Alex D. Federman

Improving Patient Understanding of Prescription Drug Label Instructions

BackgroundPatient misunderstanding of instructions on prescription drug labels is common and a likely cause of medication error and less effective treatment.ObjectiveTo test whether the use of more explicit language to describe dose and frequency of use for prescribed drugs could improve comprehension, especially among patients with limited literacy.DesignCross-sectional study using in-person, structured interviews.PatientsThree hundred and fifty-nine adults waiting for an appointment in two hospital-based primary care clinics and one federally qualified health center in Shreveport, Louisiana; Chicago, Illinois; and New York, New York, respectively.MeasurementCorrect understanding of each of ten label instructions as determined by a blinded panel review of patients’ verbatim responses.ResultsPatient understanding of prescription label instructions ranged from 53% for the least understood to 89% for the most commonly understood label. Patients were significantly more likely to understand instructions with explicit times periods (i.e., morning) or precise times of day compared to instructions stating times per day (i.e., twice) or hourly intervals (89%, 77%, 61%, and 53%, respectively, p < 0.001). In multivariate analyses, dosage instructions with specific times or time periods were significantly more likely to be understood compared to instructions stating times per day (time periods — adjusted relative risk ratio (ARR) 0.42, 95% Confidence Interval (CI) 0.34–0.52; specific times — ARR 0.60, 95% CI 0.49–0.74). Low and marginal literacy remained statistically significant independent predictors of misinterpreting instructions (low - ARR 2.70, 95% CI 1.81–4.03; marginal -ARR 1.66, 95% CI 1.18–2.32).ConclusionsUse of precise wording on prescription drug label instructions can improve patient comprehension. However, patients with limited literacy were more likely to misinterpret instructions despite use of more explicit language.

Health Literacy and Cognitive Performance in Older Adults

OBJECTIVES: To study the relationship between health literacy and memory and verbal fluency in older adults.

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1. Fried TR, Tinetti ME, Towle V, O’Leary JR, Iannone L. Effects of benefits and harms on older persons’ willingness to take medication for primary cardiovascular prevention. Arch Intern Med. 2011;171(10):923-928. 2. Leipzig RM, Whitlock EP, Wolff TA, et al; US Preventive Services Task Force Geriatric Workgroup. Reconsidering the approach to prevention recommendations for older adults. Ann Intern Med. 2010;153(12):809-814. 3. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference. New York, NY: 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. 4. Fried TR, Tinetti M, Agostini J, Iannone L, Towle V. Health outcome prioritization to elicit preferences of older persons with multiple health conditions. Patient Educ Couns. 2011;83(2):278-282. 5. Nease RF Jr, Kneeland T, O’Connor GT, et al; Ischemic Heart Disease Patient Outcomes Research Team. Variation in patient utilities for outcomes of the management of chronic stable angina: implications for clinical practice guidelines. JAMA. 1995;273(15):1185-1190. 6. Man-Son-Hing M, Gage BF, Montgomery AA, et al. Preference-based antithrombotic therapy in atrial fibrillation: implications for clinical decision making. Med Decis Making. 2005;25(5):548-559. 7. Rosenfeld KE, Wenger NS, Kagawa-Singer M. End-of-life decision making: a qualitative study of elderly individuals. J Gen Intern Med. 2000;15(9):620-625. 8. Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061-1066. 9. Ditto PH, Druley JA, Moore KA, Danks JH, Smucker WD. Fates worse than death: the role of valued life activities in health-state evaluations. Health Psychol. 1996;15(5):332-343.

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OBJECTIVE To determine whether literacy mediates the association between education, hypertension knowledge and control. METHODS In-person interviews with a literacy assessment and chart review were conducted with 330 hypertensive patients from six primary care safety net clinics. Mediational analysis was used to test the role of literacy skills in explaining the relationship between education and hypertension knowledge and control. RESULTS In multivariate analyses that did not make an adjustment for the other variable, both lower educational attainment and more limited literacy were found to be significant independent predictors of poorer hypertension knowledge and control. When literacy was entered into models that included education only, the association between education and knowledge was fully attenuated and no longer significant (Grades 1-8: beta=-0.30, 95% CI=-1.44-0.83), while the relationship between education and blood pressure control was only minimally reduced (AOR 2.46, 95% CI 2.10-2.88). More limited literacy skills also was associated with hypertension control in the final model (AOR 2.68, 95% CI 1.54-4.70). CONCLUSION Patient literacy mediated the relationship between education and hypertension knowledge. Literacy was a significant independent predictor of blood pressure control, but only minimally explained the relationship between education and blood pressure. PRACTICE IMPLICATIONS Health literacy is critical to the design of educational tools to improve knowledge acquisition. However, in order to impact health outcome, future health literacy studies should also address other psychosocial factors that impact motivation and capability to manage disease.

Education, literacy, and health: Mediating effects on hypertension knowledge and control

Background:Electronic health records (EHRs) have been promoted as an important tool to improve quality of care. We examined the association between EHR components, a complete EHR, and the quality of care. Methods:Using data from the 2005 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we conducted a cross-sectional analysis of all visits with an established primary care provider and examined the association between presence of EHR components and: (1) blood pressure control; and (2) receipt of appropriate therapy for chronic conditions. We examined similar associations for complete EHRs which we defined as one that includes physician and nursing notes, electronic reminder system, computerized prescription order entry, test results, and computerized test order entry. We constructed multivariate models to examine the association between EHR components and each outcome controlling for patient sociodemographic, health, physician practice, and geographic factors. Results:We found no association between electronic physician notes and blood pressure control or receipt of appropriate therapies, with the exception of inhaled steroids among asthmatics (adjusted odds ratio 2.86; 95% confidence interval, 1.12–7.32). We found no association between electronic reminder systems and blood pressure control or receipt of appropriate therapies, with the exception of angiotensin converting enzyme inhibitors or angiotensin receptor blockers in patients with diabetes with hypertension (odds ratio 2.58; 95% confidence interval, 1.22–5.42). We found no association between electronic physician notes and any measure of quality. We found no relationship between having a complete EHR and any of the quality measures investigated. Conclusions:We found no consistent association between blood pressure control, management of chronic conditions, and specific EHR components. Future research focusing on how an EHR is implemented and used and how care is integrated through an EHR will improve our understanding of the impact of EHRs on the quality of care.

Electronic Health Record Components and the Quality of Care

BACKGROUND Given the rising costs of health care, policymakers are increasingly interested in identifying the inefficiencies in our health care system. The objective of this study was to determine whether the overuse and misuse of health care services in the ambulatory setting has decreased in the past decade. METHODS Cross-sectional analysis of the 1999 and 2009 National Ambulatory Medical Care Survey and the outpatient department component of the National Hospital Ambulatory Medical Care Survey, which are nationally representative annual surveys of visits to non-federally funded ambulatory care practices. We applied 22 quality indicators using a combination of current quality measures and guideline recommendations. The main outcome measures were the rates of underuse, overuse, and misuse and their 95% CIs. RESULTS We observed a statistically significant improvement in 6 of 9 underuse quality indicators. There was an improvement in the use of antithrombotic therapy for atrial fibrillation; the use of aspirin, β-blockers, and statins in coronary artery disease; the use of β-blockers in congestive heart failure; and the use of statins in diabetes mellitus. We observed an improvement in only 2 of 11 overuse quality indicators, 1 indicator became worse, and 8 did not change. There was a statistically significant decrease in the overuse of cervical cancer screening in visits for women older than 65 years and in the overuse of antibiotics in asthma exacerbations. However, there was an increase in the overuse of prostate cancer screening in men older than 74 years. Of the 2 misuse indicators, there was a decrease in the proportion of patients with a urinary tract infection who were prescribed an inappropriate antibiotic. CONCLUSIONS We found significant improvement in the delivery of underused care but more limited changes in the reduction of inappropriate care. With the high cost of health care, these results are concerning.

Trends in the Overuse of Ambulatory Health Care Services in the United States

Objective To compare the survival and risk of serious adverse events in older patients with stages II-IIIA non-small cell lung cancer treated with or without postoperative platinum based chemotherapy. Design Observational cohort study. Setting Cases of lung cancer in Surveillance Epidemiology and End Results registry linked to Medicare files, 1992-2005, and follow-up data to December 2007. Participants 3324 patients aged more than 65 years with resected stages II-IIIA lung cancer. Main outcome measures Primary outcome was overall survival and secondary outcome was the rate of serious adverse events among older patients treated with or without adjuvant chemotherapy. Results Overall, 21% (n=684) of patients received platinum based chemotherapy. Analyses adjusted, stratified, or matched by propensity scores showed that chemotherapy was associated with improved survival (hazard ratio range 0.78-0.81). The beneficial effect of chemotherapy was also observed among patients treated with radiation therapy (0.75-0.77) or without radiation therapy (0.74-0.77); however, chemotherapy was not beneficial for patients aged 80 or more (1.32-1.46). Adjuvant chemotherapy was associated with an increased odds of serious adverse events (odds ratio 2.0, 95% confidence interval 1.5 to 2.6). Conclusions Platinum based adjuvant chemotherapy is associated with reduced mortality and increased risk of serious adverse events in older patients with stages II-IIIA lung cancer. The magnitude of the benefit is similar to that observed in randomised controlled trials carried out among selected patients.

Survival and risk of adverse events in older patients receiving postoperative adjuvant chemotherapy for resected stages II-IIIA lung cancer: observational cohort study

Objective. To examine the impact of depressive symptoms on asthma outcomes and medication adherence in inner-city elderly patients with asthma. Methods. Cohort study of elderly asthmatics receiving primary care at three clinics in New York City and Chicago from 1 January 2010 to 1 January 2012. Depressive symptoms were ascertained with the Patient Health Questionnaire (PHQ-9). Outcomes included asthma control (Asthma Control Questionnaire, ACQ), asthma-related quality of life (Asthma Quality of Life Questionnaire, AQLQ), and acute resource utilization (inpatient and outpatient visits). Asthma medication adherence was evaluated using the Medication Adherence Reporting Scale (MARS). Results. Three hundred and seventeen participants ≥60 years were included in the study (83% women, 30% Hispanic, and 31% Black). In unadjusted analyses, participants with depressive symptoms were more likely to report poor asthma control (p < .001), worse AQLQ scores (p < .001), and higher rates of inpatient asthma-related visits (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.04–3.99). Those with depressive symptoms also reported lower medication adherence (OR: 0.23, 95%CI: 0.10–0.54). Similar results were obtained in analyses adjusting for age, sex, race/ethnicity, income, asthma medication prescription, years with asthma, intubation history, comorbidities, and health literacy. Conclusion. In this cohort of elderly inner-city participants, depressive symptoms were associated with poorer asthma control and quality of life, as well as with lower rates of adherence to controller medications. Future work exploring possible mediators, including adherence, might elucidate the relationship between depression and poorer asthma outcomes in this population.

Depressive Symptoms, Low Adherence, and Poor Asthma Outcomes in the Elderly

IMPORTANCE Increasing numbers of older, community-dwelling adults have functional impairments that prevent them from leaving their homes. It is uncertain how many people who live in the United States are homebound. OBJECTIVES To develop measures of the frequency of leaving and ability to leave the home and to use these measures to estimate the size of the homebound population in the US population. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional data from the National Health and Aging Trends Study collected in 2011 in the contiguous United States. Participants were a nationally representative sample of 7603 noninstitutionalized Medicare beneficiaries 65 years and older. MAIN OUTCOMES AND MEASURES We defined homebound persons as those who never (completely homebound) or rarely (mostly homebound) left the home in the last month. We defined semihomebound persons as those who only left the home with assistance or had difficulty or needed help leaving the home. We compared demographic, clinical, and health care utilization characteristics across different homebound status categories. RESULTS In 2011, the prevalence of homebound individuals was 5.6% (95% CI, 5.1%-6.2%), including an estimated 395,422 people who were completely homebound and 1,578,984 people who were mostly homebound. Among semihomebound individuals, the prevalence of those who never left home without personal assistance was 3.3% (95% CI, 2.8%-3.8%), and the prevalence of those who required help or had difficulty was 11.7% (95% CI, 10.9%-12.6%). Completely homebound individuals were more likely to be older (83.2 vs 74.3 years, P < .001), female (67.9% vs 53.4%, P < .006), and of nonwhite race (34.1% vs 17.6%, P < .001) and have less education and income than nonhomebound individuals. They also had more chronic conditions (4.9 vs 2.5) and were more likely to have been hospitalized in the last 12 months (52.1% vs 16.2%) (P < .001 for both). Only 11.9% of completely homebound individuals reported receiving primary care services at home. CONCLUSIONS AND RELEVANCE In total, 5.6% of the elderly, community-dwelling Medicare population (approximately 2 million people) were completely or mostly homebound in 2011. Our findings can inform improvements in clinical and social services for these individuals.

Epidemiology of the Homebound Population in the United States.

Objectives. To examine the relationship between suboptimal asthma beliefs and inadequate health literacy among older adults with asthma. Methods. The authors interviewed 100 English- and Spanish-speaking asthmatics (ages ≥50 years) in a New York City primary care clinic (response, 83%). Outcomes included the belief that one does not have asthma when symptoms are absent (no symptoms–no asthma), that asthma is temporary, is curable, and that medications work better if not used all the time. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Belief and health literacy associations were measured with multivariable logistic regression adjusting for age, sex, and race. Results. The mean age was 61 years; 35% had inadequate health literacy. Those with inadequate literacy were more likely than those with adequate or marginal literacy to have suboptimal beliefs: no symptoms–no asthma, 60% versus 34%, p = .01; temporary, 23% versus 9%, p = .07; curable, 54% versus 25%, p = .004; medication use, 44% versus 21%, p = .03. These relationships remained statistically significant in multivariable analyses that adjusted for age, sex, and race. Conclusions. Suboptimal asthma beliefs were more common among older asthmatics with inadequate health literacy. Interventions to improve asthma self-management in older adults should address both belief and health literacy barriers.