Readability of patient education materials for lumbar disc replacement
Original Article

Readability of patient education materials for lumbar disc replacement

Anil Sedani1 ORCID logo, Eric Kholodovsky2 ORCID logo, William A. Marmor1 ORCID logo, Justin Trapana1 ORCID logo, Frank Mota1, Evan Trapana1

1Department of Orthopaedics, University of Miami Miller School of Medicine, Miami, FL, USA; 2University of Miami Miller School of Medicine, Miami, FL, USA

Contributions: (I) Conception and design: A Sedani, WA Marmor, J Trapana; (II) Administrative support: F Mota, E Trapana; (III) Provision of study materials or patients: A Sedani, E Kholodovsky, WA Marmor; (IV) Collection and assembly of data: A Sedani, E Kholodovsky, WA Marmor; (V) Data analysis and interpretation: A Sedani, E Kholodovsky, WA Marmor; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Eric Kholodovsky, BS. University of Miami Miller School of Medicine, 1600 NW 10th Ave #1140, Miami, FL 33136, USA. Email: edk46@miami.edu.

Background: Many patients refer to internet-based patient education materials (PEMs) to learn about lumbar disc replacement. The purpose of this study is to assess the readability of PEMs on lumbar disc replacement.

Methods: The Google search engine was queried with the phrase “lumbar disc replacement patient information”. Readability scores were calculated for the initial 25 websites that met inclusion criteria by copying the PEM to http://www.readabilityformulas.com. SPSS version 28.0.0 was used to calculate descriptive statistics for each measure.

Results: The mean average reading level was 12.08±1.73. The mean readability score for Flesch-Kincaid Reading Ease Score was 45.60±9.16. Additional scores include Gunning Fog, 14.50±2.06; Flesch-Kincaid Grade Level (FKGL), 10.94±2.14; The Coleman Liau Index, 12.82±1.50; Simple Measure of Gobbledygook (SMOG) Index, 10.51±1.56; Automated Readability Index, 11.81±2.46; Linsear Write Formula, 11.08±3.49. Zero PEMs were found to be below the 6th-grade or 8th-grade reading level.

Conclusions: PEM readability is a crucial part of the patient care experience, and the current readability of lumbar disc replacement PEMs is not at an acceptable level. Given their current state, PEMs can make it difficult for a sizable proportion of the general population to comprehend the nature of their medical condition and how to appropriately treat it.

Keywords: Readability; lumbar disc replacement; spine; patient education materials (PEMs)

Submitted Mar 25, 2025. Accepted for publication May 09, 2025. Published online Aug 22, 2025.

doi: 10.21037/jss-25-50

Highlight box

Key findings

• This study determined that patient education materials (PEMs) exceed the recommended 6th grade reading level for lumbar disc replacement.

What is known and what is new?

• Previous studies have determined that this is true across nearly all topics in medicine including other orthopaedic topics such as anterior cervical discectomy and fusion and lateral epicondylitis.

• This study highlights the shortcomings of PEMs for lumbar disc replacement. Lumbar disc replacement PEMs are written at an average grade level of 12.08, nearly six grade levels above American Medical Association recommendations. None of the top 25 PEMs were within the recommended reading level.

What is the implication, and what should change now?

• This study calls for specific changes such as increasing the number of illustrations and removing unclear symbols from text to achieve the 6th grade reading level. These changes may help patients to better understand their condition or procedure when reading PEMs.

Introduction

Lumbar disc replacement is an emerging surgical intervention for the treatment of degenerative lumbar disc disease (1). This procedure involves removing a worn or degenerative disc and replacing it with an artificial disc, typically made from metal, ceramic, and or polymers (2). Disc replacement serves as a motion-sparing alternative to fusion with the aim of decreasing pain yet preserving lumbar motion (3). Lumbar disc replacement provides high satisfaction rates and improved pain and function, with relatively low rates of complication, which make it a valuable resource for patients with degenerative disc disease without evidence for significant facet driven pain (4). It is imperative that patients afflicted with lumbar back pain who are indicated for lumbar disc replacement understand the nature and treatment of their condition to ensure informed consent and manage post-operative expectations. There are many resources available to patients regarding lumbar disc replacement with the Internet being the primary initial source of information (5).

Online resources known as patient education materials (PEMs) have emerged as a major information source for patients who want to learn more about their medical condition. Traditionally, PEMs were online websites, however large language models (LLM) and artificial intelligence (AI) have emerged as an additional rapidly growing source of PEMs (6). After doctors, PEMs are the second most important source of medical information (5). They contain data that might be useful in a patient’s medical care, such as the patient’s condition overview, diagnosis, therapy, and recovery. PEMs are widely available, but their utility depends on the patient’s capacity to read, comprehend, and analyze the information they are provided. Most PEMs have been authored by highly qualified medical experts who are able to decipher complex data from scientific research publications. The translation of complex medical concepts into a comprehensive and clear format that is comprehensible by the public is a challenge.

When creating PEMs, it’s critical to take the population’s reading comprehension level into account. The average reading level in the United States is at the 8th-grade level, according to the US Department of Education (7). According to the Centers for Disease Control (CDC) and the National Institute of Health (NIH), PEMs should be written between a 6th- and 8th-grade reading level to ensure a high level of comprehension, however there are many studies in the literature on PEM readability that indicate current PEMs are written above this level (7-12). The purpose of this study is to evaluate the readability of PEMs on lumbar disc replacement.

Methods

In November 2024, the phrase “lumbar disc replacement patient information” was used to query the Google search engine. The advanced search feature was used to isolate PEMs with “full sentence” and “English language”. The initial 25 websites for this query were evaluated. Websites that only utilized tables or graphics were excluded. Websites were identified as either a clinical practice (CP) or a general health information (GHI) website. “Clinical practice” and “General health information website” were defined as an adaptation from a previous PEM study by Duymaz et al. (11).

The initial 25 texts that adhered to the inclusion criteria regarding lumbar disc replacement were changed into a text-only format. Text that was not directly related to educational information such as disclaimers, copyright notices, website Uniform Resource Locators (URL), references, tables, figures, addresses, and telephone numbers were removed to ensure reliability of scoring.

Readability scores were calculated by transferring the texts to http://www.readabilityformulas.com (13). Readability analyses were calculated using the following evaluations: Average Reading Level Consensus Calc, Flesch-Kincaid (FK) Reading Ease Score, Gunning Fog, The Flesch-Kincaid Grade Level (FKGL), The Coleman-Liau Index, Simple Measure of Gobbledygook (SMOG) Index, Automated Readability Index, and Linsear Write Formula. Calculation formulas are summarized in a previous publication by Miskiewicz et al. (9).

Statistical analysis

In order to compare general health and CP and to give insight into readability ratings, descriptive statistics were employed. The mean and standard deviation are used to express quantitative variables. Absolute numbers or percentages are used to express categorical variables. Comparative analyses were used to examine relationships and differences in continuous and categorical variables, respectively, using t-tests or Mann-Whitney U tests and Chi-squared or Fisher’s exact tests. To investigate potential connections between the variables, subgroup analyses further stratify the data according to PEM type. SPSS version 28.0.0 was used to analyze the data. A P value of less than 0.05 was considered statistically significant.

Results

The mean average reading grade level was 12.08±1.73. The mean score for the FK Reading Ease test was 45.60±9.16, Gunning Fog was 14.50±2.06; FKGL was 10.94±2.14; the Coleman Liau Index was 12.82±1.50; the SMOG Index was 10.51±1.56; the Automated Readability Index was 11.81±2.46; and the Linsear Write Formula was 11.08±3.49. Individual readability scores and source type are summarized in Table 1. None of the PEMs were written at or below a 6th- or 8th-grade reading level. None of the PEMs were written below a 6-FKGL (Figure 1). FKGL is a widely used readability tool that assesses average sentence length and word complexity to assign a reading grade level. A score of 1–100 is given and assigned an associated reading grade level (13). Sixteen PEMs were defined as CP and the other 9 were defined as GHI sources.

Table 1

Individual and mean scores of the top 25 PEMs on lumbar disc replacement

No. Source type Automated Readability Index Flesch-Kincaid Reading Ease Score Gunning Fog Index Flesch-Kincaid Grade Level Coleman-Liau Index SMOG Index Linsear Write Readability Formula Forecast Readability Formula Average Reading Level Consensus
1 GHI 10.22 51.00 13.00 9.49 12.48 9.44 8.18 11.41 12.00
2 CP 11.00 66.00 11.20 7.44 9.08 8.23 7.88 9.85 11.00
3 CP 11.64 45.00 14.70 10.64 13.63 10.67 10.76 11.54 12.00
4 CP 10.82 48.00 13.80 10.34 12.44 10.07 10.50 11.19 11.00
5 GHI 11.09 42.00 14.60 10.93 13.21 10.53 10.35 11.87 12.00
6 GHI 13.61 37.00 16.40 12.87 13.84 12.14 13.73 12.02 14.00
7 CP 10.96 42.00 15.00 10.74 13.46 10.57 10.03 11.76 12.00
8 GHI 11.93 39.00 14.10 11.34 14.44 10.15 10.06 12.40 12.00
9 CP 16.18 28.00 17.60 14.84 15.46 12.75 15.88 12.31 15.00
10 CP 11.66 50.00 13.70 10.62 12.30 10.07 11.73 11.22 12.00
11 CP 11.30 48.00 14.30 10.47 12.90 10.51 10.98 11.05 12.00
12 CP 8.42 57.00 12.20 7.81 11.56 8.74 6.24 10.64 9.00
13 CP 7.67 64.00 11.20 7.39 9.91 8.21 7.11 10.28 9.00
14 GHI 13.53 42.00 16.10 12.52 13.09 11.71 14.31 11.25 13.00
15 CP 11.25 41.00 14.80 11.13 13.48 10.53 10.48 11.77 12.00
16 GHI 14.56 39.00 16.40 13.11 13.72 12.33 14.79 12.23 14.00
17 GHI 15.87 38.00 16.30 13.71 14.38 11.93 15.57 11.86 14.00
18 CP 14.56 38.00 17.60 13.57 13.03 12.84 16.05 11.22 14.00
19 CP 13.55 47.00 14.50 12.07 12.54 10.56 14.03 11.04 13.00
20 GHI 9.71 42.00 14.10 10.20 12.94 9.68 7.44 11.80 11.00
21 CP 9.83 46.00 12.20 9.35 13.33 8.43 6.18 11.61 10.00
22 GHI 9.71 47.00 13.50 9.66 12.48 9.69 7.67 11.78 11.00
23 CP 15.83 34.00 18.30 13.99 14.99 13.34 16.20 12.09 15.00
24 CP 13.04 47.00 16.20 12.16 11.76 11.92 15.21 9.96 13.00
25 CP 7.35 62.00 10.60 7.07 10.10 7.72 5.59 11.25 9.00
Mean – 11.81 45.60 14.50 10.94 12.82 10.51 11.08 11.42 12.08
SD – 2.46 9.16 2.06 2.14 1.50 1.56 3.49 0.68 1.73
Min – 7.35 28.00 10.60 7.07 9.08 7.72 5.59 9.85 9.00
Max – 16.18 66.00 18.30 14.84 15.46 13.34 16.20 12.40 15.00

CP, clinical practice; GHI, general health information; Max, maximum; Min, minimum; PEMs, patient education materials; SD, standard deviation; SMOG, Simple Measure of Gobbledygook.

Figure 1 Flesch-Kincaid grade readability scores on lumbar disc replacement from the top 25 PEMs in relation to the AMA recommendation of a 6th-grade reading level. The red line indicates the AMA recommendation. AMA, American Medical Association; FKGL, Flesch-Kincaid Grade Level; PEMs, patient education materials.

There was no significant difference in Average Reading Level Consensus between CP PEM and GHI PEM (P=0.31) as seen in Figure 2. Comparisons of all reading score calculations are summarized in Table 2.

Figure 2 Comparison of all calculated reading level scores between clinical practice and general health information PEMs. PEMs, patient education materials; SMOG, Simple Measure of Gobbledygook.

Table 2

Mean scores comparing clinical practice PEM to general health information PEM

Readability test Clinical practice General health information P value
Mean SD Mean SD
Average Reading Level Consensus Calc 11.8 1.9 12.6 1.2 0.31
Flesch-Kincaid Reading Ease Score 47.7 10.5 41.9 4.5 0.13
Gunning Fog 14.2 2.4 14.9 1.4 0.43
Flesch-Kincaid Grade Level 10.6 2.4 11.5 1.6 0.31
The Coleman-Liau Index 12.5 1.7 13.4 0.7 0.15
SMOG Index 10.3 1.8 10.8 1.2 0.43
Automated Readability Index 11.6 2.6 12.2 2.2 0.52
Linsear Write Formula 10.9 3.7 11.3 3.3 0.78

PEM, patient education material; SD, standard deviation; SMOG, Simple Measure of Gobbledygook.

Discussion

PEM readability plays an imperative role in a provider’s ability to communicate with a patient. It enables them to more effectively participate in collaborative decision-making and improves the informed consent process. The results of this study illustrate that PEMs currently do not appropriately serve this role. This study shows that the current initial 25 PEMs on lumbar disc replacement exceed the reading level guidelines formed by the American Medical Association (AMA). The AMA suggests that PEM reading level should be at a 6th-grade level, but the calculations in this study demonstrate that lumbar disc replacement PEMs are written at a level of 12.08, roughly 6 grade levels higher (14). Additionally, no PEM materials were at or below this level consequently raising concern for denying a significant portion of the population from better understanding the lumbar disc replacement procedure. A comparison of CP PEMs to GHI PEMs shows that there was no significant difference in average PEM grade levels. This finding may be explained by the fact that both GHI and CP PEMs are written by medical professionals who are accustomed to using complex medical language and therefore unknowingly write PEMs above the recommended reading level (15). It may also be possible that PEM writers are unaware of the AMA recommendations, which may be amended by increasing awareness. PEM authors may be able to provide the general public with health information more effectively by creating materials with the reader in mind (16). However, it’s crucial to keep in mind that less well-known PEMs could differ based on the area where the search was conducted. Regardless of location, PEMs’ language and material will most likely continue to be above the suggested reading level.

These results are not unique to lumbar disc replacement. Phan et al. evaluated 90 PEMs regarding a broad array of surgical spine treatments and found PEMs on average are not only above the AMA recommendation, but they exceed the average reading level of most adults in the United States (17). Sedani et al. determined that PEMs for Anterior Cervical Discectomy and Fusion exceed recommendations (18). Other orthopedic PEMs have also exceeded the reading level recommended by the AMA. Michel et al. demonstrated that PEMs from the leading 25 orthopedic institutions have an average reading grade level of 9.3 for pediatric spinal conditions (10). Webster et al. demonstrated that increased health literacy may improve patient outcomes in spine surgery, therefore, improving readability may lead to improved pain, function, and mental health in patients (19). This may apply beyond spine surgery to other orthopedic fields. Beyond orthopedics, adequate patient readability levels continue to be a problem. According to Gu et al., PEMs in breast cancer often read at double the recommended level (20). Sharma et al. describes that PEMs regarding heart failure are written on average between a 9th- and 10th-grade level (21). This indicates that PEM readability needs to be improved in a number of patient-directed medical education domains.

Following the AMA, NIH, and CDC’s guidelines for existing PEMs would enable providers to reach a wider audience and educate the general public in a more suitable manner. Among these suggestions are reducing the length of sentences and paragraphs, employing more visual aids, and changing medical terminology to words that non-medical professionals can understand (21-25). These recommendations have improved PEM readability studies in the past. After revising articles written in Medline Plus to better follow AMA recommendations, Sheppard et al. noticed an average reduction of 1.4 reading levels for foot and ankle surgery articles (25). Furthermore, Baumann et al. found that reducing the usage of complex words and lowering sentence length to less than 15 words significantly improved readability metrics in spine related studies (26). Badarudeen et al. suggests following the AMA guideline on health literacy which include sentences that are no more than ten words, increasing the number of illustrations, using 12- or 14-point font, avoiding symbols, and avoidance of nontraditional fonts (27). A study by Stiller et al. found that when introducing changes such as decreasing sentence complexity/length, avoiding nontraditional fonts, and reducing symbols there was a significant decrease in readability scores (28). However, it was only when multiple changes were combined to PEMs that the reading level dropped below the 8th-grade mark (28). This demonstrates that the necessary changes to raise readability levels are achievable, and patients’ comprehension of their conditions or treatments may improve as a result.

One possible explanation for these PEMs’ consistently high readability ratings is that the use of extensive and intricate medical terminology is simply unavoidable. Anatomical words like “nucleus” or “intervertebral” may be too crucial to leave out when talking about specific features of lumbar disc replacement. A patient’s comprehension of lumbar disc replacement and PEMs in general can be significantly enhanced by providing straightforward definitions of these words that concurrently adhere to suggested reading level requirements.

This study is not without limitations. Firstly, analyzing readability scores alone is not comprehensive enough to understand PEMs. Images and videos may play a significant role in patient education and our study did not assess them. Secondly, this analysis only captures the initial 25 PEMs searched on the Google search engine that meet inclusion criteria. These likely represent a significant portion of PEMs used by patients, however, there may be additional sources found on other search engines such as Firefox that may not have been analyzed in this study. Despite this, given that Google dominates the search engine industry and that many people find the information they need in the first two pages of their search, this is likely a valid representation of PEMs in lumbar disc replacement (29,30). Lastly, the poor readability of PEMs may have been influenced by commercial considerations, such as the cost and time constraints associated with their development, or the impact of external financial interests which may not have been isolated. Further research and protocols that improve PEM readability should be implemented when authoring PEMs about lumbar disc replacement and online medical education materials in general. Furthermore, PEM evaluations across different languages should be performed due to their multinational relevance.

Conclusions

PEM readability is a crucial part of the patient care experience, and the current readability of lumbar disc replacement PEMs is not at an acceptable level. Given the present condition of PEMs, a large portion of the populace may find it challenging to understand the nature of their condition and their treatment options. For lumbar disc replacement and other PEMs, it is advised that existing PEMs be updated, and that new PEMs be developed in accordance with the NIH, AMA, and CDC criteria for online PEMs at a 6th-grade reading level or lower. Actionable changes such as decreasing sentence length and complexity, increasing the number of illustrations, using 12- or 14-point font, and avoiding nontraditional fonts may help achieve this goal.

Acknowledgments

None.

Footnote

Data Sharing Statement: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-50/dss

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-50/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-25-50/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Sedani A, Kholodovsky E, Marmor WA, Trapana J, Mota F, Trapana E. Readability of patient education materials for lumbar disc replacement. J Spine Surg 2025;11(3):430-437. doi: 10.21037/jss-25-50

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