{"doi":"10.1016/j.jdin.2022.05.002","title":"Evaluation of reading level of online patient education materials discussing dermatologic care for patients undergoing dialysis","abstract":"To the Editor: Dialysis for end-stage renal disease is associated with dermatologic conditions, including xerosis and uremic pruritus.1Markova A. Lester J. Wang J. Robinson-Bostom L. Diagnosis of common dermopathies in dialysis patients: a review and update.Semin Dial. 2012; 25: 408-418https://doi.org/10.1111/j.1525-139x.2012.01109.xCrossref PubMed Google Scholar Patient education materials (PEMs) for chronic kidney disease are often presented above the average patient's literacy level.2Morony S. Flynn M. McCaffery K.J. Jansen J. Webster A.C. Readability of written materials for CKD patients: a systematic review.Am J Kidney Dis. 2015; 65: 842-850https://doi.org/10.1053/j.ajkd.2014.11.025Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Moreover, the readability of PEMs addressing cutaneous symptoms in patients undergoing dialysis is unknown. The National Institutes of Health recommends that PEMs should not surpass a sixth-grade level in readability,3National Institutes of HealthClear & simple: developing effective print materials for low-literate readers (NIH Publication No. 95-3594). National Cancer Institute, 1994https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/clear-simpleDate accessed: April 15, 2022Google Scholar and dermatologic PEMs often fail to meet this recommendation.4Yousif R. Zheng D.X. Chang I.A. Wong C. Trinidad J. Carr D.R. Readability of online patient educational materials for transgender dermatologic care.J Am Acad Dermatol. 2022; S0190-9622: 00001-9https://doi.org/10.1016/j.jaad.2021.12.041Abstract Full Text Full Text PDF Scopus (3) Google Scholar Because the progression to end-stage renal disease is associated with low socioeconomic status,5Patzer R.E. McClellan W.M. Influence of race, ethnicity and socioeconomic status on kidney disease.Nat Rev Nephrol. 2012; 8: 533-541https://doi.org/10.1038/nrneph.2012.117Crossref PubMed Scopus (147) Google Scholar it is of particular importance that PEMs pertaining to dialysis skin care are presented at an adequate reading level. Our aim was to describe the readability of online PEMs related to dermatologic issues for patients undergoing dialysis. We conducted a Google search in February 2022 using the term \"dialysis skin care\" and extracted texts from PEMs available from the first 5 search pages. To mitigate bias, the search was conducted using incognito mode. Journal articles and records not in English were excluded. Eligible texts were entered on the software www.readabilityformulas.com, which uses the following validated tools to determine readability by grade level: the Flesch-Kincaid grade level, the Coleman-Liau index, simple measure of Gobbledygook index, automated readability index, and Linsear Write formula. If a tool provided an output of \"college\" (ie, readability at the college level), the coded grade level for analysis was \"13.\" Word and character counts, topics discussed, and visual aids were also analyzed. A total of 40 records were identified; 22 met the inclusion criteria, of which 18 were from the nonacademic sources (Table I). All records discussed either dialysis-induced xerosis or pruritus, and 8 records examined additional cutaneous manifestations such as pigmentation and nail changes. A total of 19 articles discussed pharmacologic and/or nonpharmacologic interventions, and 18 articles explained the possible underlying causes of dialysis-associated pruritus. The mean grade reading levels ranged from 6 (n = 1) to 13 (n = 3), with an overall mean of 9.98 (Table II). The mean number of words and characters were 903.7 and 5627.3, respectively, with an average of 6.18 characters per word. A direct relationship between the average characters per word and the overall mean grade-level readability across texts (r = 0.67, r2 = 0.44) suggests that texts with longer words are associated with increased reading difficulty. 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