P-031 - (Poster #31) Readability of Patient Pain Medication Management Instructions for Regimens Which Alternate Acetaminophen and Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Adequate health literacy is critical for understanding medication instructions and healthcare provider advice. Health literacy is defined as the ability to find, understand, and use information and services to make health-related decisions. [Brach 2024] It is estimated that 88% of adults have inadequate health literacy. [Lopez 2022] Thus, the reading level of patient education and instruction materials is recommended to be no higher than the 8th grade according to the U.S. Food and Drug Administration (FDA) and 6th grade according to the American Medical Association (AMA). [FDA 2010; Weiss 2006]

Although alternating acetaminophen and an NSAID may be more effective in controlling pediatric fever than use of a single agent, the American Academy of Pediatrics does not recommend such regimens based on concerns that combined treatment may be more complicated and contribute to the unsafe use.  [Sullivan 2011] In contrast, a combined regimen of acetaminophen and an NSAID is often recommended for adults with acute pain. [Pino 2025] A large proportion of adult patients or caregivers may have difficulty understanding instructions for alternating acetaminophen and an NSAID. To our knowledge, no prior studies have evaluated the readability of instructions for managing pain with regimens that alternate acetaminophen and an NSAID.

Purpose/Objectives:

The internet is a commonly used resource for many patients to access health or medical information, which could lead to self-treatment using over-the-counter drugs. [Wang 2023] We sought to determine the readability level of patient pain medication management instructions for regimens using alternating acetaminophen and an NSAID that are available to patients through an internet search.

Methods:

A Google search was conducted on April 16, 2025, at 11:10 am EST using the parameter "discharge instructions for alternating acetaminophen and NSAIDs for pain." The first 100 websites returned were independently reviewed by 2 pharmacists. Websites were included if they provided patient instructions, including dosing, for alternating acetaminophen and an NSAID for pain management. Websites that were duplicates, promotional, non-U.S. based, inaccessible, intended for healthcare professionals, news articles, health blogs, social media posts, or for pediatric patients were not included.

The reviewers independently identified instruction and dosing text. The Flesch-Kincaid Grade (FKG) Level, the Simple Measure of Gobbledygook (SMOG) Index, and the Gunning Fog Index (FGI) were calculated for the identified text from each website using an online readability tool. Periods were added to bullet points and table entries, and extraneous symbols and page dividers were removed to enhance consistency of readability calculations. The reading levels independently calculated by each reviewer were averaged; if reading levels differed by more than 1 grade-level, independent review by a third physician reviewer resolved discrepancies.

No human patients were recruited for the study. All data were collected from websites that are publicly accessible and thus did not require Institutional Review Board review.

Results:

The total number of websites included in the analysis was 29. Discrepancies between reviewers in the inclusion or exclusion of 6 websites were resolved through consensus. Readability discrepancies were identified and resolved for 6 instances.

The readability of patient pain medication management instructions for regimens alternating acetaminophen and an NSAID were found to have a median FKG level of 8.9 (interquartile range [IQR], 7.4-9.6). However, using indices designed to measure the years of education required to fully understand the written content found a median of 12.0 (IQR, 11.1-12) based on the SMOG Index and 10.9 (IQR, 9.7-12.5) based on the GFI.  The highest-grade reading level identified was 12.0 for FKG, 12.0 for SMOG, and 15.1 for GFI, whereas the lowest was 4.6 for FKG, 9.2 for SMOG, and 7.6 for GFI.

Very few of the identified patient pain medication management instructions for regimens alternating with acetaminophen and an NSAID were written at or below a 6th grade reading level (17.2% based on FKG, 0% based on SMOG Index, and 0% based on GFI).  More than half of the instructions were written at or below an 8th grade reading level based on FKG (55.2%); however, fewer instructions were written at or below an 8th grade reading level based on the SMOG Index (0%) and the GFI (10.3%). The SMOG and GFI indices place greater weight on the complexity of the words used, whereas FKG places greater weight on the length of sentences.

This study used 1 search engine, with specific search terms, performed at a single time point. Results could vary if a different search engine, different search terms, or another time point were used. This study was limited to pain medication management instructions available online, and the instructions available online may not necessarily be representative of printed instructions handed to patients or verbal instructions spoken to patients at the time of an evaluation by a healthcare professional.

Conclusions/Implications for future research and/or clinical care:

Low health literacy is associated with lower compliance with health interventions, more frequent and longer hospital stays, higher personal costs, and higher societal costs. [Lopez 2022] Patient misunderstanding of complicated instructions for alternating administration of acetaminophen and an NSAID has the potential to result in errors or inappropriate use, increasing the risk of harm or reducing the efficacy of pain relief.

The finding that the majority of instructions for alternating acetaminophen and an NSAID were written at higher than a 6th grade reading level suggests that clinicians should consider reviewing their patient instructions to ensure appropriate readability and format for optimal patient understanding.

Any new patient instructions related to alternating pain medications should be developed at or below a 6th to 8th grade reading level as recommended by health agencies or professional organizations, such as the FDA and AMA.  This should enhance their usefulness to patients, support comprehension, and make instructions more actionable.