Darren A. DeWalt, MD, MPH

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Addressing Health Literacy Critical to Good
Health Outcomes

• Darren A. DeWalt, MD, MPH
• Assistant Professor of Medicine
• University of North Carolina School of Medicine
• December 11, 2008

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Patient Centered Medical Home

• Patient centered requires understanding the
  skills and desires of the patient
• Medical home implies seamless and supportive care
  that is coordinated
• Helping the individual patient thrive
• Health literacy is at the center of PCMH

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Summary

• What is health literacy?
• Literacy in America
• Literacy and health outcomes
• Strategies to address low health literacy

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Health Literacy

• The degree to which individuals have the
  capacity to obtain, process, and understand basic
  health information and services needed to make
  appropriate health decisions.
• Healthy People 2010

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How Well Do We Read and Write?
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National Assessment of Adult Literacy (NAAL)

• n 19,714
• ? Most up to date portrait of literacy in U.S.
• ? Scored on 4 levels
• ? Lowest 2 levels cannot
• ? Use a bus schedule or bar graph
• ? Explain the difference in two types of
  employee benefits
• ? Write a simple letter explaining an error on a
  bill

National Center for Education Statistics, U.S.
Department of Education
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2003 National Assessment of Adult Literacy
13
14
Below Basic
Proficient
29
Basic
44
Intermediate
Basic or Below Basic 52 of H.S. Grads 61 of
Adults 65
93 Million Adults have Basic or Below Basic
Literacy
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Inadequate Literacy Increases with Age
Slide by Terry Davis, PhD
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(No Transcript)
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Video
Its hard to be a patient
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Relationship between Literacy and Health Outcomes
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Health Outcomes Associated with Literacy

• Health Outcomes/Health Services
• General health status
• Hospitalization
• Prostate cancer stage
• Depression
• Asthma
• Diabetes control
• HIV control
• Mammography
• Pap smear
• Pneumococcal immunization
• Influenza immunization
• STD screening
• Cost
• Mortality

• Behaviors Only
• Substance abuse
• Breastfeeding
• Behavioral problems
• Adherence to medication
• Smoking
• Knowledge Only
• Birth control knowledge
• Cervical cancer screening
• Emergency department instructions
• Asthma knowledge
• Hypertension knowledge
• Prescription labels

DeWalt, et al. JGIM 2004191228-1239
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Asthma Patients with Low Literacy have Poorer
Metered Dose Inhaler (MDI) Skills
Mean MDI Score 0 - 4
Williams et al. Chest 1998, 114(4)1008-1015.
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Adult Hospitalization

• People with low literacy have 30-70 increased
  risk of hospitalization
• RR 1.29 (1.07-1.55) Medicare Managed Care
• RR 1.69 (1.13-2.53) Urban Public Hospital

Adjusted for age, gender, socioeconomic status,
health status, and regular source of care.
Baker et al. AJPH. 2002. 921278.
Baker et al. JGIM. 1998. 13791.
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Can Patients Comprehend Rx Drug Warning Labels?
Davis et al. JGIM 2006 21 847-851
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Simple Familiar Wording Understood by
Most Patients
84
(1st grade.)
Slide by Terry Davis
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More Complex Message Limited Comprehension
59
(10th-12th grade.)
Slide by Terry Davis
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Unfamiliar Multi-step Instructions Rarely
Understood
8
(12th-13th grade)
Slide by Terry Davis
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Comprehension Increased with Patient
Literacy Level
plt.0001, plt.05
lt6 7-8 gt9 79 86 88 35 66 78
8 64 82 8 18 23 0 6 15
In multivariate analysis only literacy and age
predicted comprehension. Patients with low
literacy (lt 6th gd.) 3x more likely to
incorrectly interpret warning labels.
Davis et al. JGIM 2006 21847851.
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What does this picture mean?

• Someone swallowed a nickel
• Indigestion
• Bladder
• Looks like a ghost- Casper

Slide by Terry Davis
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Show Me How Many Pills You Would Take in 1 Day
John Smith Dr. Red Take two tablets by
mouth twice daily. Humibid LA 600MG 1
refill
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Rates of Correct Understanding vs. Demonstration
Take Two Tablets by Mouth Twice Daily
89
84
80
71
63
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Video
Its easy to make a mistake
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Many things we assume people understand, they
dont.And, health outcomes are affected.
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We have a problem and must alter systems of care

• The complexity of the care system exacerbates
  literacy vulnerabilities
• All aspects of our system can raise barriers
• Appointments and referrals
• Getting tests done
• Paying for medicine or treatment
• Understanding bills and insurance

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The Continuum of Confusion Now go home and
safely manage your care
PPPrior to seeing physician
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Skills Needed by Patient

• Read
• Remember
• Implement
• Figure out complex processes
• Relentlessly pursue.

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What Works?
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Improving Written Health Information

• Most materials written well above the average
  literacy of the population
• Guidelines available for better clear written
  health information
• Any letter or form we send to patients should be
  vetted by experts in our health system

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Improving Communication

• All members of team physicians, nurses, social
  workers, PT/OT, dentists, nutrition, health
  educators, phone room, front desk staff
• Principles of Clear Communication
• Limit number of points
• Write them down
• Avoid using jargon (would your mother
  understand?)
• Teach-back method

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Teach-back
Explain
Assess
Clarify
Understanding
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Ask Me 3

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

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Changing Systems of Care

• Redesign how care is provided
• Simplify care tasks
• Make care seamless and organized
• Integrate a well-trained workforce

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Examples of System Changes
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Planned Care
Usual Care
Intensive Self-care Education
compared to

Rothman et al. Am J Med 2005 118276-284.
DeWalt et al. BMC Health Services Research.
630 2006.
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Heart Failure
47 lower hospitalization rate for those in
planned care
DeWalt et al. BMC Health Services Research.
630 2006.
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Diabetes
Rothman et al. Am J Med 2005 118276-284.
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Results According to Literacy Status
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Diabetes Control Results for Patients with
Literacy Above 6th Grade Level
Rothman et al. JAMA 2004, 292(14)1711-1716.
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Diabetes Control Results for Patients with
Literacy at or Below 6th Grade Level
Rothman et al. JAMA 2004, 292(14)1711-1716.
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Patient Centered Medical Home

• Success requires us to apply the principles we
  tested in diabetes and heart failure to all
  patients and all problems
• This requires all staff to attend to the needs of
  individuals
• Clear and helpful communication will help us to
  achieve this goal

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Summary

• Low health literacy is common and we need to
  consider patient understanding every time
• Take health literacy into account for every
  initiative we do in clinic
• Today Think about whether your patient
  understands. Write it down for the patient. Ask
  them to tell you back (when appropriate).