English rather than their primary language, and letter readability did not differ between letters to primary English speakers and non-English speakers. Patient education level (college graduates versus non-graduates) also did not predict the Flesch-Kincaid grade level at which their letter was written. Procedures performed without a fellow and by attending endoscopists over 60 years old were associated with letters written at higher grade levels versus those performed by attending endoscopists under age 60 (mean Flesch-Kincaid grade level 11.6 vs 9.8, pZ0.015). Colonoscopies performed with a fellow were followed by more readable letters than endoscopies not involving fellows (mean grade level 8.8 vs 10.5, pZ0.016). There were no differences in letter readability based on patient age, patient gender, patient ethnicity, whether upper endoscopy was performed concurrently with colonoscopy, or procedural indication. Conclusions: Letters to patients reporting colonoscopy pathology results and follow up recommendations were usually written at a grade level that exceeded those recommended for communication with patients, and the language of the letters did not differ based on easily identifiable risk factors for lower literacy, including patients' educational attainment and primary language. Interventions are necessary to improve the readability of written communication with patients following endoscopic procedures. Figure 1. Comparison of actual vs predicted ADR with regression line.
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