flesch Reading EaseFlesch Kincaid Grade LevelGunning Fog ScoreColeman Liau IndexSMOG IndexAutomated Readability IndexSpache Readability ScoreDale-Chall Readability ScoreFORCAST Grade LevelIllustration/figures
      Arthritis of the Shoulder49.79.411.912.112.29.15.46.111.35.0
      Biceps Tendinitis49.88.99.811.910.78.35.26.212.07.0
      Biceps Tendon Tear at the Shoulder61.17.48.310.29.87.05.05.611.23.0
      Brachial Plexus Injuries50.09.912.611.912.69.85.86.511.410.0
      Burners and Stingers61.07.89.510.510.27.75.15.511.23.0
      Chronic Shoulder Instability49.29.110.712.311.38.75.15.711.64.0
      Clavicle Fracture (Broken Collarbone)63.07.29.210.010.26.94.84.910.66.0
      Common Shoulder Injuries55.18.210.011.810.88.25.05.311.41.0
      Complex Regional Pain Syndrome (Reflex Sympathetic Dystrophy)48.69.111.412.611.68.85.97.211.82.0
      Dislocated Shoulder56.48.09.011.010.07.54.85.211.11.0
      Erb's Palsy (Brachial Plexus Birth Palsy)62.67.810.19.410.77.35.15.510.54.0
      Frozen Shoulder53.38.49.812.010.68.45.25.811.87.0
      Joint Replacement Infection45.310.213.112.912.910.05.46.711.34.0
      Nerve Injuries64.18.010.29.210.77.65.04.910.22.0
      Rotator Cuff Tears57.58.210.710.511.37.75.15.410.914.0
      Rotator Cuff Tears: Freuqently Asked Questions53.89.512.410.612.38.75.75.510.72.0
      Scapula (Shoulder Blade) Fractures53.88.811.011.311.58.35.45.811.41.0
      Scapula (Shoulder Blade) Disorders51.19.112.011.812.28.75.46.311.35.0
      Shoulder Impingement/Rotator Cuff Tendinitis58.47.910.210.611.07.45.15.410.84.0
      Shoulder Injuries in Throwing Athlete60.49.211.011.311.69.65.66.011.111.0
      Shoulder Joint Tear (Glenoid Labrum Tear)49.39.711.811.411.98.85.66.011.52.0
      Shoulder Pain and Common Shoulder Problems53.58.810.511.711.48.65.35.711.31.0
      Shoulder Separation48.210.112.511.512.59.25.46.311.13.0
      Shoulder Trauma (Fractures and Dislocations)45.49.610.812.711.79.05.56.511.84.0
      SLAP Tears55.08.710.711.211.38.35.35.811.37.0
      Sternoclavicular (SC) Joint Disorders52.89.311.811.312.18.95.46.110.85.0
      Thoracic Outlet Syndrome56.98.510.511.911.49.05.15.310.93.0
      Upper Extremity Limb Length Discrepancy55.78.811.410.711.98.25.35.410.55.0
      Mean (SD)54.3 (5.3)8.8 (0.8)10.8(1.2)11.3 (0.9)11.4 (0.8)8.4 (0.8)5.3 (0.3)5.8 (0.5)11.2 (0.4)4.5 (3.2)
      Flesch Reading Ease
      Flesch Kincaid Grade Level
      Gunning Fog Score
      Coleman Liau Index
      SMOG Index
      Automated Readability Index
      Dale-Chall Readability Score
      FORCAST Grade Level
      Fry Grade Level
      Each of these algorithms have been used extensively for analyzing the readability of patient education materials
      • Badarudeen S.
      • Sabharwal S.
      Readability of patient education materials from the American Academy of Orthopaedic Surgeons and Pediatric Orthopaedic Society of North America web sites.
      ,
      • Roberts H.
      • Zhang D.
      • Dyer G.S.
      The Readability of AAOS Patient Education Materials: Evaluating the Progress Since 2008.
      ,
      • Wang S.W.
      • Capo J.T.
      • Orillaza N.
      Readability and comprehensibility of patient education material in hand-related web sites.
      and are based on the sample text’s syllables, words, and sentences to varying degrees (Table 1). While there is no gold-standard readability scoring system, each of these formulas has been shown to strongly correlate and the use of multiple scores is recommended to increase the validity
      • Badarudeen S.
      • Sabharwal S.
      Assessing readability of patient education materials: current role in orthopaedics.
      . A list of suggested word changes to improve the readability of included articles was compiled from Readable Pro. The average number of illustrations (images and/or videos) included per article was documented.
      Table 1Formulas used to calculate the readability scores of included articles
      Flesch-Kincaid Grade Level(0.39×mean#ofsyllablesperword)+11.8xmean#ofwordspersentence)
      Flesch Reading Ease

      206.835(1.015×mean#ofwordspersentence)(84.6×mean#ofsyllablesperword)
      Gunning Fog Index0.4(mean#ofwordsmean#ofsentences×+100×mean#ofwords3syllablesmean#ofwords)
      Coleman-Liau Index(0.0588×mean#oflettersword)(0.296×mean#ofsentences100words)
      Simple Measure of the Gobbledygook Index1.043×(#ofwordswith3syllables)×(30#ofsentences)+3.1291
      Automated Readability Index

      4.71(letterswords)+0.5(wordssentences)21.43
      FORCAST20(#ofsinglesyllablewordsin150wordsample10)
      New Dale and Chall Index0.0496×(mean#ofwordsmean#ofsentences)+0.1579×(unfamiliarwordsmean#ofwords)+3.6365

      Results

      Twenty eight articles were included for analysis. For each of the algorithms studied, the average scores were as follows: Flesch Kincaid Grade Level was 8.8±.8 [range 7.2-10.2]; recommended score: ≤ 8.0, Flesch Reading Ease 54.3±5.3 [range 45.3-64.1]; recommended score: ≥ 60, Gunning Fog 10.8±1.2 [range 8.3-13.1]; recommended score: ≤ 8.0, Coleman-Liau 11.2±.9 [range 9.2-12.9]; recommended score: ≤8.0, SMOG index 11.4±.8 [range 9.2-12.9]; recommended score: ≤ 8.0 , Automated Readability Index 8.4±.8 [range 6.9-10.0]; recommended score: ≤ 8.0, FORCAST 11.2±.4 [range 10.2-12.0]; recommended score: ≤ 9.0, and New Dale and Chall Index 5.8±.5 [range 4.9-7.2 recommended score: ≤ 6.0-6.9]. The average number of illustrations per article was 4.5±3.1 [range 1-14]. Overall, the average FK score was 8.8 ± 0.8 [range 7.2-10.2], with only 21% [6 of 28] of articles at or below the eighth grade reading level (Figure 1). A comprehensive list of suggested word changes to improve the readability of these articles is provided in Table 3.
      Figure thumbnail gr1
      Figure 1Flesch Kincaid Grade Level for each of the 28 AAOS articles pertaining to disease and conditions of the shoulder
      Table 3Suggested word changes to improve the readability of included articles
      TermAlternative
      AbnormalitiesDefects
      AdditionallyAlso
      AntibioticsMedications
      ArthroplastyJoint replacement
      ArthroscopicallyWith a small camera
      AssociatedRelated
      CapsolabralJoint
      ChlorhexidineWash
      ColonizationGrowth
      ComplicationsProblems
      ComprehensiveComplete
      ConsiderationsTips
      ContaminatedPolluted
      CorrespondingRelated
      CorticosteroidSteroid
      DegenerationBreakdown
      DifferentiateSeparate
      DisadvantagesDownsides
      DiscolorationColor changes
      DiscrepancyDifference
      DramaticallyGreatly
      EffectivenessPower
      Electrodiagnostic StudiesNerve tests
      EvaluateChecked
      ExaminationCheck
      FamiliarityExperience with
      GlenohumeralShoulder
      HemiarthroplastyPartial joint replacement
      ImmediatelyRight away
      ImmobilizationCasting, splinting
      ImmobilizerCast, sling, splint
      IndividualPerson, single
      InstabilityImbalance
      LaboratoryLab
      MiniaturizedSmall
      ModificationChange
      NonfunctioningNonworking
      OccasionallySometimes
      OverexertionOver working
      ParticularlyEspecially
      ProgressivelyGradually
      PsychologicalMental
      PulmonologistLung specialist
      RecommendationsSuggestions
      ReconstructingRebuilding
      RegenerationRegrowth
      RehabilitationRehab
      SatisfactorySuitable
      SensitivityFeeling
      SignificantlySeriously
      SpontaneouslyOn its own
      SterilizationCleaning
      TemporarilyBriefly
      UnderestimateMisjudge
      VisualizationImaging

      Discussion

      Numerous agencies including the National Institutes of Health (NIH), Centers for Disease Control (CDC), and American Medical Association (AMA) recommend that patient education materials be written at or below the fourth to eighth grade reading level

      Centers for Disease Control and Prevention Simply Put: a guide for creating easy-to-understand materials.; 2009. https://www.cdc.gov/healthliteracy/pdf/simply_put.pdf.

      ,

      National Cancer Institute Making health communication programs work; 2004. https://www.cancer.gov/publications/health-communication/pink-book.pdf.

      ,

      Weiss BD. Health literacy. 2003.

      ,
      • Weiss B.D.
      How to bridge the health literacy gap.
      . In the present analysis, we found that the current AAOS patient education materials pertaining to disease and conditions of the shoulder are not in accordance with these standards. Overall, the average Flesch Kincaid Grade Level [FK] score was 8.8 +/- 0.8 [range 7.2-10.2], with only 21% [6 of 28] of articles at or below the eighth grade reading level. FK score has been used to reflect the overall readability in multiple studies
      • Badarudeen S.
      • Sabharwal S.
      Assessing readability of patient education materials: current role in orthopaedics.
      ,
      • Badarudeen S.
      • Sabharwal S.
      Readability of patient education materials from the American Academy of Orthopaedic Surgeons and Pediatric Orthopaedic Society of North America web sites.
      ,
      • Roberts H.
      • Zhang D.
      • Dyer G.S.
      The Readability of AAOS Patient Education Materials: Evaluating the Progress Since 2008.
      ,
      • Stelzer J.W.
      • Wellington I.J.
      • Trudeau M.T.
      • Mancini M.R.
      • LeVasseur M.R.
      • Messina J.C.
      • et al.
      Readability assessment of patient educational materials for shoulder arthroplasty from top academic orthopedic institutions.
      . Even so, the validity of reading scores is accomplished with the inclusion of multiple algorithms
      • Badarudeen S.
      • Sabharwal S.
      Assessing readability of patient education materials: current role in orthopaedics.
      . In our study, the readability of each article was higher than recommended by Readability Pro across each algorithm .
      Roberts et al previously assessed the change in readability scores of AAOS patient education materials across all subspecialties
      • Roberts H.
      • Zhang D.
      • Dyer G.S.
      The Readability of AAOS Patient Education Materials: Evaluating the Progress Since 2008.
      . In 2008, the mean FK grade level was 10.4, which significantly reduced to 9.3 in 2014
      • Roberts H.
      • Zhang D.
      • Dyer G.S.
      The Readability of AAOS Patient Education Materials: Evaluating the Progress Since 2008.
      . Although it is difficult to determine if this change represents a practical difference, this data suggests that some improvement in the readability of AAOS patient education resources has occurred.
      Few studies have assessed the readability of patient education materials for shoulder
      conditions. In 2018, the readability of 6 patient education brochures provided by the American Shoulder and Elbow Surgeons [ASES] was assessed. Topics included arthritis and total shoulder replacement, arthroscopy of the shoulder and elbow, rehabilitation of the shoulder, rotator cuff tendonitis and tears, tennis elbow, and the unstable shoulder. It was found that the brochures were written well above the eighth grade level, ranging in difficulty from a grade level of 13.4 to 15.3 22. More recently, the readability of online patient education materials for shoulder arthroplasty provided by the top 25 orthopedic institutions was assessed. Overall, the mean FK score was 9.5 and only 16% of institutions included online material at or below the 8 the grade level
      • Stelzer J.W.
      • Wellington I.J.
      • Trudeau M.T.
      • Mancini M.R.
      • LeVasseur M.R.
      • Messina J.C.
      • et al.
      Readability assessment of patient educational materials for shoulder arthroplasty from top academic orthopedic institutions.
      . The findings from these studies suggest that the readability of patient education materials differs by the source and topic of information. Therefore, while our study implies that the shoulder articles from the AAOS website may be more inclusive to patients [lower average FK score] when compared to the information provided by ASES brochures and top academic centers, these comparisons should not be made given the differences in topic number and distribution. However, it is important to recognize that the majority of patient educational materials for shoulder conditions provided by these outlets are likely not suitable for the majority of readers in the United States

      Centers for Disease Control and Prevention Simply Put: a guide for creating easy-to-understand materials.; 2009. https://www.cdc.gov/healthliteracy/pdf/simply_put.pdf.

      ,

      National Institutes of Health Office of Communications and Public Liaison Clear & simple; 2015. https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/clear-simple.

      . It is therefore prudent to understand the components of the readability scores and means for improvement.
      There may be several ways to improve the readability of written patient education materials. Previous studies have suggested that shorter words, using more concise sentence structure, using fewer words per paragraph, and providing more visual material may aid in lowering the readability score
      • Weiss B.D.
      Health Literacy Research: Isn't There Something Better We Could Be Doing?.
      . The article with the highest FK score (10.2) in our study was related to joint replacement infection. Several issues pertaining to word density and writing style were associated with this article. Specifically, 32% of the sentences contained more than 30 syllables and 52% of sentences contained more than 20 syllables. This represents a significant area for improvement given the fact that highly readable content is often associated with roughly 6% of sentences containing less than 30 syllables and roughly 12% of sentences with less than 20 syllables. Additionally, 47 words used in this article were classified as “hard words”. While the poor readability of this article may be due to the intrinsic complexity of periprosthetic infection, readability may be improved by substituting exhaustive explanations related to anatomic references, procedural steps, and implant design materials with brief descriptions
      • Stelzer J.W.
      • Wellington I.J.
      • Trudeau M.T.
      • Mancini M.R.
      • LeVasseur M.R.
      • Messina J.C.
      • et al.
      Readability assessment of patient educational materials for shoulder arthroplasty from top academic orthopedic institutions.
      . It is important to note that this article did include a total of 3 images. The use of visual supplementary material in the form of pictures and videos has been shown to improve readability and has been cited as a missed opportunity to increase health literacy
      • Parsa A.
      • Nazal M.
      • Molenaars R.J.
      • Agrawal R.R.
      • Martin S.D.
      Evaluation of Hip Preservation-related Patient Education Materials From Leading Orthopaedic Academic Centers in the United States and Description of a Novel Video Assessment Tool.
      ,
      • Stelzer J.W.
      • Wellington I.J.
      • Trudeau M.T.
      • Mancini M.R.
      • LeVasseur M.R.
      • Messina J.C.
      • et al.
      Readability assessment of patient educational materials for shoulder arthroplasty from top academic orthopedic institutions.
      . However, despite an average number of 4.5 illustrations per article, the overall readability score was still higher than recommended for included articles in our study. This may suggest that the complexity of shoulder topics is high and that significant improvements in readability are unable to be achieved with the incorporation of illustrations alone. As such, emphasis should be placed on improving sentence structure and writing style in addition to the incorporation of visual supplementary material.
      Our study is not without limitations. The formulas used to generate readability scores are determined based upon syllable and character counts in each word, sentence, and paragraph. Therefore, readability scores may be misleading in instances where short but unfamiliar medical terms are used or in cases where short sentences are presented with complex ideas. For example, although the word “arthroplasty” has the same number of syllables as “joint replacement”, the latter may be easier to understand for the general public. Yet, based on syllable count, both words would contribute equally to the readability score. Additionally, each of the algorithms used are unable to evaluate the effect of supplementary visual aids or reader comprehension on the readability score. Therefore, despite a relatively high average number of illustrations used per article in our study, the readability scores may be inflated. Finally, the reading level of the AAOS target population may be different than that of the general patient population. Therefore, although our findings suggest that the readability of these resources is higher than the national recommendations, they may be relevant to this specific audience of readers.
      The readability of most patient education materials from the AAOS pertaining to diseases and conditions of the shoulder is higher than recommended across a variety of algorithms. Efforts to revise the readability of online education materials are important to facilitate shared-decision making, particularly in practice settings where most decisions are preference-sensitive.

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