Dean Schillinger

Limited literacy and mortality in the elderly: the health, aging, and body composition study.

BACKGROUND: While limited literacy is common and its prevalence increases with age, no prospective study has assessed whether limited literacy is associated with mortality in older adults.OBJECTIVE: To assess the association of limited literacy with mortality.DESIGN AND SETTING: Five-year prospective study from 1999 to 2004 of community-dwelling elders from Memphis, TN, and Pittsburgh, PA, who were from the Health, Aging, and Body Composition study. Subjects’ literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine. Scores were categorzied into limited (0 to 8th grade reading level) or adequate literacy (≥9th grade reading level).PARTICIPANTS: Two thousand five hundred and twelve black and white elders without baseline functional difficulties or dementia.MEASUREMENTS: Time to death.RESULTS: Participants’ mean age was 75.6 years, 48% were male, 38% were black, and 24% had limited literacy; the median follow-up time was 4.2 years. Compared with those with adequate literacy, those with limited literacy had a higher risk of death (19.7% vs 10.6%) with a hazard ratio (HR) of 2.03 (95% confidence intervals [CI], 1.62 to 2.55). After adjusting for demographics and socioeconomic status, co-morbid conditions, self-rated health status, health-related behaviors, health care access measures, and psychosocial status, limited literacy remained independently associated with mortality (HR 1.75; 95% CI, 1.27 to 2.41).CONCLUSIONS: Limited literacy is independently associated with a nearly 2-fold increase in mortality in the elderly. Given the growth of the aging population and the prevalence of chronic diseases, the mechanisms by which limited literacy is associated with mortality in the elderly warrant further investigation.

Physician Language Ability and Cultural Competence: An Exploratory Study of Communication with Spanish-speaking Patients

AbstractOBJECTIVE: We studied physician-patient dyads to determine how physician self-rated Spanish-language ability and cultural competence affect Spanish-speaking patients’ reports of interpersonal processes of care. SETTING/PARTICIPANTS: Questionnaire study of 116 Spanish-speaking patients with diabetes and 48 primary care physicians (PCPs) at a public hospital with interpreter services. MEASURES: Primary care physicians rated their Spanish ability on a 5-point scale and cultural competence by rating: 1) their understanding of the health-related cultural beliefs of their Spanish-speaking patients; and 2) their effectiveness with Latino patients, each on a 4-point scale. We assessed patients’ experiences using the interpersonal processes of care (IPC) in diverse populations instrument. Primary care physician responses were dichotomized, as were IPC scale scores (optimal vs nonoptimal). We analyzed the relationship between language and two cultural competence items and IPC, and a summary scale and IPC, using multivariate models to adjust for known confounders of communication. RESULTS: Greater language fluency was strongly associated with optimal IPC scores in the domain of elicitation of and responsiveness to patients, problems and concerns [Adjusted Odds Ratio [AOR], 5.25; 95% confidence interval [CI], 1.59 to 17.27]. Higher score on a language-culture summary scale was associated with three IPC domains — elicitation/responsiveness (AOR, 6.34; 95% CI, 2.1 to 19.3), explanation of condition (AOR, 2.7; 95% CI, 1.0 to 7.34), and patient empowerment (AOR, 3.13; 95% CI, 1.2 to 8.19)—and not associated with two more-technical communication domains. CONCLUSION: Physician self-rated language ability and cultural competence are independently associated with patients’ reports of interpersonal process of care in patient-centered domains. Our study provides empiric support for the importance of language and cultural competence in the primary care of Spanish-speaking patients.

Health insurance status, cost-related medication underuse, and Outcomes among diabetes patients in three systems of care

BackgroundChronically ill patients often experience difficulty paying for their medications and, as a result, use less than prescribed. ObjectivesThe objectives of this study were to determine the relationship between patients with diabetes’ health insurance coverage and cost-related medication underuse, the association between cost-related underuse and health outcomes, and the role of comorbidity in this process. Research DesignWe used a patient survey with linkage to insurance information and hemoglobin A1C (A1C) test results. Patients.We studied 766 adults with diabetes recruited from 3 Veterans Affairs (VA), 1 county, and 1 university healthcare system. Main Outcomes.Main outcomes consisted of self-reported medication underuse as a result of cost, A1C levels, symptom burden, and Medical Outcomes Study 12-Item Short-Form physical and mental functioning scores. ResultsFewer VA patients reported cost-related medication underuse (9%) than patients with private insurance (18%), Medicare (25%), Medicaid (31%), or no health insurance (40%; P <0.0001). Underuse was substantially more common among patients with multiple comorbid chronic illnesses, except those who used VA care. The risk of cost-related underuse for patients with 3+ comorbidities was 2.8 times as high among privately insured patients as VA patients (95% confidence interval, 1.2–6.5), and 4.3 to 8.3 times as high among patients with Medicare, Medicaid, or no insurance. Individuals reporting cost-related medication underuse had A1C levels that were substantially higher than other patients (P <0.0001), more symptoms, and poorer physical and mental functioning (all P <0.05). ConclusionsMany patients with diabetes use less of their medication than prescribed because of the cost, and those reporting cost-related adherence problems have poorer health. Cost-related adherence problems are especially common among patients with diabetes with comorbid diseases, although the VA’s drug coverage may protect patients from this increased risk.

Social disparities in internet patient portal use in diabetes: evidence that the digital divide extends beyond access

The authors investigated use of the internet-based patient portal, kp.org, among a well-characterized population of adults with diabetes in Northern California. Among 14,102 diverse patients, 5671 (40%) requested a password for the patient portal. Of these, 4311 (76%) activated their accounts, and 3922 (69%), logged on to the patient portal one or more times; 2990 (53%) participants viewed laboratory results, 2132 (38%) requested medication refills, 2093 (37%) sent email messages, and 835 (15%) made medical appointments. After adjustment for age, gender, race/ethnicity, immigration status, educational attainment, and employment status, compared to non-Hispanic Caucasians, African-Americans and Latinos had higher odds of never logging on (OR 2.6 (2.3 to 2.9); OR 2.3 (1.9 to 2.6)), as did those without an educational degree (OR compared to college graduates, 2.3 (1.9 to 2.7)). Those most at risk for poor diabetes outcomes may fall further behind as health systems increasingly rely on the internet and limit current modes of access and communication.

The Literacy Divide: Health Literacy and the Use of an Internet-Based Patient Portal in an Integrated Health System—Results from the Diabetes Study of Northern California (DISTANCE)

Internet-based patient portals are intended to improve access and quality, and will play an increasingly important role in health care, especially for diabetes and other chronic diseases. Diabetes patients with limited health literacy have worse health outcomes, and limited health literacy may be a barrier to effectively utilizing internet-based health access services. We investigated use of an internet-based patient portal among a well characterized population of adults with diabetes. We estimated health literacy using three validated self-report items. We explored the independent association between health literacy and use of the internet-based patient portal, adjusted for age, gender, race/ethnicity, educational attainment, and income. Among 14,102 participants (28% non-Hispanic White, 14% Latino, 21% African-American, 9% Asian, 12% Filipino, and 17% multiracial or other ethnicity), 6099 (62%) reported some limitation in health literacy, and 5671 (40%) respondents completed registration for the patient portal registration. In adjusted analyses, those with limited health literacy had higher odds of never signing on to the patient portal (OR 1.7, 1.4 to 1.9) compared with those who did not report any health literacy limitation. Even among those with internet access, the relationship between health literacy and patient portal use persisted (OR 1.4, 95% CI 1.2 to 1.8). Diabetes patients reporting limited health literacy were less likely to both access and navigate an internet-based patient portal than those with adequate health literacy. Although the internet has potential to greatly expand the capacity and reach of health care systems, current use patterns suggest that, in the absence of participatory design efforts involving those with limited health literacy, those most at risk for poor diabetes health outcomes will fall further behind if health systems increasingly rely on internet-based services.

Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population.

AbstractBACKGROUND: Patient-provider communication is essential for effective care of diabetes and other chronic illnesses. However, the relative impact of general versus disease-specific communication on self-management is poorly understood, as are the determinants of these 2 communication dimensions. DESIGN: Cross-sectional survey. SETTING: Three VA heath care systems, 1 county health care system, and 1 university-based health care system. PATIENTS: Seven hundred fifty-two diabetes patients were enrolled. Fifty-two percent were nonwhite, 18% had less than a high-school education, and 8% were primarily Spanish-speaking. MEASUREMENTS AND MAIN RESULTS: Patients’ assessments of providers’ general and diabetes-specific communication were measured using validated scales. Self-reported foot care; and adherence to hypoglycemic medications, dietary recommendations, and exercise were measured using standard items. General and diabetes-specific communication reports were only moderately correlated (r=.35) and had differing predictors. In multivariate probit analyses, both dimensions of communication were independently associated with self-care in each of the 4 areas examined. Sociodemographically vulnerable patients (racial and language minorities and those with less education) reported communication that was as good or better than that reported by other patients. Patients receiving most of their diabetes care from their primary provider and patients with a longer primary care relationship reported better general communication. VA and county clinic patients reported better diabetes-specific communication than did university clinic patients. CONCLUSIONS: General and diabetes-specific communication are related but unique facets of patient-provider interactions, and improving either one may improve self-management. Providers in these sites are communicating successfully with vulnerable patients. These findings reinforce the potential importance of continuity and differences among VA, county, and university health care systems as determinants of patient-provider communication.

Shared Decision Making and the Experience of Partnership in Primary Care

PURPOSE Communication has been researched either as a set of behaviors or as a facet of the patient-physician relationship, often leading to conflicting results. To determine the relationship between these perspectives, we examined shared decision making (SDM) and the subjective experience of partnership for patients and physicians in primary care. METHODS From a convenience sample of experienced primary care physicians in 3 clinics, we recruited a stratified sample of 18 English- or Spanish-speaking patients. Direct observation of visits was followed by videotape-triggered stimulated recall sessions with patients and physicians. We coded decision moments for objective evidence of SDM, using a structured instrument. We classified patients’ and physicians’ subjective experience of partnership as positive or negative by a consensus analysis of stimulated recall sessions. We combined results from these 2 analyses to generate 4 archetypes of engagements and used grounded theory to identify themes associated with each archetype. RESULTS The 18 visits yielded 125 decisions, 62 (50%) of which demonstrated SDM. Eighty-two decisions were discussed in stimulated recall and available for combined analysis, resulting in 4 archetypes of engagement in decision making: full engagement (SDM present, subjective experience positive)—22%; simulated engagement (SDM present, subjective experience negative)—38%; assumed engagement (SDM absent, subjective experience positive)—21%; and nonengagement (SDM absent, subjective experience negative)—19%. Thematic analysis revealed that both relationship factors (eg, trust, power) and communication behavior influenced subjective experience of partnership. CONCLUSIONS Combining direct observation and assessment of the subjective experience of partnership suggests that communication behavior does not ensure an experience of collaboration, and a positive subjective experience of partnership does not reflect full communication. Attempts to enhance patient-physician partnership must attend to both effective communication style and affective relationship dynamics.

Does literacy mediate the relationship between education and health outcomes? A study of a low-income population with diabetes

Objectives. We sought to determine whether literacy mediates the relationship between education and glycemic control among diabetes patients. Methods. We measured educational attainment, literacy using the Short Test of Functional Health Literacy in Adults (s-TOFHLA), and glycemic control (HbA1c) in 395 diabetes patients at a U.S. public hospital. We performed path analysis to compare two competing models to explain glycemic control. The direct effects model estimated how education was related to HbA1c; the mediational model estimated the strength of the direct relationship when the additional pathway from education to literacy to HbA1c was added. Results. Both the model with a direct effect of education on HbA1c and the model with literacy as a mediator were supported by good fit to observed data. The mediational model, however, was a significant improvement, with the additional path from literacy to HbA1c reducing the discrepancy from observed data (p<0.01). After including this path, the direct relationship between education and HbA1c fell to a non-significant threshold. Conclusions. In a low-income population with diabetes, literacy mediated the relationship between education and glycemic control. This finding has important implications for both education and health policy.

Interventions to improve patient comprehension in informed consent for medical and surgical procedures: a systematic review

Background. Patient understanding in clinical informed consent is often poor. Little is known about the effectiveness of interventions to improve comprehension or the extent to which such interventions address different elements of understanding in informed consent. Purpose. To systematically review communication interventions to improve patient comprehension in informed consent for medical and surgical procedures. Data Sources. A systematic literature search of English-language articles in MEDLINE (1949–2008) and EMBASE (1974–2008) was performed. In addition, a published bibliography of empirical research on informed consent and the reference lists of all eligible studies were reviewed. Study Selection. Randomized controlled trials and controlled trials with nonrandom allocation were included if they compared comprehension in informed consent for a medical or surgical procedure. Only studies that used a quantitative, objective measure of understanding were included. All studies addressed informed consent for a needed or recommended procedure in actual patients. Data Extraction. Reviewers independently extracted data using a standardized form. All results were compared, and disagreements were resolved by consensus. Data Synthesis. Forty-four studies were eligible. Intervention categories included written information, audiovisual/multimedia, extended discussions, and test/feedback techniques. The majority of studies assessed patient understanding of procedural risks; other elements included benefits, alternatives, and general knowledge about the procedure. Only 6 of 44 studies assessed all 4 elements of understanding. Interventions were generally effective in improving patient comprehension, especially regarding risks and general knowledge. Limitations. Many studies failed to include adequate description of the study population, and outcome measures varied widely. Conclusions. A wide range of communication interventions improve comprehension in clinical informed consent. Decisions to enhance informed consent should consider the importance of different elements of understanding, beyond procedural risks, as well as feasibility and acceptability of the intervention to clinicians and patients. Conceptual clarity regarding the key elements of informed consent knowledge will help to focus improvements and standardize evaluations.

How health care systems can begin to address the challenge of limited literacy.

ConclusionThe growing literacy and health literature calls attention to the ways in which the U.S. health care system is inadequate and even unjust, not only for the estimated 90 million U.S. adults with limited literacy, but for many other users to the system. We have presented 3 overarching principles for health system transformation that focus on promoting productive interactions between patients and providers, reorganizing health care delivery, and embracing a community level and ecological perspective. We believe that instituting such changes could improve the quality of care not only for patients with limited literacy, but for all health care consumers, and could contribute to the development of a more “health literate” society.