Ekaterina Sadikova

Health Literacy and 30-Day Postdischarge Hospital Utilization

Low health literacy is associated with higher mortality, higher rates of hospitalization, and poor self-management skills for chronic disease. Early, unplanned hospital reutilization after discharge is a common and costly occurrence in U.S. hospitals. Still, few studies have examined the relation between health literacy and 30-day hospital reutilization rates. The authors examined the association between health literacy and 30-day reutilization of hospital services (readmission or return to the emergency department) in an urban safety net hospital, and conducted a secondary analysis of data from the control arm subjects of the Project RED and the RED-LIT trials. Health literacy was measured using the REALM tool. The primary outcome was rate of 30-day reutilization. The authors used multivariate Poisson regression analysis to control for potential confounding. Of the 703 subjects, 20% had low health literacy, 29% had marginal health literacy, and 51% had adequate health literacy. Sixty-two percent of subjects had a 12th-grade education or less. Subjects with low health literacy were more likely to be insured by Medicaid (p < .001); Black non-Hispanic (p < .001); unemployed, disabled, or retired (p < .001); low income (p < .001); and less educated (high school education or less, p < .001). The fully adjusted incidence rate ratio for low health literacy compared with adequate health literacy was 1.46 (CI [1.04, 2.05]). Low health literacy is a significant, independent, and modifiable risk factor for 30-day hospital reutilization after discharge. Interventions designed to reduce early, unplanned, hospital utilization after discharge should include activities to mitigate the effect of patients’ low health literacy.

A Pilot Study of Motivational Interviewing Training in a Virtual World

Background Motivational interviewing (MI) is an evidence-based, patient-centered counseling strategy proven to support patients seeking health behavior change. Yet the time and travel commitment for MI training is often a barrier to the adoption of MI by health care professionals. Virtual worlds such as Second Life (SL) are rapidly becoming part of the educational technology landscape and offer not only the potential to improve access to MI training but also to deepen the MI training experience through the use of immersive online environments. Despite SL’s potential for medical education applications, little work is published studying its use for this purpose and still less is known of educational outcomes for physician training in MI using a virtual-world platform. Objective Our aims were to (1) explore the feasibility, acceptability, and effectiveness of a virtual-world platform for delivering MI training designed for physicians and (2) pilot test instructional designs using SL for MI training. Methods We designed and pilot tested an MI training program in the SL virtual world. We trained and enrolled 13 primary care physicians in a two-session, interactive program in SL on the use of MI for counseling patients about colorectal cancer screening. We measured self-reported changes in confidence and clinical practice patterns for counseling on colorectal cancer screening, and acceptability of the virtual-world learning environment and the MI instructional design. Effectiveness of the MI training was assessed by coding and scoring tape-recorded interviews with a blinded mock patient conducted pre- and post-training. Results A total of 13 physicians completed the training. Acceptability ratings for the MI training ranged from 4.1 to 4.7 on a 5-point scale. The SL learning environment was also highly rated, with 77% (n = 10) of the doctors reporting SL to be an effective educational medium. Learners’ confidence and clinical practice patterns for colorectal cancer screening improved after training. Pre- to post-training mean confidence scores for the ability to elicit and address barriers to colorectal cancer screening (4.5 to 6.2, P = .004) and knowledge of decision-making psychology (4.5 to 5.7, P = .02) and behavior change psychology (4.9 to 6.2, P = .02) increased significantly. Global MI skills scores increased significantly and component scores for the MI skills also increased, with statistically significant improvements in 4 of the 5 component skills: empathy (3.12 to 3.85, P = .001), autonomy (3.07 to 3.85, P < .001), collaboration (2.88 to 3.46, P = .02), and evocative response (2.80 to 3.61, P = .008). Conclusions The results of this pilot study suggest that virtual worlds offer the potential for a new medical education pedagogy that will enhance learning outcomes for patient-centered communication skills training.

Yoga, Physical Therapy, or Education for Chronic Low Back Pain: A Randomized Noninferiority Trial

Background Yoga is effective for mild to moderate chronic low back pain (cLBP), but its comparative effectiveness with physical therapy (PT) is unknown. Moreover, little is known about yogas effectiveness in underserved patients with more severe functional disability and pain. Objective To determine whether yoga is noninferior to PT for cLBP. Design 12-week, single-blind, 3-group randomized noninferiority trial and subsequent 40-week maintenance phase. (ClinicalTrials.gov: NCT01343927). Setting Academic safety-net hospital and 7 affiliated community health centers. Participants 320 predominantly low-income, racially diverse adults with nonspecific cLBP. Intervention Participants received 12 weekly yoga classes, 15 PT visits, or an educational book and newsletters. The maintenance phase compared yoga drop-in classes versus home practice and PT booster sessions versus home practice. Measurements Primary outcomes were back-related function, measured by the Roland Morris Disability Questionnaire (RMDQ), and pain, measured by an 11-point scale, at 12 weeks. Prespecified noninferiority margins were 1.5 (RMDQ) and 1.0 (pain). Secondary outcomes included pain medication use, global improvement, satisfaction with intervention, and health-related quality of life. Results One-sided 95% lower confidence limits were 0.83 (RMDQ) and 0.97 (pain), demonstrating noninferiority of yoga to PT. However, yoga was not superior to education for either outcome. Yoga and PT were similar for most secondary outcomes. Yoga and PT participants were 21 and 22 percentage points less likely, respectively, than education participants to use pain medication at 12 weeks. Improvements in yoga and PT groups were maintained at 1 year with no differences between maintenance strategies. Frequency of adverse events, mostly mild self-limited joint and back pain, did not differ between the yoga and PT groups. Limitations Participants were not blinded to treatment assignment. The PT group had disproportionate loss to follow-up. Conclusion A manualized yoga program for nonspecific cLBP was noninferior to PT for function and pain. Primary Funding Source National Center for Complementary and Integrative Health of the National Institutes of Health.

Medical reconciliation of dietary supplements: Don’t ask, don’t tell

OBJECTIVE To explore inpatient reconciliation of dietary supplement (DS) use and determine characteristics associated with DS documentation. METHODS We analyzed DS use among 558 inpatients recruited from the Re-Engineered Discharge clinical trial to identify: (1) if patients self-reported DS and (2) if DS use was documented at admission. We examined socio-demographics for association with documentation using chi squares and t-tests. Logistic regression was performed to assess adjusted associations with DS documentation. RESULTS Sixty percent reported DS use (n=333). Among users, 36% had admission DS documentation, 20% were asked about use at admission, 18% reported disclosing use to a provider, and 48% reported they would continue to use DS. Overall, 6% of participants were asked, disclosed, and had documentation of DS. Logistic regression revealed increased age associated with lower odds of DS documentation. Identifying as Hispanic or African American reduces DS documentation odds compared to those identifying as white. CONCLUSIONS There is lack of consistent DS medical reconciliation in the inpatient setting. While more than half of patients used DS prior to hospitalization, most were not asked about use on admission. PRACTICE IMPLICATIONS This study adds to literature on medical reconciliation which requires that providers inquire and document patient DS use.

Medical group visits: a feasibility study to manage patients with chronic pain in an underserved urban clinic.

Background: Chronic pain affects millions of racially diverse Americans. Evidence suggests that group medical visits are effective for treating chronic pain; similarly, a number of studies demonstrate the effectiveness of certain evidence-based complementary therapies in managing pain. Objectives: The primary goal of this study is to evaluate the feasibility of the integrative medical group visit (IMGV) care model in an inner-city racially diverse outpatient clinic. IMGV combines patient-centered, non-pharmacologic strategies and principles of mindfulness-based stress-reduction with a group medical visit to reduce pain and associated symptoms. Methods: We surveyed patients pre and post an 8-session IMGV program to evaluate changes in pain in the last week (0—10 point scale) and comorbid symptoms including depression (Patient Health Questionaire-8 [PHQ-8]), perceived stress, and sleep quality. We also recorded referrals to the program, patients screened for eligibility, total enrollment, loss to follow-up, and attendance. Results: Seventy patients joined IMGV, and of these, 65 (93%) enrolled in the study. Over the course of 12 months, 7 groups met (median 9 patients/group; range 8—13 participants). Mean difference in pain level for all patients between baseline and 8 weeks was 0.7 (SD=2.0, P=.005). Mean diference in PHQ-8 depression score for patients with baseline score ≥5 was 2.6 (SD=4.6, P<.001). Statistically significant improvements were also seen in sleep quality and perceived stress. Conclusion: A group visits program combining conventional and integrative medicine for predominantly racially diverse patients is feasible.

Dose‐response relationship between depressive symptoms and hospital readmission

BACKGROUND Evidence suggests depression increases hospital readmission risk. OBJECTIVE Determine whether depressive symptoms are associated with unplanned readmission within 30 days of discharge of general medical patients. DESIGN Secondary analysis of the Project Re-Engineered Discharge (RED) randomized controlled trials. SETTING Urban academic safety-net hospital. PATIENTS A total of 1418 hospitalized adult English-speaking patients. INTERVENTION The 9-Item Patient Health Questionnaire (PHQ-9) was used to screen patients for depressive symptoms. MEASUREMENTS Hospital readmission within 30 days of discharge. Poisson regression was used to control for confounding variables. RESULTS There were 225 (16%) patients who screened positive for mild depressive symptoms (5 ≤PHQ-9 ≤ 9) and 336 (24%) for moderate or severe depressive symptoms (PHQ-9 ≥ 10). After controlling for confounders, a higher rate of readmission was observed in subjects with mild depressive symptoms compared to subjects with PHQ-9 <5, incidence rate ratio (IRR) 1.49 (95% confidence interval [CI]: 1.11-2.00). The adjusted IRR of readmission for those with moderate-to-severe symptoms was 1.96 (95% CI: 1.51-2.49) compared to those with no depression. CONCLUSIONS Screening positive for mild and moderate-to-severe depressive symptoms during a hospitalization on a general medical service is associated with an increased dose-dependent readmission rate within 30 days of discharge in an urban, academic, safety-net hospital. Further research is needed to determine whether treatments targeting the reduction of depressive symptoms reduce the risk of readmission.

Reducing Preconception Risks Among African American Women with Conversational Agent Technology

Background: Systems and tools are needed to identify and mitigate preconception health (PCH) risks, particularly for African American (AA) women, given persistent health disparities. We developed and tested “Gabby,” an online preconception conversational agent system. Methods: One hundred nongravid AA women 18–34 years of age were screened for over 100 PCH risks and randomized to the Gabby or control group. The Gabby group interacted with the system for up to six months; the control group received a letter indicating their health risks with a recommendation to talk with their clinician. The numbers, proportions, and types of risks were compared between groups. Results: There were 23.7 (SD 5.9) risks identified per participant. Eighty-five percent (77 of 91) provided 6 month follow up data. The Gabby group had greater reductions in the number (8.3 vs. 5.5 risks, P < .05) and the proportion (27.8% vs 20.5%, P < 0.01) of risks compared to controls. The Gabby group averaged 63.7 minutes of interaction time. Seventy-eight percent reported that it “was easy to talk to Gabby” and 64% used information from Gabby to improve their health. Conclusion: Gabby was significantly associated with preconception risk reduction. More research is needed to determine if Gabby can benefit higher risk populations and if risk reduction is clinically significant.

Health Literacy and Complementary and Alternative Medicine Use Among Underserved Inpatients in a Safety Net Hospital

Little is known about the relationship between health literacy and complementary and alternative medicine (CAM) use in low-income racially diverse patients. The authors conducted a secondary analysis of baseline data from 581 participants enrolled in the Re-Engineered Discharge clinical trial. The authors assessed sociodemographic characteristics, CAM use, and health literacy. They used bivariate and multivariate logistic regression to test the association of health literacy with four patterns of CAM use. Of the 581 participants, 50% reported using any CAM, 28% used provider-delivered CAM therapies, 27% used relaxation techniques, and 21% used herbal medicine. Of those with higher health literacy, 55% used CAM. Although there was no association between health literacy and CAM use for non-Hispanic Black participants, non-Hispanic White (OR = 3.68, 95% CI [1.27, 9.99]) and Hispanic/other race (OR = 3.40, 95% CI [1.46, 7.91]) participants were significantly more likely to use CAM if they had higher health literacy. For each racial/ethnic group, there were higher odds of using relaxation techniques among those with higher health literacy. Underserved hospitalized patients use CAM. Regardless of race, patients with high health literacy make greater use of relaxation techniques.

Medication and Dietary Supplement Interactions among a Low-Income, Hospitalized Patient Population Who Take Cardiac Medications

Purpose. To identify characteristics associated with the use of potentially harmful combinations of dietary supplements (DS) and cardiac prescription medications in an urban, underserved, inpatient population. Methods. Cardiac prescription medication users were identified to assess the prevalence and risk factors of potentially harmful dietary supplement-prescription medication interactions (PHDS-PMI). We examined sociodemographic and clinical characteristics for crude (χ 2 or t-tests) and adjusted multivariable logistic regression associations with the outcome. Results. Among 558 patients, there were 121 who also used a DS. Of the 110 participants having a PHDS-PMI, 25% were asked about their DS use at admission, 75% had documentation of DS in their chart, and 21% reported the intention to continue DS use after discharge. A multivariable logistic regression model noted that for every additional medication or DS taken the odds of having a PHDS-PMI increase and that those with a high school education are significantly less likely to have a PHDS-PMI than those with a college education. Conclusion. Inpatients at an urban safety net hospital taking a combination of cardiac prescription medications and DS are at a high risk of harmful supplement-drug interactions. Providers must ask about DS use and should consider the potential for interactions when having patient discussions about cardiac medications and DS.

Stress Management and Relaxation Techniques use among underserved inpatients in an inner city hospital

OBJECTIVE Little is known about the use of Stress Management and Relaxation Techniques (SMART) in racially diverse inpatients. We hope to identify socioeconomic status (SES) factors, health behavior factors, and clinical factors associated with the use of SMART. DESIGN AND MAIN OUTCOME MEASURES We conducted a secondary analysis of baseline data from 623 hospitalized patients enrolled in the Re-Engineered Discharge (RED) clinical trial. We assessed socio-demographic characteristics and use of SMART. We used bivariate and multivariate logistic regression to test the association of SMART with socio-demographic characteristics, health behaviors, and clinical factors. RESULTS A total of 26.6% of participants reported using SMART and 23.6% used mind body techniques. Thirty six percent of work disabled patients, 39% of illicit drug users, and 38% of participants with depressive symptoms used SMART. Patients who both reported illicit drug use and screened positive for depression had significantly increased odds of using SMART [OR=4.94, 95% CI (1.59, 15.13)]. Compared to non-Hispanic whites, non-Hispanic blacks [0.55 (0.34-0.87)] and Hispanic/other race individuals [0.40 (0.20-0.76)] were less likely to use SMART. CONCLUSIONS We found greater utilization of SMART among all racial groups compared to previous national studies. In the inner city inpatient setting, patients with depression, illicit drug use, and work disability reported higher rates of using SMART.