YES. Even the CMS guide I referenced (Writing and Designing Print Materials for Beneficiaries) says that the Flesch-Kincaid reading grade level score in MS Word is usually 2 grades lower than the actual grade-level of the document.  I usually do a SMOG (by hand)when I want a more accurate reading. 

But using Flesch-Kincaid in MS Word can still be helpful, in that it is a tool almost everyone has access to. Our organization is rather large, with nearly 750 physicians practicing in 41 (soon to be 47) clinics in the northern half of Wisconsin. Each center, each department can purchase or create patient education materials. Up until now, most of what was developed never went through any evaluation, except to make sure the logo was in the right place. Over the past 2 years, we have been working to standardize our patient education materials, creating them as companion pieces to our evidence-based clinical practice guidelines. While we work on standardizing patient education materials, there are still letters, brochures, newsletters and other print materials that are sent to patients that are not always classified as patient education, but should still be evaluated for health literacy. 

We're trying to raise awareness of health literacy and provide recommendations for improving how we communicate with patients. Even if I can show some of our staff how to use Flesch-Kincaid in MS Word, it's a step in the right direction, and it gets them thinking about how they write and how they can improve their writing. If you aim for a score between 4th and 6th grade, your piece will most likely be 2 grades above that. But as I said in my earlier post, it may be impossible to get a low score if you have any medical terms in your piece. You can rewrite "make modifications in your food choices" (11 syllables) to "change what you eat" (4 syllables) and get a better score and improve your piece. But there isn't a simpler word for triglycerides. And you actually need more words to define it and explain it, which can raise the score. 

As far as the accuracy of Flesch-Kincaid in MS Word, there are several things that can affect the score. Bulleted lists of information often cause trouble, especially if there is no punctuation. You can have a list of symptoms, for example, and Flesch-Kincaid in MS Word will read the entire list as one sentence, and include the next sentence as well, because it's looking for the next period and treats everything written between the periods as one sentence. As readers, we often put in the punctuation even when it is not there. When we read a bulleted list of words (symptoms, for example) or phrases (actions steps or safety tips, for example), we process them as separate sentences or thoughts, even if there is no punctuation (periods) after each item in the list. When you run Flesch-Kincaid in MS Word, put in the periods (you can always remove them) after each item in the list and you'll get a more accurate reading grade level score. This is just one of many tips for improving!
  the accuracy of Flesch-Kincaid in MS Word.  

We can't solely rely on a reading grade level score when we evaluate written patient education for health literacy. Flesch-Kincaid in MS Word, nonetheless, is often still worth doing.

Doug Seubert
Guideline Editor
Quality Improvement & Care Management
Marshfield Clinic
1000 N Oak Avenue
Marshfield, WI 54449
(715) 387-5096 (1-800-782-8581 ext. 75096)
seubert.douglas at marshfieldclinic.org


------Reply Message------
From:	"Janet Sorensen" <Jsorensen at afmc.org>
Date:	Mon Oct 15, 2007 -- 01:45:04 PM
To:	"The Health and Literacy Discussion List" <healthliteracy at nifl.gov>
Subject:	[HealthLiteracy 1346] Re: simple information ondiabetesandhypertension

I have heard this as well. More recently someone told me it's a little
better now but I have not checked. But it's always a good idea to do
some kind of formula the old-fashioned way when it really matters. It's
not that hard.

-----Original Message-----
From: healthliteracy-bounces at nifl.gov
[mailto:healthliteracy-bounces at nifl.gov] On Behalf Of Rebecca Metternich
Sent: Monday, October 15, 2007 12:06 PM
To: 'The Health and Literacy Discussion List'
Subject: [HealthLiteracy 1344] Re: simple information on
diabetesandhypertension

Several years ago when I attended IHA's Health Literacy Conference, we
were told that the Flesch-Kincaid in M/S Word is not reliable.  The
results are approximately two grade levels lower than the actual
grade-level of the document.  Since then, if I use it, I keep this in
mind.

Rebecca Metternich
Central Illinois Adult Education Service Center Western Illinois
University Horrabin Hall 5B Macomb, IL 61455
Phone: 800-572-9033 or 309-298-2285
Fax: 309-298-2288  

-----Original Message-----
From: healthliteracy-bounces at nifl.gov
[mailto:healthliteracy-bounces at nifl.gov] On Behalf Of
seubert.douglas at marshfieldclinic.org
Sent: Monday, October 15, 2007 11:23 AM
To: healthliteracy at nifl.gov
Subject: [HealthLiteracy 1342] simple information on diabetes
andhypertension


I'm new to the list, but I've been reading a lot of the discussions and
thought it was time I start contributing.  I work for Marshfield Clinic
(www.marshfieldclinic.org) in Marshfield, Wisconsin. My main
responsibility is working with a team of physicians and providers to
write and publish clinical practice guidelines. I also help write
patient education materials as companion pieces for our evidence-based
guidelines.

Marshfield Clinic is currently one of ten sites participating in a
physician group practice CMS demonstration project. We developed
extensive clinical practice guidelines for the management and treatment
of chronic disease (hypertension, heart failure, diabetes, and
dyslipidemia) within the primary care setting. Corresponding patient
education resources were developed on these topics. Each is about a
30-page booklet, but they can also be printed as a series of individual
handouts. 

Because this is part of a CMS demonstration project, we closely followed
the recommendations in the CMS guide "Writing and Designing Print
Materials for Beneficiaries."  By now, most of us interested in health
literacy are familiar with the recommendations for choosing fonts,
writing shorter sentences, using plain language, etc. By following these
recommendations, we were able to produce patient education books divided
into 4 main areas:  1) an overview of the chronic condition (what is
high blood pressure? how is it treated? what do my numbers mean?), 2) an
extensive section of lifestyle modification (including DASH diet, tips
for reducing sodium, and stressing the importance of physical activity),
3) a shorter section on pharmacologic therapy (overview of medicines to
manage high blood pressure, safety tips for taking medicines, "my
medicines" work sheet, etc.), and 4) self management tools and resources
(how to take your blood pressure at home, tips for purchasing a blood!
  pressure monitor, home blood pressure monitoring log, etc.). Each of
the four books follows this structure.

We did use a lot of information from NIH, but rewrote much of it. Our
final products average a Flesch-Kincaid reading grade level score of
7.7. We used the word "hypertension" in the beginning section because we
feel it's important for patients to see and hear that word (because
their doctors use it often), but we made sure it was clear to the
patient that hypertension and high blood pressure mean the same thing.
In our medication section, we explained the different classes of drugs
(ACE1, ARBs, diuretics) and provided the generic names of drugs, again
because we felt it was important for patients to have this information.
We worked hard to write simple explanations of how each medication
works. 

We print 1500-2000 copies at a time (we have our own in-house print shop
and Graphic Arts department) and in between each printing, we work on
each section and always find one or two sentences here and there that
could be improved.

My point is, you may never find that one perfect piece of patient
education that includes all of the information you want to give to your
patients, and be written at an appropriate reading grade level. The
information from the NIH is a good place to look., but you may need to
rewrite some of it. 

Don't just rely on a reading grade level score either. If you work hard
enough, you can get any piece of education down to 5th or 6th grade
level.
It may require taking out all medical terms and names of medications to
do it, but I think that can sometimes be a bad choice. An effective
education piece explaining high cholesterol and how read the results of
a fasting lipoprotein panel, for example,  should include the words
cholesterol, low-density and high-density lipoproteins and
triglycerides. They just need to be explained and defined as simply as
possible. All patients, no matter what their reading level, appreciate
clear, simple explanations. It may not result in a piece that scores at
6th grade when you run a SMOG, but that doesn't mean it's not a good
piece to use with patients.

Doug Seubert
Guideline Editor
Quality Improvement & Care Management
Marshfield Clinic
1000 N Oak Avenue
Marshfield, WI 54449
(715) 387-5096 (1-800-782-8581 ext. 75096)
seubert.douglas at marshfieldclinic.org


------Original Message------
From:	"Steinbacher Mikal" <Mikal.Steinbacher at lwtc.edu>
Date:	Mon Oct 15, 2007 -- 09:47:11 AM
To:	"The Health and Literacy Discussion List"
<healthliteracy at nifl.gov>
Subject:	[HealthLiteracy 1341] Re: Need hel with teaching
advocates
&clientsmedication co

Barbara, 
 
I scanned several of the high blood pressure documents and found them
written at too high a level for even intermediatel 'ESL learners.   I
will
review the diabetes site later.  
 
Thanks for sharing this info.  I will share it with the RN we have on
campus, who sees a lot of our ESL students and also comes to our ESL
classes to talk about how to get the most out of doctor visits, and low
cost/free medical care.  She's a gem!  
 
Mikal Steinbacher
Instructor, ABE/ESL/English
Lake Washington Technical College

________________________________

From: healthliteracy-bounces at nifl.gov on behalf of Barbara Gordon
Sent: Fri 10/12/2007 3:42 PM
To: The Health and Literacy Discussion List
Subject: [HealthLiteracy 1336] Re: Need hel with teaching advocates
&clients medication compliance,chronic disease education
tools(asthma,diabetes and
hypertsion) very simple



For simple information on diabetes and hypertension, check out the
National Institutes of Health's web site(www.nih.gov and select health
topics A-Z list). 

They offer a limited literacy diabetes education series in both English
and Spanish. You can also order a certain quantity of printed
publications for free, or a nominal charge, by calling NIH's National
Diabetes Information Clearinghouse at 1-800-860-8747.

Barbara Gordon, RD

Public Health Consultant
HealthComm Solutions
www.healthcommsolutions.net


--- Gae <gae at everestkc.net> wrote:


>  I am located in a health service agency which is in a church & I am 

> the only clinical component.  My mission includes working with 

> advocates, clients & safety net clinics.  I will be working with 

> several chronic diseases starting with diabetes & hypertension. 60% of



> the population speak Spanish & many can not read. Looking for very 

> simple info on diabetes & hypertension, info on taking meds, use of 

> chronic disease model in such an area and any experience on group 

> brown bag clinics (to go over medications). The agency has no forms or



> anything; therefore, I am starting from scratch.  I am seeing 

> patients, setting up a clinical area and inservicing advocates. Do you



> have anything that would help me?

> Would appreciate your help! Thanks.  

>    

> George Ann Eaks ARNP, CDE, BC-ADM

> Riverview Health Services

> 722 Reynolds

> KC. Ks. 66101

> E-mail: gae at everestkc.net

>

>

>

>

>

>

>

>

>

>

>

> George Ann Eaks ARNP, CDE, BC-ADM

>

>

>

>

>

>

>

>

>

> George Ann Eaks ARNP, CDE, BC-ADM

> >

----------------------------------------------------

> National Institute for Literacy

> Health and Literacy mailing list

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