Accepted Manuscript A Picture is Worth a Thousand Words….Does Health Literacy Level Matter in Patients with Heart Failure? Karen S. Yehle, PhD, MS, RN, FAHA PII:
S1071-9164(15)00178-5
DOI:
10.1016/j.cardfail.2015.06.002
Reference:
YJCAF 3521
To appear in:
Journal of Cardiac Failure
Received Date: 1 June 2015 Revised Date:
1 June 2015
Accepted Date: 8 June 2015
Please cite this article as: Yehle KS, A Picture is Worth a Thousand Words….Does Health Literacy Level Matter in Patients with Heart Failure?, Journal of Cardiac Failure (2015), doi: 10.1016/ j.cardfail.2015.06.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
A Picture is Worth a Thousand Words…. Does Health Literacy Level Matter in Patients with Heart Failure?
RI PT
Karen S. Yehle, PhD, MS, RN, FAHA West Lafayette, IN Correspondence:
SC
Karen S. Yehle, PhD, MS, RN, FAHA Purdue University, School of Nursing 502 N. University Street West Lafayette, IN 47907-2069
Disclosures:
M AN U
Phone: 765-494-4011 Fax: 765-494-6339 E-mail: [email protected]
The author has no conflicts of interest to declare. Short title:
AC C
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Health Literacy Level in Patients with HF
ACCEPTED MANUSCRIPT
RI PT
Have you considered just how important your heart failure (HF) patient’s health literacy level is to their health? Only 12% of the U.S. population is estimated to have the level of health literacy needed for health decisions1, suggesting that many patients may struggle to understand the information necessary to make informed decisions to manage their health. Even patients who are literate may grapple with comprehending and acting on health information. If educational materials are not understandable, what is the ultimate cost to patients, providers, and the entire healthcare system?
SC
Health literacy is defined by the Institute of Medicine as ‘‘the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.’’2. Inadequate health literacy is associated with increased healthcare costs and worse outcomes3. Low health literacy is also burdensome for providers who, despite their provision of guideline directed care, may not achieve the patient outcomes they are seeking. This is especially salient to providers treating HF because of the 30 day risk-standardized mortality and readmission measures instituted by CMS4.
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M AN U
We know that HF care is a complex condition for patients and providers alike to manage outside of the hospital setting. However, for patients who live in rural areas, it is even more challenging. Rural-residing patients have higher rates of diabetes and obesity, as well as poorer health outcomes when living with these diseases5,6. In this issue of the Journal of Cardiac Failure, Moser et al found that, in rural patients diagnosed with HF, lower health literacy was a risk factor for all-cause mortality or readmission7. Additionally, McNaughton and colleagues recently found an association between a higher risk for death post-discharge in patients with HF who had low health literacy8. These patients had the burdens of both a rural residence and low health literacy. Think about what additional challenges patients residing in rural areas face, such as variable access to healthcare, prolonged distances to travel to access healthcare, increased time that must be allotted for travel, and additional travel costs, such as gasoline and meals.
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EP
How can we as busy HF clinicians approach this issue of health literacy? How can we assess health literacy? Informally, cues to watch for include statements such as “I’ll read it later” or “I forgot my glasses at home”. Instruments have also been developed to assess health literacy. The Short Test of Functional Health Literacy in Adults (S-TOFHLA) is the gold standard for assessing health literacy, but 7 minutes must be allocated for administration9. Though the Newest Vital Sign is a shorter tool with 6 questions, it takes approximately 3 minutes to administer10. Even less time consuming are the 3 questions developed by Chew et al, which were helpful in distinguishing patients with inadequate health literacy: ●“How often do you have someone help you read hospital materials?” ● “How confident are you filling out medical forms by yourself?” and ● “How often do you have problems learning about your medical condition because of difficulty understanding written information?” 11.
Incorporating one or more health literacy questions such as these is feasible in busy healthcare settings, and can assist providers in identifying patients that may struggle with reading health information. Addressing health literacy also needs to be included in approaches to reduce HF readmissions. The Newest Vital Sign10 and Brief Questions to Assess Health Literacy11 are readily available to clinicians and require only a few minutes for administration and interpretation. Providing education without knowing
ACCEPTED MANUSCRIPT
RI PT
the patient’s health literacy level is a gamble, as we do not know what will “stick”. We cannot afford to ignore the impact our patient’s health literacy has on their understanding of the management of their disease state. In addition to identifying health literacy levels in our patients, institutions and professional organizations focused on HF care need to ensure that websites, pamphlets, and other materials are written at an appropriate literacy level and avoid jargon. Additionally, we must use design principles to enhance reader comprehension, including using mediums other than the written word, such as video clips and pictorials. There are few studies that have tested interventions for low literacy patients with HF. DeWalt et al. developed an education booklet for low literacy patients with HF as part of a disease management program, and improved daily weighing behavior and quality of life12. We need to develop and widely test interventions to help patients with lower health literacy be successful in their daily HF self-care, regardless of where they live.
AC C
EP
TE D
M AN U
SC
Simply put, we need to assess the health literacy level of every patient, regardless of their educational level. Clearly, their lives depend on it.
ACCEPTED MANUSCRIPT
References
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M AN U
SC
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1. Agency for Healthcare Research and Quality. 2007 National Healthcare Disparities Report. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality. 2008. AHRQ Pub. No. 08-0041. Rockville, MD: Agency for Healthcare Research and Quality. 2. Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004. Washington, DC: National Academy of Sciences. 3. Berkman ND, DeWalt DA, Pignone MP, Sheridan SL, Lohr KN, Lux L, et al. Literacy and health outcomes. 2004. AHRQ Pub. No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality. 4. www.cms.gov 5. Eberhardt MS, Pamuk ER. The importance of place of residence: examining health in rural and nonrural areas. Am J Public Health 2004; 94(10):1682–6. 6. Hartley D. Rural health disparities, population health, and rural culture. Am J Public Health 2004; 94(10):1675–8. 7. Moser DK, Robinson S, Pelter M, Nesbitt T, Southard J, Biddle M, et al. Health literacy predicts morbidity and mortality in rural patients with heart failure. J Card Fail 2015; 21(8): PLEASE ADD PAGE NUMBERS. 8. McNaughton CD, Cawthon C, Kripalani S, Liu D, Storrow AB, Roumie CL. Health literacy and Mortality: a cohort study of patients hospitalized for acute heart failure. J Am Heart Assoc 2015; 4: e001799 doi:10.1161/JAHA.115.001799 9. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Couns 1999; 38:33-42. 10. Weiss, BD, Mays MZ, Martz W, Cstro KM, DeWalt DA, Pignone MP, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med 2005; 3(6): 514-522. 11. Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med 2004; 36(8):588-94. 12. DeWalt DA, Pignone M, Malone R, Rawls C, Kosnar M, George G, et al. Development and pilot testing of a disease management program for low literacy patients with heart failure. Patient Educ Couns 2004; 55(1):78-86.
S1071-9164(15)00178-5
DOI:
10.1016/j.cardfail.2015.06.002
Reference:
YJCAF 3521
To appear in:
Journal of Cardiac Failure
Received Date: 1 June 2015 Revised Date:
1 June 2015
Accepted Date: 8 June 2015
Please cite this article as: Yehle KS, A Picture is Worth a Thousand Words….Does Health Literacy Level Matter in Patients with Heart Failure?, Journal of Cardiac Failure (2015), doi: 10.1016/ j.cardfail.2015.06.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
A Picture is Worth a Thousand Words…. Does Health Literacy Level Matter in Patients with Heart Failure?
RI PT
Karen S. Yehle, PhD, MS, RN, FAHA West Lafayette, IN Correspondence:
SC
Karen S. Yehle, PhD, MS, RN, FAHA Purdue University, School of Nursing 502 N. University Street West Lafayette, IN 47907-2069
Disclosures:
M AN U
Phone: 765-494-4011 Fax: 765-494-6339 E-mail: [email protected]
The author has no conflicts of interest to declare. Short title:
AC C
EP
TE D
Health Literacy Level in Patients with HF
ACCEPTED MANUSCRIPT
RI PT
Have you considered just how important your heart failure (HF) patient’s health literacy level is to their health? Only 12% of the U.S. population is estimated to have the level of health literacy needed for health decisions1, suggesting that many patients may struggle to understand the information necessary to make informed decisions to manage their health. Even patients who are literate may grapple with comprehending and acting on health information. If educational materials are not understandable, what is the ultimate cost to patients, providers, and the entire healthcare system?
SC
Health literacy is defined by the Institute of Medicine as ‘‘the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.’’2. Inadequate health literacy is associated with increased healthcare costs and worse outcomes3. Low health literacy is also burdensome for providers who, despite their provision of guideline directed care, may not achieve the patient outcomes they are seeking. This is especially salient to providers treating HF because of the 30 day risk-standardized mortality and readmission measures instituted by CMS4.
TE D
M AN U
We know that HF care is a complex condition for patients and providers alike to manage outside of the hospital setting. However, for patients who live in rural areas, it is even more challenging. Rural-residing patients have higher rates of diabetes and obesity, as well as poorer health outcomes when living with these diseases5,6. In this issue of the Journal of Cardiac Failure, Moser et al found that, in rural patients diagnosed with HF, lower health literacy was a risk factor for all-cause mortality or readmission7. Additionally, McNaughton and colleagues recently found an association between a higher risk for death post-discharge in patients with HF who had low health literacy8. These patients had the burdens of both a rural residence and low health literacy. Think about what additional challenges patients residing in rural areas face, such as variable access to healthcare, prolonged distances to travel to access healthcare, increased time that must be allotted for travel, and additional travel costs, such as gasoline and meals.
AC C
EP
How can we as busy HF clinicians approach this issue of health literacy? How can we assess health literacy? Informally, cues to watch for include statements such as “I’ll read it later” or “I forgot my glasses at home”. Instruments have also been developed to assess health literacy. The Short Test of Functional Health Literacy in Adults (S-TOFHLA) is the gold standard for assessing health literacy, but 7 minutes must be allocated for administration9. Though the Newest Vital Sign is a shorter tool with 6 questions, it takes approximately 3 minutes to administer10. Even less time consuming are the 3 questions developed by Chew et al, which were helpful in distinguishing patients with inadequate health literacy: ●“How often do you have someone help you read hospital materials?” ● “How confident are you filling out medical forms by yourself?” and ● “How often do you have problems learning about your medical condition because of difficulty understanding written information?” 11.
Incorporating one or more health literacy questions such as these is feasible in busy healthcare settings, and can assist providers in identifying patients that may struggle with reading health information. Addressing health literacy also needs to be included in approaches to reduce HF readmissions. The Newest Vital Sign10 and Brief Questions to Assess Health Literacy11 are readily available to clinicians and require only a few minutes for administration and interpretation. Providing education without knowing
ACCEPTED MANUSCRIPT
RI PT
the patient’s health literacy level is a gamble, as we do not know what will “stick”. We cannot afford to ignore the impact our patient’s health literacy has on their understanding of the management of their disease state. In addition to identifying health literacy levels in our patients, institutions and professional organizations focused on HF care need to ensure that websites, pamphlets, and other materials are written at an appropriate literacy level and avoid jargon. Additionally, we must use design principles to enhance reader comprehension, including using mediums other than the written word, such as video clips and pictorials. There are few studies that have tested interventions for low literacy patients with HF. DeWalt et al. developed an education booklet for low literacy patients with HF as part of a disease management program, and improved daily weighing behavior and quality of life12. We need to develop and widely test interventions to help patients with lower health literacy be successful in their daily HF self-care, regardless of where they live.
AC C
EP
TE D
M AN U
SC
Simply put, we need to assess the health literacy level of every patient, regardless of their educational level. Clearly, their lives depend on it.
ACCEPTED MANUSCRIPT
References
AC C
EP
TE D
M AN U
SC
RI PT
1. Agency for Healthcare Research and Quality. 2007 National Healthcare Disparities Report. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality. 2008. AHRQ Pub. No. 08-0041. Rockville, MD: Agency for Healthcare Research and Quality. 2. Institute of Medicine. Health Literacy: A Prescription to End Confusion. 2004. Washington, DC: National Academy of Sciences. 3. Berkman ND, DeWalt DA, Pignone MP, Sheridan SL, Lohr KN, Lux L, et al. Literacy and health outcomes. 2004. AHRQ Pub. No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality. 4. www.cms.gov 5. Eberhardt MS, Pamuk ER. The importance of place of residence: examining health in rural and nonrural areas. Am J Public Health 2004; 94(10):1682–6. 6. Hartley D. Rural health disparities, population health, and rural culture. Am J Public Health 2004; 94(10):1675–8. 7. Moser DK, Robinson S, Pelter M, Nesbitt T, Southard J, Biddle M, et al. Health literacy predicts morbidity and mortality in rural patients with heart failure. J Card Fail 2015; 21(8): PLEASE ADD PAGE NUMBERS. 8. McNaughton CD, Cawthon C, Kripalani S, Liu D, Storrow AB, Roumie CL. Health literacy and Mortality: a cohort study of patients hospitalized for acute heart failure. J Am Heart Assoc 2015; 4: e001799 doi:10.1161/JAHA.115.001799 9. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Couns 1999; 38:33-42. 10. Weiss, BD, Mays MZ, Martz W, Cstro KM, DeWalt DA, Pignone MP, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med 2005; 3(6): 514-522. 11. Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med 2004; 36(8):588-94. 12. DeWalt DA, Pignone M, Malone R, Rawls C, Kosnar M, George G, et al. Development and pilot testing of a disease management program for low literacy patients with heart failure. Patient Educ Couns 2004; 55(1):78-86.
