Pyun S and Malik R: Assessing the quality of online patient decision aids for urological conditions. Urol Pract 2021; 8: 692.

Patient decision aids (PtDAs) are designed to educate patients evaluating medical or surgical treatments for a medical condition, providing explanations for various options with risks and benefits and helping to clarify treatment goals further. PtDAs are frequently utilized in urology to assist patients in shared decision-making for conditions such as pelvic organ prolapse (POP), urinary incontinence (UI), benign prostatic hyperplasia (BPH) and overactive bladder (OAB). With more PtDAs available online for easy access, it has become increasingly important to evaluate existing PtDAs to ensure high accuracy and readability for patients of varying health literacy backgrounds. Prior studies have shown that many online PtDAs are written above the recommended reading level while not meeting quality standards.^1–3

In this study, PtDAs for the previously mentioned urological conditions were analyzed to determine the readability and quality of consumer health information.⁴ This study is the first to analyze urological PtDAs using 3 different measures specifically: readability formula scores, DISCERN quality criteria scores and the International Patient Decision Aid Standards (IPDASi v4.0) minimum standards criteria scores.

A total of 23 urological patient decision aids were found by searching Google, PubMed®, Embase® and decision aid repositories, including the Decision Aid Library Inventory (DALI), National Institute for Health and Care Excellence (NICE), UK Clinical Trials Gateway (National Institute of Health Research [NIHR]) and the National Health Service (NHS) website. Of these 23 PtDAs, 14 were included as they had content relevant to the urological conditions of interest, were written in English and text format, were directed at patients and were identified as a decision aid. Sources were excluded if they acted mainly as an advertisement, were costly or required patient registration. The 14 identified PtDAs were analyzed for their readability, DISCERN and IPDASi v4.0 scores.

Readability scores were measured using the average of 4 different formulas, with each estimating an approximate U.S. grade level required to comprehend the text. A higher score indicates a required higher level of education for comprehension.⁵ Quality scores were obtained using the DISCERN instrument, which analyzes the quality of written consumer health information, with a range of possible scores from 15 to 75, and scores above 63 categorized as excellent and below 26 as poor.^6,7 The IPDASi v4.0 minimum standards criteria were simplified for this study to assess the overall quality of the PtDAs, focusing on qualification as a patient decision aid and certification to avoid harmful bias.^2,3

On evaluating the identified urological PtDAs, we found that variable quality and readability exist in the available online health information. The mean grade level readability score of 11 far exceeded the 6th grade reading level recommended by the National Institutes of Health (NIH; see table). This is consistent with other studies assessing online educational materials in medicine, which found that an average 11th grade reading level was needed for comprehension.⁴ The elderly population is typically of a lower health literacy level. With many urological conditions being more prevalent in this group, we found that online urological PtDAs are likely not appropriate for this population.⁸ Prior studies have shown that shortening sentences and substituting polysyllabic words to reduce syllable length can improve readability by 1 to 3 grade levels.^9,10

The average DISCERN score of 57.6 indicated good quality of information. However, the IPDAsi v4.0 criteria found that none of the identified urological aids met the international minimum standards of a patient decision aid. This suggests that currently available urological PtDAs are lacking in quality and reliability. Both quality measures can be addressed by authors self-assessing for completeness during the development of these aids.

While patient decision aids can be of immense benefit to facilitate shared decision-making, online resources may present poor quality information that may be difficult to comprehend. With more patients turning to the Internet for assistance in medical decision-making, patient decision aids must be better addressed and adapted for this growing audience. Based on this evaluation of existing urological PtDAs, the development of aids with lower reading levels and more consistent quality is recommended. Together, providers and patients can better utilize these aids to decide on the appropriate treatment modality that aligns best with the patient’s goals.