Donna Carden

Tipping the scales: the effect of literacy on obese patients' knowledge and readiness to lose weight.

Objectives: The purpose of this study was to determine the association between the literacy level of overweight/obese patients and their weight-loss knowledge, attitudes, and readiness. Methods: Structured patient interviews and a literacy screening instrument were administered in two primary care clinics at a university-based public hospital. Results: A convenience sample of 210 overweight or obese adult outpatients (body mass index ≥25 kg/m2 or ≥30 kg/m2, respectively) were enrolled. Mean respondent age was 52 years; 74% were female, and 76% were black. Two thirds of patients read below a 9th grade level. Half of patients across all literacy levels reported currently attempting weight loss. There was a significant relation between literacy level and weight-loss knowledge, attitudes, and readiness (P < 0.05). Conclusions: Patients with low literacy were significantly less likely to understand the adverse health consequences of obesity and the need to lose weight and to report being ready to lose weight. Patient education and counseling for weight loss should be tailored for patients with low literacy skills.

Potentially Preventable Use of Emergency Services: The Role of Low Health literacy

Background:Limited health literacy is a barrier for understanding health information and has been identified as a risk factor for overuse of the emergency department (ED). The association of health literacy with access to primary care services in patients presenting to the ED has not been fully explored. Objective:To examine the relationship between health literacy, access to primary care, and reasons for ED use among adults presenting for emergency care. Methods:Structured interviews that included health literacy assessment were performed involving 492 ED patients at one Southern academic medical center. Unadjusted and multivariable logistic regression models assessed the relationship between health literacy and (1) access to a personal physician; (2) doctor office visits; (3) ED visits; (4) hospitalizations; and (5) potentially preventable hospital admissions. Results:After adjusting for sociodemographic and health status, those with limited health literacy reported fewer doctor office visits [odds ratio (OR)=0.6; 95% confidence interval (CI), 0.4–1.0], greater ED use, (OR=1.6; 95% CI, 1.0–2.4), and had more potentially preventable hospital admissions (OR=1.7; 95% CI, 1.0–2.7) than those with adequate health literacy. After further controlling for insurance and employment status, fewer doctor office visits remained significantly associated with patient health literacy (OR=0.5; 95% CI, 0.3–0.9). Patients with limited health literacy reported a preference for emergency care, as the services were perceived as better. Conclusions:Among ED patients, limited health literacy was independently associated with fewer doctor office visits and a preference for emergency care. Policies to reduce ED use should consider steps to limit barriers and improve attitudes toward primary care services.

Research directions in emergency medicine

Abstract The goal of emergency medicine is to improve health while preventing and treating disease and illness in patients seeking emergency medical care. Improvements in emergency medical care and the delivery of this care can be achieved through credible and meaningful research efforts. Improved delivery of emergency medical care through research requires careful planning and the wise use of limited resources. To achieve this goal, emergency medicine must provide appropriate training of young investigators and attract support for their work. Promotion of multidisciplinary research teams will help the specialty fulfill its goals. The result will be the improvement of emergency medical care which will benefit not only the patients emergency physicians serve but also, ultimately, the nations health.

Prevalence of overweight, obesity, and associated diseases among outpatients in a public hospital.

Background The prevalence of obesity is increasing and may be particularly high among indigent public hospital patients. The purpose of this study was to determine the prevalence of obesity and its associated chronic medical conditions among outpatients at Louisiana State University Health Sciences Center–Shreveport, an urban tertiary health center that serves a mostly black, indigent population. Methods A cross-sectional survey was conducted on 1,507 primary care patients. Age, sex, weight, height, and diagnoses were recorded, and body mass index (BMI) was calculated. Results Eighty-one percent of patients were overweight or obese and 75% had one or more obesity-associated conditions. Higher BMI was significantly associated with increased prevalence of obesity-related diseases (P < 0.001) even when adjusted for age and sex. Conclusion Overweight and obesity rates at this public hospital are alarming and may indicate a problem in public hospitals across the United States. The process and structure of care for overweight and obese patients need to be evaluated, and training for residents needs to address this problem.

Compliance with outpatient stress testing in low-risk patients presenting to the emergency department with chest pain.

Recent evidence suggests that stress testing prior to emergency department (ED) release in low-risk chest pain patients identifies those who can be safely discharged home. When immediate stress testing is not feasible, rapid outpatient stress testing has been recommended. The objective of this study was to determine compliance rate and incidence of adverse cardiac events in patients presenting to the ED with low-risk chest pain referred for outpatient stress testing. Retrospective chart and social security death index review were conducted in 448 consecutive chest pain patients who presented to a university hospital and level I trauma center between April 30 and December 31, 2007. Patients were evaluated with an accelerated chest pain protocol defined as a 4-hour ED rule out and referral for outpatient stress testing within 72 hours of ED release. Only patients without known cardiac disease, a thrombolysis in myocardial infarction risk score ≤2, negative serial ECGs and cardiac biomarkers, and benign ED course were eligible for the protocol. Primary outcome measures included compliance with outpatient stress testing and documented 30-day incidence of adverse cardiac events following ED release. The social security death index was queried to determine 12-month incidence of all-cause mortality in enrolled patients. Logistic regression analysis of characteristics associated with outpatient stress test compliance was determined and incidence of adverse cardiac events in those who were and were not compliant with outpatient stress testing was compared. Significance was set at P < 0.05. A total of 188 patients (42%) completed outpatient stress testing, but only 27 (6%) completed testing within 72 hours of ED discharge. Compliance was correlated with insurance and race, but not patient age, gender, or thrombolysis in myocardial infarction risk score. No significant differences in adverse cardiac events were documented in patients who did and did not comply with outpatient stress testing. Compliance with outpatient stress testing is poor in low-risk chest pain patients following ED release. Despite poor compliance, the documented incidence of adverse cardiac events in this low-risk cohort was lower than that reported in patients with negative provocative testing prior to ED release.

Non-High-Density Lipoprotein Cholesterol in Patients With Metabolic Syndrome

Background Metabolic syndrome (MS) represents a cluster of cardiovascular risk factors that includes hypertriglyceridemia. Although low-density lipoprotein (LDL) cholesterol is the critical therapeutic target in patients with coronary artery disease, LDL cannot be calculated in those with excessive hypertriglyceridemia. Non-high-density lipoprotein (HDL) does not require LDL for calculation and may be an alternative therapeutic target in MS. The purpose of this study was to determine non-HDL cholesterol in relation to other lipid components and comorbidities in MS patients. Methods A cross-sectional chart review on 928 public hospital patients was performed. Results Metabolic syndrome was present in 53% of all patients. Among those with MS, 87% had triglyceride level of greater than 150 mg/dL, 85% had low HDL, 71% had LDL of greater than 100 mg/dL, and 74% had non-HDL of greater than 130 mg/dL. The level of non-HDL cholesterol, but not total cholesterol or LDL cholesterol, was significantly higher (P < 0.05) and less at goal (P < 0.0001) in patients with MS. Diagnoses of coronary artery disease, hypertension, obesity, dyslipidemia, and diabetes were significantly more prevalent in MS patients (P < 0.0001). Conclusion Compared with those without MS, non-HDL level was significantly higher and undertargeted in patients with MS, in parallel with significantly higher prevalence of comorbidities.

Funding Strategies for Emergency Medicine Research

The importance of adequate funding for sustaining research efforts cannot be overemphasized. This article addresses funding strategies for emergency physicians including the necessity of establishing a research track record, developing a well-written grant proposal, and anticipating the grant review process. Funding sources are reviewed with an emphasis on federal institute support and private foundations (including the Emergency Medicine Foundation) in the United States. Sources of current grant support information available from the Internet are provided. Recommendations for enhancing research funding in emergency medicine are made, including enhancement of formal research training, promotion of emergency medicine research and investigators, federal study section membership, and collaboration with established investigators.

Research Directions in Emergency Medicine

The goal of emergency medicine is to improve health while preventing and treating disease and illness in patients seeking emergency medical care. Improvements in emergency medical care and the delivery of this care can be achieved through credible and meaningful research efforts. Improved delivery of emergency medical care through research requires careful planning and the wise use of limited resources. To achieve this goal, emergency medicine must provide appropriate training of young investigators and attract support for their work. Promotion of multidisciplinary research teams will help the specialty fulfill its goals. The result will be the improvement of emergency medical care which will benefit not only the patients emergency physicians serve but also, ultimately, the nations health.

Assessing patient activation and health literacy in the ED

BACKGROUND Low health literacy and patient activation are linked to unmet health needs, excess emergency department (ED) use, and hospital admission. However, most studies have assessed these measures in non-ED populations. OBJECTIVE The objective of the study is to assess health literacy and patient activation in the ED. METHODS A cross-sectional study in adults older than 18 years presenting to an ED were selected using systematic sampling. Demographic data and reason for ED visit were collected. Health literacy was assessed using Rapid Estimate of Adult Literacy in Medicine (REALM). Patient activation was assessed using Patient Activation Measure. Kruskal-Wallis tests compared groups. Spearman rank correlations compared numeric variables. RESULTS A total of 140 patients were approached, and 108 enrolled. Average age was 51 years. Most were unemployed (71%), were unmarried (80%), had a primary physician (62%), were male (60%), were African American (63%), and were on public insurance (58%). Most had an activation level of 3 or 4. The mean REALM score was 52. Patients with higher REALM scores had higher activation levels (rs = 0.30; P = .0017), although, when adjusted for age, this association was no longer significant. Sex, education, insurance status, and race were not significantly associated with REALM or activation levels. Activation levels decreased with increasing age (rs = -0.24; P = .01). Low activation levels and limited health literacy were significantly associated with admission (odds ratio, 4.4; 95% confidence interval, 1.5-12.6; P = .0061). CONCLUSIONS This is the first study to assess Patient Activation Measure in the ED. Low activation levels and limited REALM scores assessed in the ED population were significantly associated with hospital admission. Assessing activation levels of ED patients could lead to better education and tailored discharge planning by ED clinicians potentially reducing ED revisits.

Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation

Introduction Older, chronically ill patients with limited health literacy are often under-engaged in managing their health and turn to the emergency department (ED) for healthcare needs. We tested the impact of an ED-initiated coaching intervention on patient engagement and follow-up doctor visits in this high-risk population. We also explored patients’ care-seeking decisions. Methods We conducted a mixed-methods study including a randomized controlled trial and in-depth interviews in two EDs in northern Florida. Participants were chronically ill older ED patients with limited health literacy and Medicare as a payer source. Patients were assigned to an evidence-based coaching intervention (n= 35) or usual post-ED care (n= 34). Qualitative interviews (n=9) explored patients’ reasons for ED use. We assessed average between-group differences in patient engagement over time with the Patient Activation Measure (PAM) tool, using logistic regression and a difference-in-difference approach. Between-group differences in follow-up doctor visits were determined. We analyzed qualitative data using open coding and thematic analysis. Results PAM scores fell in both groups after the ED visit but fell significantly more in “usual care” (average decline −4.64) than “intervention” participants (average decline −2.77) (β=1.87, p=0.043). There were no between-group differences in doctor visits. Patients described well-informed reasons for ED visits including onset and severity of symptoms, lack of timely provider access, and immediate and comprehensive ED care. Conclusion The coaching intervention significantly reduced declines in patient engagement observed after usual post-ED care. Patients reported well-informed reasons for ED use and will likely continue to make ED visits unless strategies, such as ED-initiated coaching, are implemented to help vulnerable patients better manage their health and healthcare.