Poster Number-37 - Evaluating the Literacy Levels of Opioid Agreements

Evaluating the Literacy Levels of Opioid Agreements

Purpose:

Readability formulas are often used to determine reading levels, however, these formulas may not be capturing the realities of the content within the documents. Given that healthcare professionals are taught throughout their training to use nonmedical language to increase patient understanding, it is important to look closely at the language and themes portrayed in medical documents.  This research focused specifically on opioid agreements.

Every step in patient care should help the patient achieve their goals in a safe and effective manner; the opioid agreement should not be an exception.  Opioid agreements are part of risk mitigation and in some instances a requirement for prescription. The worry about these agreements is that in their current form, they may not be easily understood and thus not patient centered. The hypothesis was that the opioid agreements were not written at a literacy level that could easily be understood. This led to the formation of a working group that spanned different colleges within the university.

The university’s Humanities Center brings together this interdisciplinary team of researchers from the field of education and medicine to evaluate the literacy levels of opioid agreements. Also known as opioid contracts, these documents inform patients of the risks and expectations of the use of opioids for pain management. The reading difficulty of these documents have a significant impact on a patient’s ability to comprehend the associated risks, benefits, and expectations of this treatment plan. This research focused on one university hospital system serving an Appalachian population and consisted of two phases: (1) a review of the readability levels and (2) a content analysis of the university’s Non-Chronic Pain Contract for Use of Opioid Medications (Pain Contract) and the university’s Consent to Treat with Opioid Medications (Consent Form). Two readability formulas were used; the Fleisch-Kincaid Grade Level (FK) formula and the Simple Measure of Gobbledygook (SMOG).

The research questions that guided this study were: 

 1.       How are readability formulas used to evaluate the reading difficulty of opioid agreements?

2.       What themes emerged during a content analysis of an opioid agreement?

Methods:

Using a case study approach (Yin, 2009) the readability levels of the university’s opioid documents were first analyzed using three easily accessible and (presumably) free tools (e.g., Microsoft Word, Readabilityformulas.com, and Textcompare.org) to evaluate the reading grade levels of the document. The reading scores are reported using the grade level and month within the grade (e.g., a score of 12.9 is the equivalent of reading abilities typical of someone in the ninth month of twelfth grade).

The documents had different total numbers of words; the Pain Contract had 915 words and the Consent Form had 446 words.  To control for consistency in assessing the reading levels of the documents, the exact number of words were used from the beginning of each document to calculate the individual reading levels and then the documents were combined (1361 total words) to determine an overall reading grade level.

Each document and then both together were entered into each of the three readability tools and scored using the FK formula and the SMOG.  The FK was selected because this is often used in educational settings and the SMOG was selected because this is typically used by the medical field.

Content analysis was used in the second phase to look more closely at the meaningful language units within each of the documents.  This social science approach includes a critical examination of text, an interpretation of the texts through either an emerging or a priori lens, and an understanding that socially constructed perspectives are brought to the text during analysis.

Initially, codes emerged from both of the university documents.  Then, to more clearly see the emerging code patterns, the educational team members separated the documents and the codes.  After this separation, the codes from both documents were merged and color coded to establish one code list.  The code list was shared with the medical team researchers, so that they could use their specific disciplinary knowledge to categorize the codes.  The categorization groups were then titled by the collective team members to capture the codes within each of these groups.

Results:

The evaluation of the opioid agreements using multiple readability formulas and tools led to several insights regarding the reading difficulty of the documents. The opioid medication agreement documentation at WVU Medicine is 1,361 words. The document was entered into the readability calculators to evaluate the reading difficulty of the documents.   An evaluation using the FK formula yielded three grade level scores: 12.9 (Microsoft Word), 12.2 (readabilityformulas.com), and 12.9 (text compare.org). An evaluation using the SMOG index yielded two scores (Microsoft Word does not calculate SMOG score): 12 (readabilityformulas.com) and 15.61 (textcompare.org).

Regardless of the readability formula used, there is variation in readability scores. This raises questions about the accuracy of the formulas and calculators. These readability scores are higher than expected by the researchers and call for further consideration of the reading difficulty of opioid agreements.

The content analysis identified several pieces of text within the document. Forty-two unique codes were identified and classified into seven categories within three themes. By coding the documents and placing the codes into categories, researchers were able to identify and describe the most meaningful elements of the documents and capture the purpose and significance of the document.

1. Expectations




1. Acknowledgements




1. Agree to conditions


2. Consent


3. Patients understands document


4. Patient Responsibility statement


5. Risk acknowledgment


6. Start/End date




2. Administration




1. Directions for completing contract


2. Introduction


3. Patient signature


4. Pharmacy name


5. Practitioner signature


6. Prescription authorization


7. Questions answered


8. Read to me


9. Witness signature




3. Objective Medication Information




1. Dosage/Frequency


2. Medication schedule/refill


3. Pill counts


4. Quantity


5. Types of medications




4. Other treatments




1. Other possible treatment options




5. Punitive Consequences




1. Disclaimer on prescription duration


2. Expiration of consent/termination of medication


3. Reference local, state, federal law


4. Termination of medication


5. Termination of provider-patient relationship




6. Rules




1. Attend scheduled appointments


2. Illegal/illicit drugs


3. Notification of other medications


4. Prescriptor


5. Random drug screenings


6. Responsibility for tracking prescription


7. Specimen tampering