A Readability Analysis of Online Patient Education Materials Regarding Endoscopic Retrograde Cholangiopancreatography

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Sunkara, Ali Arif, Saumya L. Karne DO, Samara Rifkin, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7133599/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Nov, 2025 Read the published version in Digestive Diseases and Sciences → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used to diagnose and treat hepato-biliary and pancreatic conditions. Many patients use internet search engines for educational purposes prior to procedures, such as ERCP. The American Medical Association (AMA) recommends patient education materials be written at a 5th -6th grade reading level. There is no prior literature examining the reading level of ERCP education materials. The primary objective of this study is to assess the readability of online patient education materials regarding ERCP. Methods Using the Google search engine, the top 75 search results for 5 ERCP-related keywords (total 375 websites) were screened. After exclusion, readability was assessed using the Simple Measure of Gobbledygook (SMOG) and three other tools (Flesch-Kincaid, Coleman-Liau and Automated Readability Index). Websites were categorized as academic or non-academic. A word substitution analysis assessed readability after replacing complex words with simpler alternatives. Results A total of 131 websites met inclusion criteria. The mean SMOG reading grade level was 9.42 (n = 131). Academic websites (n = 79) had a statistically significantly lower mean reading level than non-academic websites (n = 52) (SMOG 9.15 vs. 9.83, p < 0.01). Similar trends were found with the other readability tools. Substituting easier words for complex words resulted in a significantly lower mean reading level (SMOG 8.96, p < 0.01). Conclusion Online ERCP patient education materials are at a 9th -11th grade reading level, exceeding the AMA recommendations. Word substitution analysis significantly decreased the mean reading level, but not to the recommended levels. Medical organizations should prioritize accessible health information to improve patient understanding. ERCP Patient education Readability Internet Uses Figures Figure 1 Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is an important interventional endoscopy diagnostic and therapeutic procedure, used to evaluate and treat numerous hepato-biliary and pancreatic conditions, ranging from obstructive jaundice to tissue sampling for possible malignancies. [1,2] The procedure is the primary endoscopic approach for evaluating and treating many conditions, with over 650,000 procedures performed yearly in the United States. [2] Yet, it is a complex procedure that can result in post-intervention complications. [1,2] As a result, interventional endoscopists face the challenge of consolidating important pre-procedural information to ensure patient comprehension and decision-making. Health literacy is defined as the ability to comprehend and act on healthcare information. [3] It is an essential component of guiding patients’ decision-making about treatment options, including endoscopic interventions. During pre-procedural encounters, patients are usually provided with information to help them understand the benefits and potential complications. In the digital age, patients often turn to the internet and search engines to supplement their understanding of proposed medical interventions and treatment options. [4] During this process, patients come across online education materials that are usually written at an advanced reading level. [5–7] The American Medical Association (AMA) recommends that education materials be written at 5th -6th grade reading levels to accommodate the health literacy levels of all patients. [8] In general, lower health literacy levels may play a role in poorer health outcomes and complications. [9,10] Thus, providing easy-to-understand education material may result in adherence to periprocedural instructions, improving patient care and increasing patient satisfaction. Prior studies of health literacy have used readability tools to assess the grade reading level of online patient education materials. [7,11] More specifically, readability analyses have been performed on patient education materials regarding endoscopic procedures such as colonoscopy and EGD and found that they did not meet the AMA standards [12–14] However, there is no previous literature performing this analysis on ERCP education materials. To address this knowledge gap, we performed a readability analysis of online patient education materials regarding ERCP to determine if available online information is written at appropriate reading levels for patients with limited health literacy. Materials and Methods Search Criteria, Content Selection and Categorization Using the Google search engine (Google, Inc., Mountain View, CA), the top 75 search results for five separate keywords related to ERCP were queried. A total of 375 websites were screened. The keywords included: “Endoscopic Retrograde Cholangiopancreatography”, “ERCP gallstone procedure”, “ERCP complications”, “ERCP side effects”, and “ERCP handout information”. Before each query, the internet browser was cleared and searched in a private browser. Cookies were cleared and disabled, and the location was turned off to limit search engine result bias. Inclusion criteria were: 1) The text must pertain to ERCP, 2) the text was accessed within one click of opening the website, and 3) the text included at least 30 sentences for analysis to ensure standardization. [15] Additionally, the full main text was assessed for included websites. Duplicate websites, websites with information that did not pertain to ERCP, websites with less than 30 sentences for analysis, websites that required subscriptions to view, scientific journal articles, pages requiring multiple clicks to access the main text, video-based websites and websites with advertisements or sponsors were excluded from the analysis. Once websites were screened, those that were included were categorized as academic websites or non-academic websites. Academic websites were defined as those associated with an academic institution, academic healthcare organization, and/or systems. Non-academic websites were defined as those associated with charitable organizations, private practices, commercial companies, and sites that did not fit the definition outlined for academic websites. Readability Assessments The full main text of each included website was collected and analyzed using the preferred readability assessment for healthcare-related information: Simple Measure of Gobbledygook (SMOG). [16] SMOG assesses grade level of a written text by counting and incorporating word complexity and number of sentences into a calculated algorithm. [17] The reading level assessment was then repeated using three other readability tools: Flesch-Kincaid Grade Level [17] (assesses average sentence length and number of syllables), Coleman-Liau Index [17] (assesses number of letters and the average number of sentences), and Automated Readability Index [18] (assesses average word length and average sentence length) (Table 1 ). The scores from all four readability tools directly correlate to the reading level of the material (e.g. 9.42 is equal to a 9th -grade reading level). The mean grade reading level of each website was calculated and compared using these four tools. Table 1 Readability Formulas and Assessment of Reading Grade Level of ERCP Patient Education Materials Abbreviations: SMOG, Simplified Measure of Gobbledygook Test Score Type Assessment Tool Formula SMOG Readability Formula Grade Level Word complexity ( ≳ 3 syllables), Sentence length G = 1.0430*√X + 3.1291 Flesch-Kincaid Grade Level Grade Level Average Sentence length and Number of Syllables G = 0.39(W/S) + 11.8(U/W) – 15.59 Coleman-Liau Index Grade Level Number of letters, Sentence length G = ((5.88*C)/W) − ((29.5*S)/ W) − 15.8 Automated Readability Index Grade Level Average number of characters per word (AWL) and the average number of words per sentence (ASL) G = 4.71*(C/W) + 0.5*(W/S)-21.43 Where G = grade level, W = number of words, C = number of characters, S = number of sentences, X = number of complex words (> 3 syllables), U = number of syllables Word Substitution Analysis A word substitution analysis was performed to evaluate changes in the reading level after replacing commonly used difficult words in the text. Word substitution has been used in previous readability analyses to show the effect of simpler words on reading level. [19] A word was determined to be “difficult” if it was a medically related term not used in everyday text, greater than seven letters long, or greater than two syllables. The original difficult words and their respective simplified words are displayed in Table 2 . The “find and replace” functionality in a word processor was used to revise the original complex words. The articles were then proofread to ensure proper grammar, parallel structure, and sentence form. Word substitutions were not used in a way to alter the meaning of the original sentence. Table 2 Frequently Used Difficult Words in ERCP Online Patient Education Materials with Suggestions for Simplified Words Original Word Revised Word Original Word Revised Word Complication Problem Jaundice Yellowing of Diagnose Find Duodenum Bowel, small bowel Therapeutic Treating, Treatment Gastroenterologist Stomach doctor Evaluate Check Intervention Treat, treatment Perforation Tear Drainage Flow, Flow out, outflow Papilla Opening Hepato-Biliary Liver, Gall bladder Condition Case Esophagus Food pipe Inflammation Swelling Perform Do, to do Stent Tube Biopsy Sample Obstruct Block Lesion Mass Discharge Release Monitor Watch Endoscopy Camera, Video exam Symptom Sign Distended Bloated Significant Major Examine To see Stricture Narrowing, thinning Statistical Analysis Statistics were computed using Google Sheets (Google, Inc., Mountain View, CA). In the main analysis, the overall mean readability score and standard deviation (SD) were calculated for SMOG. This was repeated for the other three assessment tools. In the sub-analysis, mean readability scores and standard deviations were calculated for academic and non-Academic websites. An unpaired t-test was calculated to compare academic and non-academic mean reading scores. Lastly, for the word substitution analysis, a two-tailed paired t-test was used to compare readability scores before and after word substitution. The paired t-test was also performed before and after word substitution when stratified by academic and non-academic websites. An additional unpaired t-test was performed to compare the change in reading level after word substitution between academic and non-academic websites. The P -value was set at 0.05. Results After screening 375 websites, 131 websites met the criteria for inclusion in the analysis. The mean reading level using SMOG was 9.42 (Range: 5.67–13.61, SD: 1.38) (Table 3 ). 3 websites (2%) met the recommended 5th -6th grade reading level. The overall mean reading level for Flesch-Kincaid was 9.33 (Range: 4.92–15.07, SD: 1.85). 11 websites (8%) met the recommended levels. The overall mean reading level for Coleman-Liau was 10.83 (Range: 6.62–15.43, SD: 1.81). 0 websites (0%) met the recommended levels. The overall mean reading level for the Automated Readability Index was 9.81 (Range: 5.12–15.98, SD: 2.10). 8 websites (6%) met the recommended levels. Table 3 Readability Scores and Grade Levels of Online Patient Education Materials in ERCP Abbreviations: RS: Readability Scores, GL: Grade Level, *: p < 0.01 between academic and non-academic websites, **:p = 0.02 between academic and non-academic websites, SMOG: Simplified Measure of Gobbledygook Category n = x (%) All n = 131 RS Mean (SD) Academic or Institutional Websites n = 79 (77%) RS Mean (SD) Non-Academic/ Institutional Websites n = 52 (23%) Mean (SD) SMOG 9.42 (1.38) 9.15 (1.32)* 9.83 (1.37) Flesch-Kincaid 9.33 (1.85) 8.95 (1.79)* 9.90 (1.82) Coleman-Liau 10.83 (1.81) 10.41 (1.68)* 11.48 (1.81) Automated Readability Index 9.81 (2.10) 9.46 (2.03)** 10.34 (2.00) Academic versus Non-Academic Websites Most websites were categorized as academic (n = 79, 60%), and the rest were non-academic (n = 52, 40%) ( Table 3 ). After analysis using SMOG, academic websites had a significantly lower reading level than non-academic websites (9.15, 9.83. P < 0.01). Furthermore, academic websites had a significantly lower reading level than non-academic websites using Flesch-Kincaid (8.95, 9.90. P < 0.01), Coleman-Liau (10.41, 11.48. P < 0.01), and Automated Readability Index (9.46, 10.34. P = 0.02). Word Substitution Analysis The word substitution analysis revealed a significantly lower mean reading level after using SMOG (9.42, 8.96. P < 0.01) (Fig. 1 ). There was also a significantly lower mean reading level after simple word substitution using Flesch-Kincaid (9.33, 8.33. P < 0.01), Coleman-Liau (10.83, 10.18), and Automated Readability Index (9.81, 9.29. P < 0.01). Word substitution analysis for academic websites revealed a significantly lower mean reading level after using SMOG (p < 0.01) and the other three readability tools (p < 0.01). Word substitution analysis for non-academic websites revealed a significantly lower mean reading level after using SMOG (p < 0.05) along with Coleman-Liau and Automated Readability Index (p < 0.01 for both). Reading level did not differ after word substitution in non-academic websites using Flesch-Kincaid (p = 0.10). The mean change in grade level after word substitution did not differ between academic and non-academic websites. Discussion ERCP is a multi-purpose advanced endoscopic procedure with complex periprocedural patient instructions and education. This creates challenges for advanced endoscopists as they obtain informed consent from patients. Patients supplement their understanding from pre- and peri-procedural visits through the Internet. Many online materials are not written at the AMA-recommended 5th -6th grade reading levels, creating an issue for patient comprehension. Previous studies have investigated the readability of online patient education materials encompassing several endoscopic procedures. Maclean et al. [12] reviewed 100 websites regarding colonoscopy prep instructions using four validated reading scales including SMOG. The study concluded that colonoscopy prep instructions were written at a high school level or above. Additionally, Priyanka et al. [13] reviewed 44 websites regarding EGD patient education material for readability using the Flesch-Kincaid tool. Their results concluded that online material was written around an 11th -grade reading level. Lastly, Nawaz et al. [14] reviewed 18 websites encompassing patient education material on EGD, colonoscopy, and sigmoidoscopy. This study used five different readability tools and concluded that materials were written between a 9th and 11th -grade reading level on average, consistent with studies published by Maclean and Priyanka. After assessing 131 websites using five different keywords, our results show that ERCP materials were written between a 9th and 11th grade reading level, which is 4–6 levels higher than recommended. Our main results primarily stemmed from using the SMOG readability index which is the preferred readability tool for healthcare-related material. [16] In addition, we included an additional three scales for further analysis to verify the results from SMOG. Most of the websites (60%) included in the analysis came from academic sources. However, there were still many websites from non-academic sources which primarily came from private practices, pancreatic foundations, and more. Our sub-analysis found that patient material from academic sources was significantly lower than non-academic sources. The literature shows mixed evidence on whether academic sources consistently provide lower reading levels than non-academic sources. For example, Duong et al. [11] show that academic sources have significantly lower reading levels regarding nerve block procedures than non-academic sources. However, there were no significant differences between sources with the other radiologic procedures analyzed. Additional literature review confirms these findings. [20–22] Mixed evidence is likely due to several factors, including: the inclusion and exclusion criteria for websites, differences in procedures studied, where the procedure is typically performed, the complexity of the procedure, the total number of websites included in analysis, and differences in the number of academic and non-academic websites analyzed upon query. Our word substitution analysis found that simple word substitution resulted in nearly a half-grade decrease in reading level which was statistically significant. However, the decrease was not to the recommended levels. As mentioned previously, word substitution has been used in prior literature. In the study by Danziel et al. [19] five full texts were reviewed; all words deemed to be complex were identified and average reading level was successfully lowered by an average of 3.1 grade levels. Our analysis used a standardized list of commonly used complex words for word substitution. The purpose of our analysis was to highlight how minor differences in text can have an impact on reading level. Yet, there are more intensive methods to meet the AMA- recommended guidelines. These can be divided into text-based changes and visual changes. With regard to text-based changes, revision of the whole text is necessary, and substituting complex medical terminology with simpler synonyms can substantially lower reading levels. [24] More specifically, these changes would include words with fewer syllables, fewer words in sentences, and using active voice to simplify text. [24] Visual changes include supplementing text with simple graphical illustrations of conditions, procedures, or processes to ensure patient comprehension. [25] Implementing diagrams, models, and videos with easy-to-understand captions are also useful. [24] Incorporation of these changes to existing websites will drastically improve reading levels which will hopefully result in better informed consent thereby leading to better patient outcomes. There are several limitations to this study. While this cross-sectional analysis compiles top searches of online patient education handouts, there are additional online sources that may not be included. This may be due to sites being newly published after the data collection was complete and also because the sites were outside of the search parameters for each keyword. Additionally, this analysis only considers online information on the internet. Some institutions have cellular phone applications for their patients that provide them with additional electronic patient information on ERCP. These handouts are not included in our analysis. Despite these limitations, the results of this study are of paramount importance and highlight an important yet under-reported issue in peri-procedural decision-making. The findings in this study also have several notable implications. This readability analysis shows that online patient education materials regarding ERCP are nearly 4–6 grade reading levels above the established guidelines. For hospitals, organizations, and other healthcare systems that plan to develop electronic patient education materials regarding ERCP, ensuring that the materials are written at the recommended levels will aid patients greatly. The hope is that the findings of this study will encourage organizations to improve existing and develop additional online education materials. By adhering to these guidelines, there may be decreases in post-procedural expectations, patient comfort, and patient satisfaction. Conclusion Available ERCP online patient education materials are at a 9th -11th grade reading level, well above the AMA recommendations. Materials from academic institutions were at lower reading levels than non-academic websites. The word substitution analysis decreased the mean reading level, but not to the recommended levels. Medical organizations that provide online education material regarding ERCP should aim to lower the reading levels of these texts to accommodate for health literacy levels of the general patient population. Declarations Conflicts of Interest: The authors have no conflicts of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Source of funding The authors have no source of funding, none declared. Clinical Trial Number Not Applicable Ethics, Consent to Participate, and Consent to Publish declarations Not Applicable Author Contribution Concept and design: PS, FA, SRAcquisition, analysis, or interpretation of data: all authorsStatistical analysis: PSDrafting of the manuscript: All authors.Critical revision of the manuscript: All authorasintellectual content: All authors References Meseeha M, Attia M. Endoscopic Retrograde Cholangiopancreatography. 2023 Aug 8. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing ; 2025 Jan. Yang HY, Wang D, Lin X, Han C, Lv YW, Huang RQ et al. Global trends of ERCP research in the last 25 years: A bibliometrics study. Medicine (Baltimore) . 2022 Aug 5;101(31):e29454. doi: 10.1097/MD.0000000000029454. Nielsen-Bohlman L, Panzer AM, Kindig DA. Health Literacy: A Prescription to End Confusion . 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Sunkara","email":"data:image/png;base64,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","orcid":"","institution":"Wayne State University","correspondingAuthor":true,"prefix":"","firstName":"Pranit","middleName":"R.","lastName":"Sunkara","suffix":""},{"id":492613157,"identity":"f0a1ba8c-d9d8-4d58-988b-50d6684fc6ca","order_by":1,"name":"Ali Arif","email":"","orcid":"","institution":"SUNY Downstate Health Sciences University","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Arif","suffix":""},{"id":492613158,"identity":"92d4c285-bb69-4d60-8332-59cbcb0f4187","order_by":2,"name":"Saumya L. Karne DO","email":"","orcid":"","institution":"Wayne State University","correspondingAuthor":false,"prefix":"","firstName":"Saumya","middleName":"L. Karne","lastName":"DO","suffix":""},{"id":492613159,"identity":"cc84a255-5a44-42b1-b0fe-06d346eaf6f2","order_by":3,"name":"Samara Rifkin","email":"","orcid":"","institution":"Wayne State University","correspondingAuthor":false,"prefix":"","firstName":"Samara","middleName":"","lastName":"Rifkin","suffix":""},{"id":492613160,"identity":"6019bc67-84a7-484e-b09f-77f6a2d8a7d8","order_by":4,"name":"Fadi Antaki","email":"","orcid":"","institution":"Wayne State University","correspondingAuthor":false,"prefix":"","firstName":"Fadi","middleName":"","lastName":"Antaki","suffix":""}],"badges":[],"createdAt":"2025-07-15 19:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7133599/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7133599/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10620-025-09571-1","type":"published","date":"2025-11-19T15:58:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88034851,"identity":"2b8a4a43-f069-4ab4-8b40-f7391745ecce","added_by":"auto","created_at":"2025-07-31 16:10:00","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":251949,"visible":true,"origin":"","legend":"\u003cp\u003eERCP Online Patient Education Material Readability Scores Pre-and Post-Word Substitution\u003c/p\u003e\n\u003cp\u003eAbbreviations: SMOG, Simplified Measure of Gobbledygook; * = p\u0026lt; 0.01\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7133599/v1/c739aad5b07031b447c73a6c.jpeg"},{"id":96651306,"identity":"d34854d6-c696-48e0-bc35-885aca316311","added_by":"auto","created_at":"2025-11-24 16:14:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":842859,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7133599/v1/a59ee398-fd06-424f-a127-bc5d88865fdb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Readability Analysis of Online Patient Education Materials Regarding Endoscopic Retrograde Cholangiopancreatography","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndoscopic retrograde cholangiopancreatography (ERCP) is an important interventional endoscopy diagnostic and therapeutic procedure, used to evaluate and treat numerous hepato-biliary and pancreatic conditions, ranging from obstructive jaundice to tissue sampling for possible malignancies.\u003csup\u003e[1,2]\u003c/sup\u003e The procedure is the primary endoscopic approach for evaluating and treating many conditions, with over 650,000 procedures performed yearly in the United States.\u003csup\u003e[2]\u003c/sup\u003e Yet, it is a complex procedure that can result in post-intervention complications.\u003csup\u003e[1,2]\u003c/sup\u003e As a result, interventional endoscopists face the challenge of consolidating important pre-procedural information to ensure patient comprehension and decision-making.\u003c/p\u003e\u003cp\u003eHealth literacy is defined as the ability to comprehend and act on healthcare information.\u003csup\u003e[3]\u003c/sup\u003e It is an essential component of guiding patients\u0026rsquo; decision-making about treatment options, including endoscopic interventions. During pre-procedural encounters, patients are usually provided with information to help them understand the benefits and potential complications. In the digital age, patients often turn to the internet and search engines to supplement their understanding of proposed medical interventions and treatment options.\u003csup\u003e[4]\u003c/sup\u003e During this process, patients come across online education materials that are usually written at an advanced reading level.\u003csup\u003e[5\u0026ndash;7]\u003c/sup\u003e The American Medical Association (AMA) recommends that education materials be written at 5th -6th grade reading levels to accommodate the health literacy levels of all patients.\u003csup\u003e[8]\u003c/sup\u003e In general, lower health literacy levels may play a role in poorer health outcomes and complications.\u003csup\u003e[9,10]\u003c/sup\u003e Thus, providing easy-to-understand education material may result in adherence to periprocedural instructions, improving patient care and increasing patient satisfaction.\u003c/p\u003e\u003cp\u003ePrior studies of health literacy have used readability tools to assess the grade reading level of online patient education materials.\u003csup\u003e[7,11]\u003c/sup\u003e More specifically, readability analyses have been performed on patient education materials regarding endoscopic procedures such as colonoscopy and EGD and found that they did not meet the AMA standards\u003csup\u003e[12\u0026ndash;14]\u003c/sup\u003e However, there is no previous literature performing this analysis on ERCP education materials. To address this knowledge gap, we performed a readability analysis of online patient education materials regarding ERCP to determine if available online information is written at appropriate reading levels for patients with limited health literacy.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cem\u003eSearch Criteria, Content Selection and Categorization\u003c/em\u003e\u003c/p\u003e\u003cp\u003eUsing the Google search engine (Google, Inc., Mountain View, CA), the top 75 search results for five separate keywords related to ERCP were queried. A total of 375 websites were screened. The keywords included: \u0026ldquo;Endoscopic Retrograde Cholangiopancreatography\u0026rdquo;, \u0026ldquo;ERCP gallstone procedure\u0026rdquo;, \u0026ldquo;ERCP complications\u0026rdquo;, \u0026ldquo;ERCP side effects\u0026rdquo;, and \u0026ldquo;ERCP handout information\u0026rdquo;. Before each query, the internet browser was cleared and searched in a private browser. Cookies were cleared and disabled, and the location was turned off to limit search engine result bias.\u003c/p\u003e\u003cp\u003eInclusion criteria were: 1) The text must pertain to ERCP, 2) the text was accessed within one click of opening the website, and 3) the text included at least 30 sentences for analysis to ensure standardization.\u003csup\u003e[15]\u003c/sup\u003e Additionally, the full main text was assessed for included websites. Duplicate websites, websites with information that did not pertain to ERCP, websites with less than 30 sentences for analysis, websites that required subscriptions to view, scientific journal articles, pages requiring multiple clicks to access the main text, video-based websites and websites with advertisements or sponsors were excluded from the analysis.\u003c/p\u003e\u003cp\u003eOnce websites were screened, those that were included were categorized as academic websites or non-academic websites. Academic websites were defined as those associated with an academic institution, academic healthcare organization, and/or systems. Non-academic websites were defined as those associated with charitable organizations, private practices, commercial companies, and sites that did not fit the definition outlined for academic websites.\u003c/p\u003e\u003cp\u003e\u003cem\u003eReadability Assessments\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe full main text of each included website was collected and analyzed using the preferred readability assessment for healthcare-related information: Simple Measure of Gobbledygook (SMOG).\u003csup\u003e[16]\u003c/sup\u003e SMOG assesses grade level of a written text by counting and incorporating word complexity and number of sentences into a calculated algorithm.\u003csup\u003e[17]\u003c/sup\u003e The reading level assessment was then repeated using three other readability tools: Flesch-Kincaid Grade Level\u003csup\u003e[17]\u003c/sup\u003e (assesses average sentence length and number of syllables), Coleman-Liau Index\u003csup\u003e[17]\u003c/sup\u003e (assesses number of letters and the average number of sentences), and Automated Readability Index\u003csup\u003e[18]\u003c/sup\u003e (assesses average word length and average sentence length) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The scores from all four readability tools directly correlate to the reading level of the material (e.g. 9.42 is equal to a 9th -grade reading level). The mean grade reading level of each website was calculated and compared using these four tools.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReadability Formulas and Assessment of Reading Grade Level of ERCP Patient Education Materials Abbreviations: SMOG, Simplified Measure of Gobbledygook\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTest\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eScore Type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAssessment Tool\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFormula\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSMOG\u003c/p\u003e\u003cp\u003eReadability Formula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWord complexity (\u0026thinsp;≳\u0026thinsp;3 syllables),\u003c/p\u003e\u003cp\u003eSentence length\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eG\u0026thinsp;=\u0026thinsp;1.0430*\u0026radic;X\u0026thinsp;+\u0026thinsp;3.1291\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFlesch-Kincaid Grade Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAverage Sentence length and Number of Syllables\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eG\u0026thinsp;=\u0026thinsp;0.39(W/S)\u0026thinsp;+\u0026thinsp;11.8(U/W) \u0026ndash; 15.59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eColeman-Liau\u003c/p\u003e\u003cp\u003eIndex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber of letters,\u003c/p\u003e\u003cp\u003eSentence length\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eG\u0026thinsp;=\u0026thinsp;((5.88*C)/W)\u0026thinsp;\u0026minus;\u0026thinsp;((29.5*S)/\u003c/p\u003e\u003cp\u003eW)\u0026thinsp;\u0026minus;\u0026thinsp;15.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAutomated Readability Index\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGrade Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAverage number of characters per word (AWL) and the average number of words per sentence (ASL)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eG\u0026thinsp;=\u0026thinsp;4.71*(C/W)\u0026thinsp;+\u0026thinsp;0.5*(W/S)-21.43\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eWhere G\u0026thinsp;=\u0026thinsp;grade level, W\u0026thinsp;=\u0026thinsp;number of words, C\u0026thinsp;=\u0026thinsp;number of characters, S\u0026thinsp;=\u0026thinsp;number of sentences, X\u0026thinsp;=\u0026thinsp;number of complex words (\u0026gt;\u0026thinsp;3 syllables), U\u0026thinsp;=\u0026thinsp;number of syllables\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eWord Substitution Analysis\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA word substitution analysis was performed to evaluate changes in the reading level after replacing commonly used difficult words in the text. Word substitution has been used in previous readability analyses to show the effect of simpler words on reading level. \u003csup\u003e[19]\u003c/sup\u003e A word was determined to be \u0026ldquo;difficult\u0026rdquo; if it was a medically related term not used in everyday text, greater than seven letters long, or greater than two syllables. The original difficult words and their respective simplified words are displayed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The \u0026ldquo;find and replace\u0026rdquo; functionality in a word processor was used to revise the original complex words. The articles were then proofread to ensure proper grammar, parallel structure, and sentence form. Word substitutions were not used in a way to alter the meaning of the original sentence.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFrequently Used Difficult Words in ERCP Online Patient Education Materials with Suggestions for Simplified Words\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOriginal Word\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRevised Word\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eOriginal Word\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRevised Word\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProblem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eJaundice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eYellowing of\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiagnose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFind\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDuodenum\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBowel, small bowel\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTherapeutic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreating, Treatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGastroenterologist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStomach doctor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEvaluate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCheck\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTreat, treatment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerforation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTear\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDrainage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFlow, Flow out, outflow\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePapilla\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOpening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHepato-Biliary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLiver, Gall bladder\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCondition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEsophagus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFood pipe\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInflammation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSwelling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePerform\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDo, to do\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTube\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBiopsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSample\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObstruct\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBlock\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLesion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMass\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDischarge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRelease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMonitor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWatch\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEndoscopy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCamera, Video exam\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSymptom\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSign\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDistended\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBloated\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSignificant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMajor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExamine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTo see\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStricture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNarrowing, thinning\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eStatistics were computed using Google Sheets (Google, Inc., Mountain View, CA). In the main analysis, the overall mean readability score and standard deviation (SD) were calculated for SMOG. This was repeated for the other three assessment tools. In the sub-analysis, mean readability scores and standard deviations were calculated for academic and non-Academic websites. An unpaired t-test was calculated to compare academic and non-academic mean reading scores. Lastly, for the word substitution analysis, a two-tailed paired t-test was used to compare readability scores before and after word substitution. The paired t-test was also performed before and after word substitution when stratified by academic and non-academic websites. An additional unpaired t-test was performed to compare the change in reading level after word substitution between academic and non-academic websites. The \u003cem\u003eP\u003c/em\u003e-value was set at 0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAfter screening 375 websites, 131 websites met the criteria for inclusion in the analysis. The mean reading level using SMOG was 9.42 (Range: 5.67\u0026ndash;13.61, SD: 1.38) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). 3 websites (2%) met the recommended 5th -6th grade reading level. The overall mean reading level for Flesch-Kincaid was 9.33 (Range: 4.92\u0026ndash;15.07, SD: 1.85). 11 websites (8%) met the recommended levels. The overall mean reading level for Coleman-Liau was 10.83 (Range: 6.62\u0026ndash;15.43, SD: 1.81). 0 websites (0%) met the recommended levels. The overall mean reading level for the Automated Readability Index was 9.81 (Range: 5.12\u0026ndash;15.98, SD: 2.10). 8 websites (6%) met the recommended levels.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReadability Scores and Grade Levels of Online Patient Education Materials in ERCP Abbreviations: RS: Readability Scores, GL: Grade Level, *: p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 between academic and non-academic websites, **:p\u0026thinsp;=\u0026thinsp;0.02 between academic and non-academic websites, SMOG: Simplified Measure of Gobbledygook\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;x (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAll\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;131\u003c/p\u003e\u003cp\u003eRS Mean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAcademic or Institutional Websites\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;79 (77%)\u003c/p\u003e\u003cp\u003eRS Mean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNon-Academic/\u003c/p\u003e\u003cp\u003eInstitutional Websites\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;52 (23%)\u003c/p\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSMOG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.42 (1.38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.15 (1.32)*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.83 (1.37)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFlesch-Kincaid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.33 (1.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.95 (1.79)*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.90 (1.82)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eColeman-Liau\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.83 (1.81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.41 (1.68)*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.48 (1.81)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAutomated Readability Index\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9.81 (2.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.46 (2.03)**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.34 (2.00)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eAcademic versus Non-Academic Websites\u003c/em\u003e\u003c/p\u003e\u003cp\u003eMost websites were categorized as academic (n\u0026thinsp;=\u0026thinsp;79, 60%), and the rest were non-academic (n\u0026thinsp;=\u0026thinsp;52, 40%) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e After analysis using SMOG, academic websites had a significantly lower reading level than non-academic websites (9.15, 9.83. P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Furthermore, academic websites had a significantly lower reading level than non-academic websites using Flesch-Kincaid (8.95, 9.90. P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), Coleman-Liau (10.41, 11.48. P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and Automated Readability Index (9.46, 10.34. P\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e\u003cp\u003e\u003cem\u003eWord Substitution Analysis\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe word substitution analysis revealed a significantly lower mean reading level after using SMOG (9.42, 8.96. P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). There was also a significantly lower mean reading level after simple word substitution using Flesch-Kincaid (9.33, 8.33. P\u0026thinsp;\u0026lt;\u0026thinsp;0.01), Coleman-Liau (10.83, 10.18), and Automated Readability Index (9.81, 9.29. P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003eWord substitution analysis for academic websites revealed a significantly lower mean reading level after using SMOG (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and the other three readability tools (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Word substitution analysis for non-academic websites revealed a significantly lower mean reading level after using SMOG (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) along with Coleman-Liau and Automated Readability Index (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01 for both). Reading level did not differ after word substitution in non-academic websites using Flesch-Kincaid (p\u0026thinsp;=\u0026thinsp;0.10). The mean change in grade level after word substitution did not differ between academic and non-academic websites.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eERCP is a multi-purpose advanced endoscopic procedure with complex periprocedural patient instructions and education. This creates challenges for advanced endoscopists as they obtain informed consent from patients. Patients supplement their understanding from pre- and peri-procedural visits through the Internet. Many online materials are not written at the AMA-recommended 5th -6th grade reading levels, creating an issue for patient comprehension.\u003c/p\u003e\u003cp\u003ePrevious studies have investigated the readability of online patient education materials encompassing several endoscopic procedures. Maclean et al.\u003csup\u003e[12]\u003c/sup\u003e reviewed 100 websites regarding colonoscopy prep instructions using four validated reading scales including SMOG. The study concluded that colonoscopy prep instructions were written at a high school level or above. Additionally, Priyanka et al.\u003csup\u003e[13]\u003c/sup\u003e reviewed 44 websites regarding EGD patient education material for readability using the Flesch-Kincaid tool. Their results concluded that online material was written around an 11th -grade reading level. Lastly, Nawaz et al.\u003csup\u003e[14]\u003c/sup\u003e reviewed 18 websites encompassing patient education material on EGD, colonoscopy, and sigmoidoscopy. This study used five different readability tools and concluded that materials were written between a 9th and 11th -grade reading level on average, consistent with studies published by Maclean and Priyanka.\u003c/p\u003e\u003cp\u003eAfter assessing 131 websites using five different keywords, our results show that ERCP materials were written between a 9th and 11th grade reading level, which is 4\u0026ndash;6 levels higher than recommended. Our main results primarily stemmed from using the SMOG readability index which is the preferred readability tool for healthcare-related material.\u003csup\u003e[16]\u003c/sup\u003e In addition, we included an additional three scales for further analysis to verify the results from SMOG. Most of the websites (60%) included in the analysis came from academic sources. However, there were still many websites from non-academic sources which primarily came from private practices, pancreatic foundations, and more.\u003c/p\u003e\u003cp\u003eOur sub-analysis found that patient material from academic sources was significantly lower than non-academic sources. The literature shows mixed evidence on whether academic sources consistently provide lower reading levels than non-academic sources. For example, Duong et al.\u003csup\u003e[11]\u003c/sup\u003e show that academic sources have significantly lower reading levels regarding nerve block procedures than non-academic sources. However, there were no significant differences between sources with the other radiologic procedures analyzed. Additional literature review confirms these findings.\u003csup\u003e[20\u0026ndash;22]\u003c/sup\u003e Mixed evidence is likely due to several factors, including: the inclusion and exclusion criteria for websites, differences in procedures studied, where the procedure is typically performed, the complexity of the procedure, the total number of websites included in analysis, and differences in the number of academic and non-academic websites analyzed upon query.\u003c/p\u003e\u003cp\u003eOur word substitution analysis found that simple word substitution resulted in nearly a half-grade decrease in reading level which was statistically significant. However, the decrease was not to the recommended levels. As mentioned previously, word substitution has been used in prior literature. In the study by Danziel et al.\u003csup\u003e[19]\u003c/sup\u003e five full texts were reviewed; all words deemed to be complex were identified and average reading level was successfully lowered by an average of 3.1 grade levels. Our analysis used a standardized list of commonly used complex words for word substitution. The purpose of our analysis was to highlight how minor differences in text can have an impact on reading level. Yet, there are more intensive methods to meet the AMA- recommended guidelines. These can be divided into text-based changes and visual changes. With regard to text-based changes, revision of the whole text is necessary, and substituting complex medical terminology with simpler synonyms can substantially lower reading levels.\u003csup\u003e[24]\u003c/sup\u003e More specifically, these changes would include words with fewer syllables, fewer words in sentences, and using active voice to simplify text.\u003csup\u003e[24]\u003c/sup\u003e Visual changes include supplementing text with simple graphical illustrations of conditions, procedures, or processes to ensure patient comprehension.\u003csup\u003e[25]\u003c/sup\u003e Implementing diagrams, models, and videos with easy-to-understand captions are also useful.\u003csup\u003e[24]\u003c/sup\u003e Incorporation of these changes to existing websites will drastically improve reading levels which will hopefully result in better informed consent thereby leading to better patient outcomes.\u003c/p\u003e\u003cp\u003eThere are several limitations to this study. While this cross-sectional analysis compiles top searches of online patient education handouts, there are additional online sources that may not be included. This may be due to sites being newly published after the data collection was complete and also because the sites were outside of the search parameters for each keyword. Additionally, this analysis only considers online information on the internet. Some institutions have cellular phone applications for their patients that provide them with additional electronic patient information on ERCP. These handouts are not included in our analysis. Despite these limitations, the results of this study are of paramount importance and highlight an important yet under-reported issue in peri-procedural decision-making.\u003c/p\u003e\u003cp\u003eThe findings in this study also have several notable implications. This readability analysis shows that online patient education materials regarding ERCP are nearly 4\u0026ndash;6 grade reading levels above the established guidelines. For hospitals, organizations, and other healthcare systems that plan to develop electronic patient education materials regarding ERCP, ensuring that the materials are written at the recommended levels will aid patients greatly. The hope is that the findings of this study will encourage organizations to improve existing and develop additional online education materials. By adhering to these guidelines, there may be decreases in post-procedural expectations, patient comfort, and patient satisfaction.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAvailable ERCP online patient education materials are at a 9th -11th grade reading level, well above the AMA recommendations. Materials from academic institutions were at lower reading levels than non-academic websites. The word substitution analysis decreased the mean reading level, but not to the recommended levels. Medical organizations that provide online education material regarding ERCP should aim to lower the reading levels of these texts to accommodate for health literacy levels of the general patient population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflicts of Interest:\u003c/h2\u003e\u003cp\u003eThe authors have no conflicts of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSource of funding\u003c/strong\u003e\u003cp\u003eThe authors have no source of funding, none declared.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003cp\u003eNot Applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics, Consent to Participate, and Consent to Publish declarations\u003c/strong\u003e\u003cp\u003eNot Applicable\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConcept and design: PS, FA, SRAcquisition, analysis, or interpretation of data: all authorsStatistical analysis: PSDrafting of the manuscript: All authors.Critical revision of the manuscript: All authorasintellectual content: All authors\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMeseeha M, Attia M. Endoscopic Retrograde Cholangiopancreatography. 2023 Aug 8. In: \u003cem\u003eStatPearls [Internet]. Treasure Island (FL): StatPearls Publishing\u003c/em\u003e; 2025 Jan.\u003c/li\u003e\n\u003cli\u003eYang HY, Wang D, Lin X, Han C, Lv YW, Huang RQ et al. Global trends of ERCP research in the last 25 years: A bibliometrics study. \u003cem\u003eMedicine (Baltimore)\u003c/em\u003e. 2022 Aug 5;101(31):e29454. doi: 10.1097/MD.0000000000029454.\u003c/li\u003e\n\u003cli\u003eNielsen-Bohlman L, Panzer AM, Kindig DA. \u003cem\u003eHealth Literacy: A Prescription to End Confusion\u003c/em\u003e. National Academies Press (US); 2004. doi:10.17226/10883\u003c/li\u003e\n\u003cli\u003eAmante DJ, Hogan TP, Pagoto SL, English TM, Lapane KL. 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Separating the Wheat From the Chaff: An Evaluation of Readability, Quality, and Accuracy of Online Health Information for Treatment of Peyronie Disease. \u003cem\u003eUrology\u003c/em\u003e. 2018;118:59-64. doi:10.1016/j.urology.2018.02.054\u003c/li\u003e\n\u003cli\u003eWeiss BD. Health Literacy and Patient Safety: Help Patients Understand. 2nd Edition. \u003cem\u003eAmerican Medical Association\u003c/em\u003e; 2007.\u003c/li\u003e\n\u003cli\u003eBerkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. \u003cem\u003eAnn Intern Med\u003c/em\u003e. 2011;155(2):97-107. doi:10.7326/0003-4819-155-2-201107190-00005\u003c/li\u003e\n\u003cli\u003eShahid R, Shoker M, Chu LM, Frehlick R, Ward H, Pahwa P. Impact of low health literacy on patients\u0026apos; health outcomes: a multicenter cohort study. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e. 2022 Sep 12;22(1):1148. doi: 10.1186/s12913-022-08527-9.\u003c/li\u003e\n\u003cli\u003eDuong PT, Moy MP, Simeone FJ, Chang CY, Wong TT. Assessing the readability of patient-targeted online information on musculoskeletal radiology procedures. \u003cem\u003eSkeletal Radiol.\u003c/em\u003e 2021 Jul;50(7):1379-1387. doi: 10.1007/s00256-020-03562-1.\u003c/li\u003e\n\u003cli\u003eMacLean SA, Basch CH, Clark A, Basch CE. Readability of information on colonoscopy preparation on the internet. \u003cem\u003eHealth Promot Perspect\u003c/em\u003e. 2018;8(2):167-170. doi: 10.15171/hpp.2018.22.\u003c/li\u003e\n\u003cli\u003ePriyanka P, Hadi, YB, Reynolds, GJ. (2018). Analysis of the patient information quality and readability on esophagogastroduodenoscopy (EGD) on the internet. \u003cem\u003eCanadian Journal of Gastroenterology and Hepatology\u003c/em\u003e, \u003cem\u003e2018\u003c/em\u003e, 1\u0026ndash;8. https://doi.org/10.1155/2018/2849390.\u003c/li\u003e\n\u003cli\u003eNawaz MS, McDermott LE, Thor S. (2021). The readability of patient education materials pertaining to gastrointestinal procedures. \u003cem\u003eCanadian Journal of Gastroenterology and Hepatology\u003c/em\u003e, \u003cem\u003e2021\u003c/em\u003e, 1\u0026ndash;6. https://doi.org/10.1155/2021/7532905.\u003c/li\u003e\n\u003cli\u003eGunning, R. FREE READABILITY FORMULAS: FREE READABILITY TOOLS: READABILITY CALCULATORS. https://readabilityformulas.com/. 1996. Accessed 2024 Feb 2.\u003c/li\u003e\n\u003cli\u003eFitzsimmons PR, Michael BD, Hulley JL, Scott GO. 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Assessing the readability of online patient education resources related to gynecomastia. \u003cem\u003eAnnals of Plastic Surgery\u003c/em\u003e, \u003cem\u003e87\u003c/em\u003e(2), 123\u0026ndash;125. https://doi.org/10.1097/sap.0000000000002620.\u003c/li\u003e\n\u003cli\u003eDocimo S, Seeras K, Acho R, Pryor A, Spaniolas K. (2022). Academic and community hernia center websites in the United States fail to meet healthcare literacy standards of readability. \u003cem\u003eHernia\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e(3), 779\u0026ndash;786. https://doi.org/10.1007/s10029-022-02584-z.\u003c/li\u003e\n\u003cli\u003eGarcia SF, Hahn EA, Jacobs EA. Addressing low literacy and health literacy in clinical oncology practice. \u003cem\u003eJ Support Oncol.\u003c/em\u003e 2010 Mar-Apr;8(2):64-9. \u003c/li\u003e\n\u003cli\u003eSeligman HK, Wallace AS, DeWalt DA, Schillinger D, Arnold CL, Shilliday BB et al. Facilitating behavior change with low-literacy patient education materials. \u003cem\u003eAm J Health Behav.\u003c/em\u003e 2007 Sep-Oct;31 Suppl 1(0 1):S69-78. doi: 10.5555/ajhb.2007.31.supp.S69.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"ERCP, Patient education, Readability, Internet Uses","lastPublishedDoi":"10.21203/rs.3.rs-7133599/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7133599/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eEndoscopic retrograde cholangiopancreatography (ERCP) is a procedure used to diagnose and treat hepato-biliary and pancreatic conditions. Many patients use internet search engines for educational purposes prior to procedures, such as ERCP. The American Medical Association (AMA) recommends patient education materials be written at a 5th -6th grade reading level. There is no prior literature examining the reading level of ERCP education materials. The primary objective of this study is to assess the readability of online patient education materials regarding ERCP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eUsing the Google search engine, the top 75 search results for 5 ERCP-related keywords (total 375 websites) were screened. After exclusion, readability was assessed using the Simple Measure of Gobbledygook (SMOG) and three other tools (Flesch-Kincaid, Coleman-Liau and Automated Readability Index). Websites were categorized as academic or non-academic. A word substitution analysis assessed readability after replacing complex words with simpler alternatives.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 131 websites met inclusion criteria. The mean SMOG reading grade level was 9.42 (n\u0026thinsp;=\u0026thinsp;131). Academic websites (n\u0026thinsp;=\u0026thinsp;79) had a statistically significantly lower mean reading level than non-academic websites (n\u0026thinsp;=\u0026thinsp;52) (SMOG 9.15 vs. 9.83, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Similar trends were found with the other readability tools. Substituting easier words for complex words resulted in a significantly lower mean reading level (SMOG 8.96, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eOnline ERCP patient education materials are at a 9th -11th grade reading level, exceeding the AMA recommendations. Word substitution analysis significantly decreased the mean reading level, but not to the recommended levels. Medical organizations should prioritize accessible health information to improve patient understanding.\u003c/p\u003e","manuscriptTitle":"A Readability Analysis of Online Patient Education Materials Regarding Endoscopic Retrograde Cholangiopancreatography","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-31 16:09:56","doi":"10.21203/rs.3.rs-7133599/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-14T04:03:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-12T03:21:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-07T01:55:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"106814368742547641367080805589505786746","date":"2025-08-26T16:23:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"27814588655409504452817726629552964786","date":"2025-08-24T18:34:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-27T12:04:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-20T18:45:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-17T07:26:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"Digestive Diseases and Sciences","date":"2025-07-15T19:14:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"digestive-diseases-and-sciences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ddsj","sideBox":"Learn more about [Digestive Diseases and Sciences](http://link.springer.com/journal/10620)","snPcode":"10620","submissionUrl":"https://submission.nature.com/new-submission/10620/3","title":"Digestive Diseases and Sciences","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"889a72fc-3f80-48a7-ac53-f414587c2ae1","owner":[],"postedDate":"July 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:12:54+00:00","versionOfRecord":{"articleIdentity":"rs-7133599","link":"https://doi.org/10.1007/s10620-025-09571-1","journal":{"identity":"digestive-diseases-and-sciences","isVorOnly":false,"title":"Digestive Diseases and Sciences"},"publishedOn":"2025-11-19 15:58:55","publishedOnDateReadable":"November 19th, 2025"},"versionCreatedAt":"2025-07-31 16:09:56","video":"","vorDoi":"10.1007/s10620-025-09571-1","vorDoiUrl":"https://doi.org/10.1007/s10620-025-09571-1","workflowStages":[]},"version":"v1","identity":"rs-7133599","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7133599","identity":"rs-7133599","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}