Readability of Screening Mammogram Recall Lay Letters: What do our patients actually “recall”?

From the 2019 HVPAA National Conference

Dr. Derek Nguyen (Johns Hopkins Department of Radiology), Ms. Mary Kate Jones (Johns Hopkins School of Medicine), Dr. Emily Ambinder (Johns Hopkins Department of Radiology), Dr. Lisa Mullen (Johns Hopkins Department of Radiology), Dr. Susan Harvey (Johns Hopkins University)


With screening mammography, patients receive either a “normal” lay letter, which communicates benign findings, or a “recall” lay letter informing them of a potential abnormality requiring additional evaluation. In accordance with the Mammography Quality Standards Act, screening mammogram recall lay letters should be written using language that is “easily understood by a lay person.” Therefore, it is crucial that lay letters are comprehensible to patients to ensure patients fully understand the implications of their results. Thus, there is a need for a controlled study to assess the impact of lay letter language on patient outcomes, specifically understanding when to return for additional imaging.


The purpose of our study is to assess patient comprehension by directly comparing our institution’s current recall lay letter statement with a revised recall lay letter statement written at a lower reading level.


The Flesch-Kincaid grade level was utilized to assess readability of the recall lay letter statement currently used at our institution. A revised statement was formulated. A single paper-based survey presented the current and revised statements and asked questions to probe patient’s understanding of expected time of return after each statement. The IRB at our institution acknowledged this as a quality improvement project exempt from approval. Surveys were provided to screening mammography patients at four institutional outpatient imaging centers. Simple randomization was utilized to distribute the surveys in the waiting rooms along with standard intake forms between October 2018 and December 2018. The categorical survey responses were compared between the two surveys using McNemar’s test. P value < 0.05 was considered statistically significant for all analyses.


The Flesch-Kincaid grade level of the current and revised statements were 12th and 4th grade level, respectively. 599 surveys were analyzed. Survey data demonstrated only 49.6% of all patients understood that the current statement requests return within 1 month specifically with the breast center compared to the 95.2% of patients with the revised statement (p < 0.001). Of the patients who misunderstood when to follow-up with the breast center, about 80% achieved less than a college degree (p < 0.001).


Patient directed written materials that exceed the national recommendation of 6th to 8th grade reading level may lead to patient misunderstandings and potentially result in poor compliance. Women are more likely to misinterpret a prompt return for additional imaging in the setting of an abnormality on the screening mammogram after reading the current recall statement if they achieve less than a college degree.

Clinical Implications

Due to changes in the perception of doctors’ authority, patient relationships have begun to shift and many patients now choose to take a more active role in their care. This has increased the importance of comprehension of written patient communications. Our data suggests that revising the language of recall statements to the recommended reading grade levels would improve patient understanding, potentially leading to better patient compliance. This study led to the implementation of the revised recall lay letter statement at our institution.


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