Readability of Patient-reported Outcome Measures Used in Plastic Surgery

Background: Patient-reported outcomes are essential to understanding success in plastic surgery procedures, many that aim to improve quality of life. Patient-reported outcome measures (PROMs) should be written at or below the sixth-grade reading level recommended by the American Medical Association. This study aimed to evaluate the readability of plastic surgery PROMs. Methods: We conducted a literature review to identify validated, commonly used PROMs in plastic surgery. We extracted PROMs' text and instructions and analyzed readability using different approaches that estimate the grade level required to understand. Our primary outcome was the Simple Measure of Gobbledygook (SMOG) index, which detects word complexity and expects 100% comprehension at the grade level rating assigned. We also included the Flesch-Kincaid grade level, Coleman-Liau index, and automated readability index. Results: Forty-three PROMs met the inclusion criteria. The mean SMOG index was 8.2 (SD = 1.3), indicating an eighth-grade reading level. Mean reading grade levels measured by the Flesch-Kincaid grade level, Coleman-Liau index, and automated readability index ranged from third to sixth grade, although these may underestimate readability difficulties. Only 6 (14%) PROMs had a SMOG index at or below the sixth-grade level. PROM instructions had significantly higher reading levels than the questions/responses for all readability indexes (P < 0.01). Conclusions: PROMs used in plastic surgery, including the instructions, exceed the reading level recommended by the American Medical Association. This may limit comprehension and accurate completion and compromise validity and reliability. PROMs should be written and designed to be accessible to patients of all literacy levels.