Lisa Renee Miller-Matero

Health literacy in patients referred for transplant: do patients have the capacity to understand?

Adequate levels of health literacy are needed for transplant recipients to be able to understand and comply with medical recommendations. However, little is known about health literacy among transplant candidates. Therefore, the purpose of this study was to examine the levels of health literacy and cognitive functioning among patients being evaluated for various types of transplantation. There were 398 patients who completed a required psychological evaluation prior to being listed for transplant. This included a screen for cognitive impairment and limited reading and math ability. The prevalence of limited reading ability was 27.5%, limited math ability was 42.8%, and 30.7% had probable cognitive impairment. Rates of limited reading and math ability and cognitive impairment varied for each type of end‐stage disease. Limited reading ability was related to poorer cognitive functioning. Those with a higher likelihood of limited reading ability included blacks and males. Those more likely to have cognitive impairment included blacks and patients who are older. Results from this study suggest that patients should be regularly screened for health literacy and cognitive impairment. Once patients with difficulties are identified, recommendations can be provided to these patients at a level that they are able to understand.

Health Literacy Status Affects Outcomes for Patients Referred for Transplant.

BACKGROUND It is hypothesized that limited health literacy affects outcomes for patients referred for transplant; however, research has not examined this for all types of end-stage organ disease. OBJECTIVE The purpose of this study was to determine whether health literacy and cognitive impairment were related to listing for transplant and posttransplant outcomes. METHODS Chart reviews were conducted on 398 patients who completed a required psychiatric evaluation before transplant listing. Information gathered from these evaluations included reading ability, math ability, and cognitive functioning. Variables before transplant and 6 months after transplantation were also collected. RESULTS Patients with limited reading ability were less likely to be listed for transplant (p = .018) and were more likely to be removed from listing (p = .042), to miss appointments prelisting (p = .021), and to experience graft failure (p = .015). Patients with limited math ability were less likely to be listed (p = .010) and receive a transplant (p = 0.031), and more likely to be readmitted posttransplant (p = .029). Patients with cognitive impairment were less likely to be listed (p = .043) and to receive a transplant (p = .010). CONCLUSIONS To achieve superior transplant access and outcomes, transplant providers should regularly screen patients for limited health literacy and cognitive impairment. Future studies should evaluate whether interventions result in better outcomes for these patients.

When treating the pain is not enough: a multidisciplinary approach for chronic pelvic pain

Chronic pelvic pain (CPP) is related to psychological distress and interference in daily activities; however, CPP is not as extensively researched as other forms of chronic pain. Therefore, the purpose of this study was to investigate the relationships among pain, psychological distress, and functional impairment in patients with CPP. There were chart reviews conducted of 107 female patients who completed a psychiatric evaluation at a specialty, CPP clinic as a part of a multidisciplinary evaluation. Results suggest that psychological distress and impairment in daily activities are common in CPP patients. Most areas of functional impairment were not associated with pain variables. Rather, several forms of functional impairment were related to higher levels of depression and anxiety. Results from this study suggest the possibility that psychiatric symptoms are contributing to functional impairment in this population. These findings highlight the importance of a multidisciplinary approach in the evaluation and treatment of CPP patients to help decrease functional impairment in these patients.

Depression and literacy are important factors for missed appointments

Abstract Multiple variables are related to missed clinic appointments. However, the prevalence of missed appointments is still high suggesting other factors may play a role. The purpose of this study was to investigate the relationship between missed appointments and multiple variables simultaneously across a health care system, including patient demographics, psychiatric symptoms, cognitive functioning and literacy status. Chart reviews were conducted on 147 consecutive patients who were seen by a primary care psychologist over a six month period and completed measures to determine levels of depression, anxiety, sleep, cognitive functioning and health literacy. Demographic information and rates of missed appointments were also collected from charts. The average rate of missed appointments was 15.38%. In univariate analyses, factors related to higher rates of missed appointments included younger age (p = .03), lower income (p = .05), probable depression (p = .05), sleep difficulty (p = .05) and limited reading ability (p = .003). There were trends for a higher rate of missed appointments for patients identifying as black (p = .06), government insurance (p = .06) and limited math ability (p = .06). In a multivariate model, probable depression (p = .02) and limited reading ability (p = .003) were the only independent predictors. Depression and literacy status may be the most important factors associated with missed appointments. Implications are discussed including regular screening for depression and literacy status as well as interventions that can be utilized to help improve the rate of missed appointments.

Pursuing bariatric surgery in an urban area: Gender and racial disparities and risk for psychiatric symptoms

BACKGROUND Bariatric surgery is effective for weight loss; however, only a small percentage of those who qualify choose to pursue it. Additionally, although psychiatric symptoms appear to be common among candidates, the risk factors for symptoms are not known. Therefore, the purpose of this study was to examine the characteristics of those who are pursuing bariatric surgery in an urban area, whether demographic disparities continue to exist, and identify characteristics of those who may be at higher risk for experiencing psychiatric symptoms. METHODS There were 424 bariatric candidates who completed a required psychological evaluation prior to bariatric surgery. RESULTS AND CONCLUSIONS Bariatric surgery candidates tended to be middle-aged, Caucasian females, which was unexpected when compared to the rates of obesity among these groups. Therefore, it appears that there are disparities in who chooses to seek out bariatric surgery compared to those who may qualify due to their obesity status. Cultural factors may play a role in why males and African Americans seek out bariatric surgery less frequently. Psychiatric symptoms among candidates are also common, with depression symptoms increasing with age and BMI. Perhaps the compounding effects of medical comorbidities over time are contributing to greater depressive symptoms in the older patients. Findings from this study suggest that we may need to explore ways of encouraging younger patients, males, and ethnic minorities to pursue bariatric surgery to increase weight loss success and decrease medical comorbidities.

Embedding a Psychologist Into Primary Care Increases Access to Behavioral Health Services

Background: Patients commonly report psychological issues during primary care visits; however, few patients will follow through with a referral for behavioral health services at an outside facility. Therefore, patients may benefit from having psychologists embedded into primary care clinics. The purpose of this study was to determine who saw a primary care psychologist and to investigate which patient characteristics predicted who was more likely to attend subsequent visits with behavioral health services. Methods: There were 96 patients referred to a primary care psychologist by their primary care physician. Chart reviews were conducted to obtain patient characteristics and to determine whether the patients attended a subsequent visit with behavioral health services after the initial evaluation. Results: There were 84.4% of patients who completed an initial evaluation with a psychologist and 15.6% either cancelled or did not show for this evaluation. Of those who completed the initial evaluation, more than half had never received treatment from a behavioral health specialist. Of the 70.4% patients recommended to attend additional behavioral health treatment, 54.4% of patients attended a subsequent visit. Gender, age, race, years of education, and whether a patient had previous behavioral treatment did not predict who was more likely to attend a subsequent behavioral health visit after the initial evaluation. Conclusions: Embedding a psychologist in a primary care clinic leads to increased access to behavioral health services, especially among patients who may not seek out these services themselves or follow through with a physician’s referral to an outside behavioral health clinic.

How do I cope with pain? Let me count the ways: awareness of pain coping behaviors and relationships with depression and anxiety

Abstract Patients with chronic pain are often undertreated with medications alone and need alternative ways of coping. Identifying pain coping skills patients use may be beneficial; however, no research has investigated whether patients are aware of their coping skills. The purpose of this study was to determine whether patients are aware of their pain coping skills, whether certain patient characteristics were related to using coping strategies, and whether coping strategies were related to psychiatric symptoms. Chart reviews were conducted on seventy-eight chronic pain patients who completed a semi-structured psychological interview. Patients endorsed using more coping strategies on the measure compared to the verbal self-report. Identifying with certain patient demographics was related to higher use of some coping strategies. Symptoms of anxiety and depression were also related to the use of some coping strategies. Anxiety was negatively related to ignoring the pain and using self-talk coping statements and positively related to catastrophizing. Depression was negatively related to the use of distraction, ignoring the pain, and using self-talk coping statements. Depression and pain severity were both positively related to catastrophizing and prayer. Results suggest that clinicians may need to help patients become aware of adaptive coping strategies they already use and that the use of certain coping strategies is related to lower levels of depression and anxiety.

The development and treatment of a food phobia after bariatric surgery

“Robert” (name changed to protect privacy) was a 47-yearold, black, morbidly obese male who had laparoscopic gastric bypass surgery. At the initial consultation, Robert weighed 430.3 pounds with a body mass index (BMI) of 58.4. Prior to surgery, he completed a routine psychiatric evaluation and denied a history of significant psychiatric symptoms and treatment. He also denied a history of eating disorders (i.e., restriction or purging). From the initial consultation to his surgery date, he lost 18.6 pounds and had a BMI of 55.8. Robert underwent a routine, laparoscopic gastric bypass surgery. Three months post-surgery he had lost an additional 74.1 pounds (weight = 337.6, BMI = 45.8). At this time, it was noted that he reported choking and vomiting in response to eating. He expressed a fear with regards to these occurring. He was admitted to the hospital, evaluated by gastroenterology, and completed an esophagogastroduodenoscopy (EGD). There were no anatomical or physiological explanations for his difficulty swallowing. Six months post-surgery, he arrived to a post-surgical follow-up appointment dehydrated and malnourished. He reported that he was unable to eat or drink for several weeks. At this time, he had lost an additional 60 pounds. He was admitted to the hospital for further evaluation and treatment. Findings from an EGD were normal. A psychiatric consultation was requested for Robert during this inpatient stay. He was not keeping a food journal and reported his food intake by memory. He reported no food intake on most days over the previous several weeks. When he did consume food, he was eating foods not appropriate to his post-surgical diet (i.e., low protein and high carbohydrate foods including fruit, corn, and oatmeal). It appears that he was experiencing frequent dumping syndrome symptoms Introduction

A New Measure of Health Numeracy: Brief Medical Numbers Test (BMNT)

BACKGROUND Approximately half of Americans have inadequate health literacy, which leads to poorer health outcomes. Health numeracy is an important component of literacy, which reflects ones ability to understand and manipulate numbers. This is especially important for transplant candidates, as adherence to medical recommendations is essential for posttransplant care. Although validated measures of numeracy exist, they can be inconvenient and time consuming to administer. OBJECTIVE The Brief Medical Numbers Test (BMNT) was created in 2011 to quickly assess the health numeracy of a patient during presurgical psychiatric transplant evaluations. The purpose of this study was to evaluate the reliability and validity of the BMNT for this use via retrospective chart review. METHODS There were 293 patients referred over a 2-year period for a presurgical psychiatric evaluation. The evaluation consisted of a semistructured interview and completion of several measures, including the BMNT, a measure of health literacy, and a brief test of cognitive functioning. RESULTS The BMNT had acceptable internal consistency (α = .71), convergent validity with health literacy and cognitive functioning, and predictive validity with surgical outcomes. CONCLUSIONS Preliminary data suggests the BMNT is a reliable and valid measure of health numeracy in patients being evaluated for transplant.

Identifying Predictors of Emergency Room Utilization in Primary Care

Emergency room (ER) utilization is a growing, costly concern for health care in the USA. Several variables have been reported as contributing factors to increased ER utilization including chronic health conditions, depression, lower cognitive abilities, and socioeconomic status.1 However, no prior research has simultaneously analyzed these patient-specific variables. Additionally, most of the research that has identified factors related to ER utilization has been conducted after patients have already sought ER services. To decrease ER use, it is important to identify patients before they visit the ER. With the growth of behavioral health services availability in primary care clinics, early identification of patients at risk for utilization of ER services may be possible. The purpose of this study was to determine whether predictors of ER utilization could be identified during a behavioral health consultation in the primary care setting and to investigate which variables were most important in predicting higher ER use.