Patient Education Materials in Dermatology: Table 1

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Patient Education Materials in Dermatology: Table 1. Readability Analysis Algorithmsa Addressing the Health Literacy Needs of Patients Assessment Scale With the increasing availability of digital educational re- for Readability sources and the growing number of media users, the Internet Analyses Formula has become an invaluable resource for the dissemination of Flesch reading 206.835 – [1.015×K–(84.6×A)] ease health care information to the general public. Seventy per- Coleman-Liau (0.0588 × E) – (0.296 × C) – 15.8 cent of American adults who use the Internet to obtain health index information have reported that it influenced their decision Flesch-Kincaid (0.39 × A) + (11.8 × L) – 15.59 about how to treat an illness or condition.1 Medical practition- grade level Gunning fog index 0.4 × [A/F + (100 × B/A)] ers have the responsibility to develop and distribute materi- FORCAST 20 – (G/10) als that are readable and comprehensible to patients across dif- Readability ferent communities.1 The mean reading ability of US adults is Formula at the 8th-grade level,2 and thus the American Medical Asso- New Dale-Chall (0.0496 × H) + (0.1579 × I) + 3.6365 formula ciation and US National Institutes of Health recommend pre- New Fog Count [K + (3 × D)/J – 3]/2 senting patient education materials at a reading level be- SMOG Index 1.043 × ͙ [M × (30/F)] + 3.1291 tween the 3rd and 7th grade.3 Herein, we assess the readability Fry Readability 100-word passage from selection selected; number of of more than 700 online dermatologic patient education re- Formula sentences in passage estimated; number of syllables in sources published by a range of dermatologic organizations, each passage determined; chart used to identify readability based on calculated metrics and we use 10 widely accepted readability algorithms to de- Raygor 100-word passage from selection selected; number of termine whether these materials meet the national guide- Readability sentences in passage estimated; number of 6 or more lines. This is a comprehensive analysis of publicly available In- Estimate letter words determined; chart used to identify readability based on calculated metrics ternet-based dermatology information using multiple Abbreviations: A, mean number of words per sentence; B, mean number of readability assessments. We hope to build on prior research that words with 3 or more syllables; C, mean number of sentences per 100 words; compared the readability of selected dermatologic patient edu- D, number of complex words; E, mean number of letters per 100 words; cation materials from the American Academy of Dermatol- F, mean number of sentences; G, number of single-syllable words in a 150-word ogy and other common sources of patient education material sample; H, mean number of words; I, percentage of unfamiliar words within 4 text; J, number of sentences; K, number of “easy” words; L, mean number of (including WebMD.com and Wikipedia.org). syllables per word; M, number of polysyllabic words. a The readability algorithms were used to analyze educational materials from 20 Methods | Institutional review board approval was not required dermatology websites (American Academy of Dermatology, American Board because all data were publicly available online for this study. In of Dermatology, American Osteopathic College of Dermatology, American Skin January and February 2016, a total of 706 dermatology- Association, American Society for Dermatologic Surgery, American Society for Mohs Surgery, Cicatricial Alopecia Research Foundation, Cutaneous related internet-based patient education materials were down- Lymphoma Foundation, Foundation for Ichthyosis and Related Skin Types, loaded from 20 professional websites (Table 1). These articles Georgia Society of Dermatology and Dermatologic Surgery, Mastocytosis were reformatted to plain text using word processing software Society, Melanoma Research Foundation, National Alopecia Areata Foundation, National Eczema Association, National Foundation for Ectodermal (Microsoft Corp), and any text unrelated to patient education, Dysplasias, National Psoriasis Foundation, Skin Care Foundation, Society for including figure legends and web page navigation text, was re- Pediatric Dermatology, Sturge-Weber Foundation, and Xeroderma Pigmentosa moved. The final edited articles were assessed for their level of Support Group). readability using Readability Studio (Oleander Software, Ltd), which employs 10 quantitative readability scales that are widely used and accepted in the medical literature (Table 1). Table 2. Readability Assessment Scores Score, Mean (SD), Results | The Readability Studio composite of the 9 readability Assessment Scales Grade Level assessments found that the 706 dermatology patient- Flesch reading ease 44.8a (14.4) oriented education materials were written at a mean 12th grade Coleman-Liau index 12.2 (2.3) reading level (mean [SD], 12.1 [2.1]; range, 8.9-14.3). Specifi- Flesch-Kincaid grade level 11.2 (2.6) cally, 691 (98%) articles were written above the recom- Gunning fog index 13.1 (2.7) mended 7th grade level. The Flesch reading ease scale, a com- FORCAST Readability Formula 11.2 (0.8) mon readability scale used in the health literacy literature, New Dale-Chall formula 11.7 (2.7) further identified the articles as being “difficult” to read, with New Fog Count 8.9 (2.7) a mean (SD) score of 44.8 (14.4) out of a possible 100 (with lower SMOG Index 13.2 (2.1) scores denoting more complex articles) (Table 2). Fry Readability Formula 14.3 (3.2)

Discussion | Low health literacy is associated with poor Raygor Readability Estimate 13.1 (3.5) adherence to medication use, increased hospitalization, and Overall 12.1 (2.1) increased mortality.5 Improving patient health literacy, of a The Flesch reading ease is scored ona0to100scale, with lower scores which readability is 1 component, could boost patients’ con- indicating more difficult text and higher scores indicating more readable text (0-29, very difficult; 30-49, difficult; 50-59, fairly difficult; 60-69, standard; fidence to play a more active role in the health care 70-79, fairly easy; 80-89, easy; 90-100, very easy). decision-making process.2

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The lack of consistent oversight of online content can result OBSERVATION in inappropriately technical patient education resources.6 Given that a majority of the patient education sources from the 20 der- Necrolytic Migratory Erythema–like Skin Lesion matology organizations were written above the National Insti- During Gefitinib Treatment: A Rare Cutaneous tutes of Health–recommended reading level, these existing re- Adverse Reaction sources should be revised to reach a broader patient audience. Gefitinib is an orally administered epidermal growth factor A limitation to this study is the lack of patient feedback in receptor (EGFR) tyrosine kinase inhibitor used to treat non– assessing the quality of online health care resources. Using small-cell lung cancer (NSCLC).1 The expression of EGFR is quality assessment metrics to subjectively evaluate the on- strong in epidermis and epidermal appendages, as well as in line user experience may capture criticisms missed by our tumor cells, and so treatment with gefitinib can result in quantitative approach. Participants could reflect on the qual- dermatologic adverse effects with various manifestations.1 ity of nontextual components such as graphics, website de- We report a case of necrolytic migratory erythema (NME)- sign, interactivity, and user friendliness. A greater emphasis like skin lesions developing during treatment with gefitinib. must be placed on developing simpler online dermatologic We believe that this case demonstrates a rare cutaneous education resources, given the influence these materials can adverse reaction to gefitinib and highlights the need for sus- have on patient decision making in the clinical setting. picion of this rare condition during the course of treatment with gefitinib. Arpan V. Prabhu, BS Raghav Gupta Report of a Case | A 56-year-old man was diagnosed with Christopher Kim NSCLC and treated with oral gefitinib (250 mg/d). After 3 Ahmed Kashkoush, BS months of gefitinib treatment, he presented with a 1-month David R. Hansberry, MD, PhD history of localized, painful, migratory, coalescing, eroded, Nitin Agarwal, MD erythematous plaques with scales on both lower extremities Ellen Koch, MD and buttocks, especially in the perineal, inguinal, and thigh regions (Figure 1). The eruption had begun as erythematous Author Affiliations: Medical student at University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (Prabhu, Kashkoush); Rutgers New Jersey macules on the perineal area and had spread to the but- Medical School, Newark (Gupta, Kim); Department of Radiology, Thomas tocks, inner thighs, and lower extremities within several Jefferson University Hospitals, Philadelphia, Pennsylvania (Hansberry); days. These lesions had coalesced, and some of them had Department of Neurosurgery, University of Pittsburgh Medical Center, been rubbed off. No mucosal lesions or active changes of the Pittsburgh, Pennsylvania (Agarwal); Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Koch). hair or nails were observed. Accepted for Publication: March 25, 2016. Initially, a diagnosis of tinea cruris was considered, but Corresponding Author: Arpan V. Prabhu, BS, University of Pittsburgh School no fungal elements were detected in the potassium hydrox- of Medicine, 518 Scaife Hall, 3550 Terrace St, Pittsburgh, PA 15261 ide test. A skin biopsy specimen from a thigh lesion showed ([email protected]). upper epidermal pallor with focal vacuolated keratinocytes Published Online: May 18, 2016. doi:10.1001/jamadermatol.2016.1135. and mild to moderate superficial perivascular dermal infil- Author Contributions: Mr Prabhu and Dr Koch had full access to all of the data trate (Figure 2). Findings of periodic acid–Schiff staining in the study and take responsibility for the integrity of the data and the accuracy were negative. A diagnosis of NME was considered, but labo- of the data analysis. Study concept and design: Prabhu, Kashkoush, Hansberry, Agarwal, Koch. ratory tests revealed normal levels of glucagon (48 pg/mL; Acquisition, analysis, or interpretation of data: Prabhu, Gupta, Kim, Hansberry, normal range, 25-250 pg/mL) and zinc (68 μg/dL; normal Agarwal. range, 60-120 μg/dL). Additional laboratory findings, includ- Drafting of the manuscript: Prabhu, Gupta, Kashkoush. ing from hemoglobin and albumin assays and liver function Critical revision of the manuscript for important intellectual content: Prabhu, Gupta, Kim, Hansberry, Agarwal, Koch. tests yielded normal results. Computed tomography of his Statistical analysis: Prabhu, Gupta, Hansberry. abdomen did not reveal any pancreatic mass. Despite treat- Administrative, technical, or material support: Koch. ment with oral prednisolone (0.5 mg/kg/d and subsequently Study supervision: Prabhu, Hansberry, Koch. tapered over 2 weeks) and clobetasol propionate, 0.05%, Conflict of Interest Disclosures: None reported. ointment, the skin eruptions worsened. Thus the treatment 1. Rainie L, Fox S. The online health care revolution. Pew Research Center with gefitinib was discontinued. website. November 26, 2000. http://www.pewinternet.org/2000/11/26 /the-online-health-care-revolution/. Accessed February 7, 2016. After withdrawal of gefitinib, the skin eruptions im- 2. Walsh TM, Volsko TA. Readability assessment of internet-based consumer proved significantly in the short term. Four weeks later, health information. Respir Care. 2008;53(10):1310-1315. gefitinib was readministered under observation by his oncolo- 3. How to write easy-to-read health materials. MedlinePlus website. https://www gist, but skin eruptions developed again. Thereafter, he be- .nlm.nih.gov/medlineplus/etr.html. Accessed April 8, 2016. gan receiving palliative care without chemotherapy, and at last 4. Tulbert BH, Snyder CW, Brodell RT. Readability of patient-oriented online follow-up, his overall health had been declining after 1 year of dermatology resources. J Clin Aesthet Dermatol. 2011;4(3):27-33. palliative care. 5. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107. Discussion | Cutaneous adverse reactions have been reported as 6. Diaz JA, Griffith RA, Ng JJ, Reinert SE, Friedmann PD, Moulton AW. Patients’ one of the most common adverse events in patients treated use of the Internet for medical information. J Gen Intern Med. 2002;17(3):180-185. with EGFR inhibitors, with prevalence ranging from 50% to

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