Abstract
This cross-sectional study examines the readability, accuracy, content, quality, and suitability of online health information on coronary artery bypass grafting or percutaneous coronary intervention for patients.
Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are the most common interventions for coronary artery disease.1 For both, patient involvement in the decision-making process is crucial and requires patient access to high-quality medical information. More than 80% of adults rely on the internet for such information.2 We systematically evaluated the readability, accuracy, content, quality, and suitability of online health information on CABG or PCI for patients.
Methods
Adapting previous methods,3,4 we performed systematic online searches using Google, Yahoo, and Bing in May 2020. Websites were included if they were designed for public consumption, discussed treatment for coronary artery disease, were 100 words or longer, and were written in English. Websites were classified as nonprofit, academic, government, communication media, and/or private. Affiliations were confirmed using the WHOis.net database.5 Institutional review board approval was not required for this study as it was a systematic review of online websites and did not involve human participants. Readability was measured by 9 standardized tests; accuracy and content regarding procedural details, eligible populations, goals of treatment, and associated adverse effects were assessed by 2 interventional cardiologists and 2 cardiac surgeons who independently adapted previous methods.3,4 Each website was assigned the median score of the respective raters. Quality and suitability were evaluated using the DISCERN and Suitability Assessment of Materials tools, respectively.4 Suitability was defined as how effectively the information facilitated comprehension, and quality as how reliably and comprehensively the source discussed treatment information.4 Continuous variables were assessed for normality and reported as mean (SD) or median (interquartile range) values. Readability and suitability were analyzed using analysis of variance. Accuracy, quality, and content were analyzed using Kruskal-Wallis test. Pairwise comparisons were performed using the Student t test or Mann-Whitney U test. Multiple linear regression and multivariable ordinal logistic regression were used to identify associations between treatment modality, website affiliations, and the readability, suitability, accuracy, content, and quality of websites. Two-sided significance testing was used, and P < .05 was considered significant without adjustment for multiple testing. All analyses were performed using SPSS, version 24 (IBM), and R (version 3.6.2; R Project for Statistical Computing) within RStudio.
Results
Of 17 250 000 websites retrieved, 126 (CABG; 83 [65.9%]; PCI, 43 [34.1%]) met inclusion criteria. Both CABG and PCI websites were difficult to read, with mean (SD) readability of 12.2 (2.2) and 12.4 (2.9) (P = .64), respectively, requiring at least 12 years of education to be comprehended (Figure, Table). The CABG websites were more accurate than the PCI websites, but had similar quality and suitability. Academic websites were more accurate and had more content than nonacademic websites. Public/nonprofit websites were more accurate and suitable than private websites (Table). On multivariable regression, CABG websites (exponent of regression coefficient [Exp (β)], 3.42; 95% CI, 1.62-7.23; P < .001), academic websites (Exp [β], 4.30; 95% CI, 1.82-10.20; P = .001), and websites with higher amount of content (Exp [β], 1.73; 95% CI, 1.24-2.41; P = .001) were associated with higher accuracy. There was no association between accuracy and readability (Exp [β], 1.19; 95% CI, 0.68-2.09; P = .54).
Figure. Readability of Online Resources on Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention.
Blue dots indicate percutaneous coronary intervention, orange dots indicate coronary artery bypass grafting, and the black line represents the mean for the education level.
Table. Readability, Accuracy, Content, Suitability, and Quality of Online Resources by Affiliation and Treatment Modality.
| Online resource | Median (IQR) | Statistically significant comparisons | P valuea |
|---|---|---|---|
| Readability | |||
| Overall, mean (SD) | 12.3 (2.5) | NA | NA |
| Treatment modality, mean (SD) | |||
| CABG | 12.2 (2.2) | NA | NA |
| PCI | 12.4 (2.9) | ||
| Affiliation, mean (SD) | |||
| Academic | 12.3 (2.0) | NA | NA |
| Nonacademic | 12.2 (2.9) | ||
| Nonprofit | 11.7 (3.0) | NA | NA |
| Private | 13.0 (2.8) | Government | .01 |
| Communication media | 12.7 (2.4) | Government | .04 |
| Government | 9.3 (2.7) | Private; communication media | .01; .04 |
| Accuracy | |||
| Overall | 4.0 (3.0-5.0) | NA | NA |
| Treatment modality | |||
| CABG | 4.0 (4.0-5.0) | NA | .02 |
| PCI | 4.0 (3.0-4.0) | ||
| Affiliation | |||
| Academic | 4.0 (4.0-5.0) | Nonacademic | <.001 |
| Nonacademic | 4.0 (3.0-4.0) | ||
| Nonprofit | 4.0 (3.8-4.0) | NA | NA |
| Private | 3.5 (3.0-4.0) | Publicb | .01 |
| Communication media | 3.5 (3.0-4.0) | NA | NA |
| Government | 3.5 (2.8-4.0) | NA | |
| Content | |||
| Overall | 3.0 (2.0-4.0) | NA | NA |
| Treatment modality | |||
| CABG | 3.0 (2.0-4.0) | NA | NA |
| PCI | 3.0(2.0-4.0) | ||
| Affiliation | |||
| Academic | 3.0 (2.0-4.0) | Nonacademic | .02 |
| Nonacademic | 2.0 (2.0-4.0) | ||
| Nonprofit | 2.5 (2.0-4.0) | NA | NA |
| Private | 2.0 (1.0-4.0) | ||
| Communication media | 3.0 (2.0-4.0) | ||
| Government | 2.0 (1.8-3.5) | ||
| Suitability | |||
| Overall, mean (SD) | 57.0 (13.1) | NA | NA |
| Treatment modality, mean (SD) | |||
| CABG | 56.3 (12.0) | NA | NA |
| PCI | 58.4 (15.0) | ||
| Affiliation, mean (SD) | |||
| Academic | 57.4 (11.2) | NA | NA |
| Nonacademic | 56.6 (15.0) | ||
| Nonprofit | 66.0 (14.7) | Communication media; private | .01; <.01 |
| Private | 52.1 (13.1) | Publicb; nonprofit | .04; <.01 |
| Communication media | 51.7 (12.6) | Nonprofit | .01 |
| Government | 65.5 (17.4) | NA | |
| Quality | |||
| Overall | 2.5 (2.0-3.1) | NA | NA |
| Treatment modality | |||
| CABG | 2.5 (2.0-3.5) | NA | NA |
| PCI | 2.0 (2.0-3.0) | ||
| Affiliation | |||
| Academic | 2.0 (2.0-3.0) | NA | NA |
| Nonacademic | 2.5 (2.0-3.1) | ||
| Nonprofit | 3.0 (2.0-4.0) | NA | NA |
| Private | 2.5 (1.9-3.0) | ||
| Communication media | 3.0 (1.9-4.0) | ||
| Government | 3.0 (2.0-4.3) | ||
Abbreviations: CABG, coronary artery bypass grafting; IQR, interquartile range; NA, not applicable; PCI, percutaneous coronary intervention.
P values represent statistically significant pairwise comparisons between treatment modalities or website affiliations.
All nonprivate websites were considered public.
Discussion
To our knowledge, this study is the first to comprehensively assess online health information on PCI and CABG for patients. We found that CABG and PCI online resources had nonsignificant difference in readability and required at least a college reading level for comprehension, far exceeding the sixth-grade level recommended by the American Medical Association and attained by only 61% of US adults.6 The CABG and PCI websites had adequate suitability and quality, but lacked images and audio, limiting opportunities for user interaction, particularly for older populations. There was no association between website accuracy and readability, suggesting that readability can be improved without sacrificing accuracy.
Our study has limitations. The analysis was restricted to online information that was written in English. We were also unable to evaluate information discussed on online forums. Additionally, we only searched the 3 most popular search engines. However, it is unlikely that important online resources were not captured. Furthermore, we did not adjust for multiplicity, and the possibility of type I error cannot be excluded.
In conclusion, online information on CABG and PCI overestimates the reading ability of patients and requires at least 12 years of education to be comprehended. Public websites and websites from academic centers are more accurate and suitable for patients.
References
- 1.Roth GA, Johnson C, Abajobir A, et al. Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015. J Am Coll Cardiol. 2017;70(1):1-25. doi: 10.1016/j.jacc.2017.04.052 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ybarra ML, Suman M. Help seeking behavior and the Internet: a national survey. Int J Med Inform. 2006;75(1):29-41. doi: 10.1016/j.ijmedinf.2005.07.029 [DOI] [PubMed] [Google Scholar]
- 3.Storino A, Castillo-Angeles M, Watkins AA, et al. Assessing the accuracy and readability of online health information for patients with pancreatic cancer. JAMA Surg. 2016;151(9):831-837. doi: 10.1001/jamasurg.2016.0730 [DOI] [PubMed] [Google Scholar]
- 4.Garfinkle R, Wong-Chong N, Petrucci A, et al. Assessing the readability, quality and accuracy of online health information for patients with low anterior resection syndrome following surgery for rectal cancer. Colorectal Dis. 2019;21(5):523-531. doi: 10.1111/codi.14548 [DOI] [PubMed] [Google Scholar]
- 5.Whois.net . Whois.net. Accessed January 28, 2021. https://www.whois.net/
- 6.Weiss BD; American Medical Association; AMA Foundation . Health literacy: help your patients understand: a continuing medical education (CME) program that provides tools to enhance patient care, improve office productivity, and reduce healthcare costs. Accessed on January 28, 2021. http://www.partnershiphp.org/Providers/HealthServices/Documents/Health%20Education/CandLToolKit/2%20Manual%20for%20Clinicians.pdf
