Steven E. Roskos

BRIEF REPORT: Screening Items to Identify Patients with Limited Health Literacy Skills

AbstractBACKGROUND: Patients with limited literacy skills are routinely encountered in clinical practice, but they are not always identified by clinicians. OBJECTIVE: To evaluate 3 candidate questions to determine their accuracy in identifying patients with limited or marginal health literacy skills. METHODS: We studied 305 English-speaking adults attending a university-based primary care clinic. Demographic items, health literacy screening questions, and the Rapid Estimate of Adult Literacy in Medicine (REALM) were administered to patients. To determine the accuracy of the candidate questions for identifying limited or marginal health literacy skills, we plotted area under the receiver operating characteristic (AUROC) curves for each item, using REALM scores as a reference standard. RESULTS: The mean age of subjects was 49.5; 67.5% were female, 85.2% Caucasian, and 81.3% insured by TennCare and/or Medicare. Fifty-four (17.7%) had limited and 52 (17.0%) had marginal health literacy skills. One screening question. “How confident are you filling out medical forms by yourself?” was accurate in detecting limited (AUROC of 0.82; 95% confidence interval [CI]=0.77 to 0.86) and limited/marginal (AUROC of 0.79; 95% CI=0.74 to 0.83) health literacy skills. This question had significantly greater AUROC than either of the other questions (P <.01) and also a greater AUROC than questions based on demographic characteristics. CONCLUSIONS: One screening question may be sufficient for detecting limited and marginal health literacy skills in clinic populations.

Suitability and readability of consumer medical information accompanying prescription medication samples.

OBJECTIVE To examine readability and formatting characteristics of consumer medication information (CMI) accompanying prescription medication samples. METHODS We collected the most commonly used prescription medication samples (n=100) from four out-patient clinics at a large teaching hospital in the Southeastern US. Seventeen percent of samples were not pills/tablets and of such diverse nature (e.g., injections, drops, and creams) that there were not enough in any category to draw conclusions. Therefore, our analyses were limited to 83pill/tablet samples, belonging to 11 drug classes (e.g., cardiovascular, and psychiatric). We noted if CMI was present, and if so we assessed it for how instructions were presented, reading level, text size, format/layout, and comprehensibility. RESULTS No CMI was present in 39 (46.9%) samples. In 19 (22.9%), CMI was contained in a package insert and in 25 (30.2%) it was printed on the medication package. Average reading difficulty of CMI was at the 10th grade level (range=6-15) using the Fry formula, and text point size was small (mean 9.9+/-2.2 on package inserts and 9.4+/-2.6 when printed on packages). CONCLUSIONS Almost half of samples did not include any type of CMI. For those that had CMI, it was often written at a reading difficulty level higher than the average reading skills of American adults, and the format of most CMI was not optimal for comprehensibility. It is likely that many patients do not understand the instructions accompanying medication samples they receive from clinicians. PRACTICE IMPLICATIONS Clinicians should be cognizant of the shortcomings of CMI accompanying medication samples and thereby, distribute them to patients with caution. Manufacturers too should consider revising CMI to comply with low-literacy guidelines.

Readability characteristics of consumer medication information for asthma inhalation devices

Purpose. Successful control of asthma relies heavily on patient adherence to prescribed inhalation therapies. Many patients are unable to use inhalers correctly and, therefore, do not reap the full therapeutic benefits. The purpose of this study was to assess the readability and related characteristics of Consumer Medication Information (CMI) for all prescription asthma inhalation devices currently available in the United States. Methods. We identified all brand-name (n = 18) and generic (n = 2) asthma inhalation devices currently available in the United States. English language CMI was obtained from pharmaceutical manufacturers of each identified product. The CMI from these products was evaluated for readability characteristics, including reading grade level using the Fry formula, text point size, dimensions (length and width), diagrams, and directions. Results. The mean Fry readability of the CMI was at grade level 8.2 ± 1.5 (range = 5–11), while the average text point size was 9.2 ± 2.2 (range = 6–12). The mean length of the pages on which the CMI was printed was 33.7 ± 21.5 cm, while the average width of pages was 12.9 ± 9.5 cm. There was an average of 6.2 ± 3.6 (range = 2–12) illustrations per CMI, while a device overview diagram was included in 14 (70%). Eleven (n = 11) instructions included detailed step-by-step diagrams to supplement directions. Conclusions. Overall, most CMI for prescription inhalers is presented with a reading difficulty level, text size, diagrams, and instructions that make it suboptimal for patient education. Prescription inhaler manufacturers should consider revising their CMI to comply with generally accepted guidelines preparing patient education information.

Documenting clinical performance problems among medical students: feedback for learner remediation and curriculum enhancement

Introduction We operationalized the taxonomy developed by Hauer and colleagues describing common clinical performance problems. Faculty raters pilot tested the resulting worksheet by observing recordings of problematic simulated clinical encounters involving third-year medical students. This approach provided a framework for structured feedback to guide learner improvement and curricular enhancement. Methods Eighty-two problematic clinical encounters from M3 students who failed their clinical competency examination were independently rated by paired clinical faculty members to identify common problems related to the medical interview, physical examination, and professionalism. Results Eleven out of 26 target performance problems were present in 25% or more encounters. Overall, 37% had unsatisfactory medical interviews, with ‘inadequate history to rule out other diagnoses’ most prevalent (60%). Seventy percent failed because of physical examination deficiencies, with missing elements (69%) and inadequate data gathering (69%) most common. One-third of the students did not introduce themselves to their patients. Among students failing based on standardized patient (SP) ratings, 93% also failed to demonstrate competency based on the faculty ratings. Conclusions Our review form allowed clinical faculty to validate pass/fail decisions based on standardized patient ratings. Detailed information about performance problems contributes to learner feedback and curricular enhancement to guide remediation planning and faculty development.

Cytomegalovirus infection in immunocompetent adults: Is observation still the best strategy?

Cytomegalovirus (CMV) infection in immunocompetent patients generally resolves with few sequelae. However, it can cause severe and relapsing symptoms that can last for several weeks. Due to the self-limiting nature of CMV disease in immunocompetent individuals, criteria for specific antiviral therapy in this cohort are not well established. Additionally the adverse effect profile of currently available anti-CMV therapy limits its use in specific patient populations .We describe 3 immunocompetent adults who developed symptomatic CMV infection and were ill for several weeks. All patients had positive CMV viral assays and ultimately received anti-CMV therapy with significant improvement in symptoms within a few days of starting therapy. Choosing appropriate candidates for anti-CMV therapy, among mmunocompetent individuals, requires further research.

Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study

Abstract Background and aims Some 100 million adults in the United States suffer from chronic pain. While research to date has focused primarily on pain interference with physical and psychological function and its effects on employment, few studies have examined the impact of pain interference on social functioning and its effects on employment. The aims of our study were to (1) evaluate the association between pain interference with ability to work and actual employment status among working age adults with chronic pain; and (2) evaluate pain interference with four types of functioning - cognitive, physical, psychological, and social - as possible mediators of pain interference with the ability to work. Methods Data were collected via a self-selected sample of individuals visiting the American Chronic Pain Association (ACPA) website. The final dataset included 966 respondents. We examined the association between pain interference with the ability to work and employment in a population with chronic pain. We then analyzed pain interference with four types of functioning, physical, psychological, cognitive, and social, for their impact on the ability to work. Results Pain interference with ability to work was significantly inversely associated with employment status, i.e., the less that pain interfered with one’s ability to work, the greater the likelihood of being employed. Moreover, pain interference with ability to work was a stronger predictor of employment status than an individual’s rating of their pain intensity. Pain interference with social functioning partially mediated the effects of pain interference with cognitive and physical functioning and fully mediated the effects of pain intensity and pain interference with psychological functioning on pain interference with the ability to work. Results suggest that pain interference with social function may be a significant contributor to pain interference with ability to work in working age adults with chronic pain.? Conclusions In the development of effective solutions to address the economic and societal burden of chronic pain, this paper highlights the role of social function as an important, yet frequently overlooked, contributor to chronic pain’s effect on the ability to work. Our findings underscore the importance of an integrated biopsychosocial approach to managing chronic pain, especially when addressing ability to work. From a clinical standpoint, assessing and managing pain intensity is necessary but not sufficient in addressing the far-reaching negative consequences of chronic pain. Implications The development of interventions that improve social function may improve the ability to work in adults with chronic pain. Likewise, sick leave should be prescribed restrictivelyin the management of chronic pain since it may further interfere with social functioning. Perspective This study highlights the importance of the assessment of pain interference with social function as a part of a comprehensive biopsychosocial approach to the evaluation and management of patients with chronic pain. Interventions that improve social function may improve the ability to work in this population. In addition, sick leave should be prescribed restrictively in the management of chronic pain since it by itself interferes with social functioning.

Development and evaluation of a Health Record Online Submission Tool (HOST)

Abstract Introduction: Health records (HRs) are crucial to quality patient care. The Michigan State University College of Human Medicine begins teaching health record (HR) writing during the second-year clinical skills courses. Prior to this project, we used a cumbersome paper system to allow graduate assistants to grade and give feedback on students’ HRs. This study discusses the development and evaluates the effectiveness of the new Health Record Online Submission Tool (HOST). Methods: We developed an electronic submission system with the goals of decreasing the logistical demands of the paper-based system; improving the effectiveness, consistency, and oversight of HR instruction and evaluation; expanding the number of students who could serve as written record graduate assistants (WRGAs); and to begin preparing students for the use of electronic health records (EHRs). We developed the initial web-based system in 2003 and upgraded it to its present form, HOST, in 2007. We evaluated the system using course evaluations, surveys of WRGAs and clinical students, and queries of course faculty and staff. Results: Course evaluation by 1,106 students during years 2001 through 2008 revealed that the students’ self-assessment of ability to write HRs improved briefly with the introduction of HOST but then returned to baseline. The initial change to electronic submission was well received, though with continued use its rating dropped. A survey of 65 (response rate 61.3%) clinical students indicated that HOST did not completely prepare them for EHRs. The WRGAs (n=14; response rate 58%) found the system easy to use to give feedback to students. Faculty (n=3) and staff (n=2) found that it saved time and made the review of students’ HRs and WRGAs grading simpler. Student perception of grading consistency did not improve. Conclusions: HOST is the first published online method of in-depth HR training for preclinical students using information gathered in clinical encounters. With it we were able to maintain effective instruction, streamline course management, and significantly decrease staff time. HOST did not improve student perception of grading consistency and did not prepare students for specific EHR use. Within the context of our class size expansion and our community-based educational program, HOST bridges geography and can support future improvements in HR instruction and faculty development. Medical educators at other institutions could use a similar system to accomplish these goals.