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Physician notification of their diabetes patients’ limited health literacy: A randomized, controlled trial

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An Erratum to this article was published on 01 November 2005

Abstract

BACKGROUND: Many patients with chronic disease have limited health literacy (HL). Because physicians have difficulty identifying these patients, some experts recommend instituting screening programs in clinical settings. It is unclear if notifying physicians of patients’ limited HL improves care processes or outcomes.

OBJECTIVE: To determine whether notifying physicians of their patients’ limited HL affects physician behavior, physician satisfaction, or patient self-efficacy.

DESIGN: We screened all patients for limited HL and randomized physicians to be notified if their patients had limited HL skills.

PARTICIPANTS: Sixty-three primary care physicians affiliated with a public hospital and 182 diabetic patients with limited HL.

MEASUREMENTS: After their visit, physicians reported their management strategies, satisfaction, perceived effectiveness, and attitudes toward HL screening. We also assessed patients’ self-efficacy, feelings regarding HL screening’s usefulness, and glycemic control.

RESULTS: Intervention physicians were more likely than control physicians to use management strategies recommended for patients with limited HL (OR 3.2, P=.04). However, intervention physicians felt less satisfied with their visits (81% vs 93%, P=.01) and marginally less effective (38% vs 53%, P=.10). Intervention and control patients’ post-visit self-efficacy scores were similar (12.6 vs 12.9, P=6). Sixty-four percent of intervention physicians and 96% of patients felt HL screening was useful.

CONCLUSIONS: Physicians are responsive to receiving notification of their patients’ limited HL, and patients support the potential utility of HL screening. However, instituting screening programs without specific training and/or system-wide support for physicians and patients is unlikely to be a powerful tool in improving diabetes outcomes.

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References

  1. Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academics Press; 2004.

    Google Scholar 

  2. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs AMA. Health literacy: report of the Council on Scientific Affairs. JAMA. 1999;281:552–7.

    Article  Google Scholar 

  3. Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995;274:1677–82.

    Article  PubMed  CAS  Google Scholar 

  4. Gazmararian JA, Baker DW, Williams MV, et al. Health literacy among Medicare enrollees in a managed care organization. JAMA. 1999;281:545–51.

    Article  PubMed  CAS  Google Scholar 

  5. Berkman ND, DeWalt DA, Pignone MP, et al. Literacy and Health Outcomes. Rockville, MD: Agency for Healthcare Research and Quality; 2004.

    Google Scholar 

  6. Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003;51:267–75.

    Article  PubMed  Google Scholar 

  7. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288:475–82.

    Article  PubMed  Google Scholar 

  8. Spandorfer JM, Karras DJ, Hughes LA, Caputo C. Comprehension of discharge instructions by patients in an urban emergency department. Ann Emerg Med. 1995;25:71–4.

    Article  PubMed  CAS  Google Scholar 

  9. Williams MV, Baker DW, Honig EG, Lee TM, Nowian A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114:1008–15.

    PubMed  CAS  Google Scholar 

  10. Kalichman SC, Benotsch E, Suarez T, Catz S, Miller J, Rompa D. Health literacy and health-related knowledge among persons living with HIV/AIDS. Am J Prev Med. 2000;18:325–31.

    Article  PubMed  CAS  Google Scholar 

  11. Kalichman SC, Rompa D, Cage M. Reliability and validity of self-reported CD4 lymphocyte count and viral load test results in people living with HIV/AIDS. Int J STD AIDS. 2000;11:579–85.

    Article  PubMed  CAS  Google Scholar 

  12. Arnold CL, Davis TC, Berkel HJ, Jackson RH, Nandy I, London S. Smoking status, reading level, and knowledge of tobacco effects among low-income pregnant women. Prev Med. 2001;32:313–20.

    Article  PubMed  CAS  Google Scholar 

  13. Baker DW, Parker RM, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997;87:1027–30.

    PubMed  CAS  Google Scholar 

  14. Kalichman SC, Rompa D. Functional health literacy is associated with health status and health-related knowledge in people living with HIV-AIDS. J Acq Immun Defic Syndr. 2000;25:337–44.

    Article  CAS  Google Scholar 

  15. Baker DW, Parker RM, Williams MV, Clark WS. Health literacy and the risk of hospital admission. J Gen Intern Med. 1998;13:791–8.

    Article  PubMed  CAS  Google Scholar 

  16. Baker DW, Gazmararian JA, Williams MV, et al. Functional health literacy and the risk of hospital admission among medicare managed care enrollees. Am J Public Health. 2002;92:1278–83.

    Article  PubMed  Google Scholar 

  17. Schillinger D, Bindman A, Stewart A, Wang F, Piette J. Functional Health Literacy and the quality of physician-patient communication among diabetes patients. Patient Educ and Counsel. 2004;52:315–23.

    Article  Google Scholar 

  18. Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med. 1999;14:267–73.

    Article  PubMed  CAS  Google Scholar 

  19. Bass PF III, Wilson JF, Griffith CH, Barnett DR. Residents’ ability to identify patients with poor literacy skills. Acad Med. 2002;77:1039–41.

    Article  PubMed  Google Scholar 

  20. Lindau ST, Tomori C, Lyons T, Langseth L, Bennett CL, Garcia P. The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. Am J Obstet Gynecol. 2002;186:938–43.

    Article  PubMed  Google Scholar 

  21. Mayeaux EJ Jr, Murphy PW, Arnold C, Davis TC, Jackson RH, Sentell T. Improving patient education for patients with low literacy skills. Am Fam Physician. 1996;53:205–11.

    PubMed  Google Scholar 

  22. Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med. 1996;5:329–34.

    Article  PubMed  CAS  Google Scholar 

  23. Doak CC, Doak LG, Friedell GH, Meade CD. Improving comprehension for cancer patients with low literacy skills: strategies for clinicians. CA. 1998;48:151–62.

    PubMed  CAS  Google Scholar 

  24. Weiss BD, Hart G, McGee DL, D’Estelle S. Health status of illiterate adults: relation between literacy and health status among persons with low literacy skills. J Am Board Fam Pract. 1992;5:257–64.

    PubMed  CAS  Google Scholar 

  25. Bennett IM, Robbins S, Al-Shamali N, Haecker T. Screening for low literacy among adult caregivers of pediatric patients. Fam Med. 2003;35:585–90.

    PubMed  Google Scholar 

  26. Hospital Provision of Care, Treatment, and Services Crosswalk, Vol. 2004. Washington, DC: Joint Commission on Accreditation of Healthcare Organizations; 2004.

  27. Bass PF III, Wilson JF, Griffith CH. A shortened instrument for literacy screening. J Gen Intern Med. 2003;18:1036–8.

    Article  PubMed  Google Scholar 

  28. Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588–94.

    PubMed  Google Scholar 

  29. Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA. The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management. J Gen Intern Med. 2002;17:243–52.

    Article  PubMed  Google Scholar 

  30. Heisler M, Vijan S, Anderson RM, Ubel PA, Bernstein SJ, Hofer TP. When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make? J Gen Intern Med. 2003;18:893–902.

    Article  PubMed  Google Scholar 

  31. Aljasen LI, Peyrot M, Wissow L, Rubin RR. The impact of barriers and self-efficacy on self-care behaviors in type 2 diabetes. Diabetes Educ. 2001;27:393–404.

    Google Scholar 

  32. Piette JD, Schillinger D, Potter MB, Heisler M. Dimensions of patient-provider communication and diabetes self-care in an ethnically diverse population. J Gen Intern Med. 2003;18:624–33.

    Article  PubMed  Google Scholar 

  33. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease: a study of patients with hypertension and diabetes. Arch Intern Med. 1998;158:166–72.

    Article  PubMed  CAS  Google Scholar 

  34. Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288:2469–75.

    Article  PubMed  Google Scholar 

  35. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84:191–215.

    Article  PubMed  CAS  Google Scholar 

  36. Lipkin M, Putnam SM, Lazare A. The Medical Interview: Clinical Care, Education, and Research. New York: Springer-Verlag, 1995.

    Google Scholar 

  37. Alazri MH, Neal RD. The association between satisfaction with services provided in primary care and outcomes in Type 2 diabetes mellitus. Diabetes Med. 2003;20:486–90.

    Article  CAS  Google Scholar 

  38. Pernandez A, Schillinger D, Grumbach K, et al. Physician language ability and cultural competence: an exploratory study of communication with Spanish-speaking patients. J Gen Intern Med. 2004;19:167–74.

    Article  Google Scholar 

  39. Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Counseling. 1996;27:33–9.

    Article  CAS  Google Scholar 

  40. Baker DW. Reading between the lines: deciphering the connections between literacy and health [editorial; comment]. J Gen Intern Med. 1999;14:315–7.

    Article  PubMed  CAS  Google Scholar 

  41. Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83–90.

    Article  PubMed  Google Scholar 

  42. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Counseling. 1999;38:33–42.

    Article  CAS  Google Scholar 

  43. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10:537–41.

    Article  PubMed  CAS  Google Scholar 

  44. Nurss JR, Parker RM, Williams MV, Baker DW. TOFHLA: test of functional health literacy in adults. Snow Camp, NC: Peppercorn Books & Press; 1995.

    Google Scholar 

  45. Doak CC, Doak LG, Root JH. Teaching Patients with Low Literacy Skills. Philadelphia, Pa: JB Lippincott; 1996.

    Google Scholar 

  46. Keyserling TC, Samuel-Hodge CD, Ammerman AS, et al. A randomized trial of an intervention to improve self-care behaviors of African-American women with type 2 diabetes: impact on physical activity. Diabetes Care. 2002;25:1576–83.

    Article  PubMed  Google Scholar 

  47. Houts PS, Bachrach R, Witmer JT, Tringali CA, Bucher JA, Localio RA. Using pictographs to enhance recall of spoken medical instructions. Patient Educ Counseling. 1998;35:83–8.

    Article  CAS  Google Scholar 

  48. Williams MV, Davis T, Parker RM, Weiss BD. The role of health literacy in patient-physician communication. Fam Med. 2002;34:383–9.

    PubMed  Google Scholar 

  49. (AHRQ). Strategies for Improving Minority Healthcare Quality. Report No.: Evidence Report/Technology Assessment Number 90, 2004 January.

  50. Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview [see comments]. JAMA. 1997;277:678–82.

    Article  PubMed  CAS  Google Scholar 

  51. Levinson W, Stiles WB, Inui TS, Engle R. Physician frustration in communicating with patients. Med Care. 1993;31:285–95.

    Article  PubMed  CAS  Google Scholar 

  52. Howie JG, Heaney DJ, Maxwell M, Walker JJ. A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations. Fam Pract. 1998;15:165–71.

    Article  PubMed  CAS  Google Scholar 

  53. Barton P, Gurrin L, Sly P. Extending the simple linear regression model to account for correlated responses: an introduction to generalized estimating equations and multi-level mixed modelling. Stat Med. 1998;17:1261–91.

    Article  Google Scholar 

  54. Statistical Analyses System (SAS). Version 8. Gary, NC: SAS Institute Inc.; 1999.

  55. Lobosco AF, Newman DL. Teaching special needs populations and teacher job satisfaction: implications for teacher education and staff development. Urban Educ. 1992;27:21–31.

    Article  Google Scholar 

  56. Rosenberg MS, Griffin CC, Kilgore KL, Carpenter SL. Beginning teachers in special education: a model for providing individualized support. Teacher Educ Spec Educ. 1997;20:301–21.

    Google Scholar 

  57. Rost K, Nutting P, Smith JL, Elliott CE, Dickinson M. Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care. BMJ. 2002;325:934.

    Article  PubMed  Google Scholar 

  58. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136:765–76.

    PubMed  Google Scholar 

  59. Nelson HD, Nygren P, McInerney Y, Klein J. Screening women and elderly adults for family and intimate partner violence: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140:387–96.

    PubMed  Google Scholar 

  60. Saitz R, Horton NJ, Sullivan LM, Moskowitz MA, Samet JH. Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention. The Screening and Intervention in Primary Care (SIP) Study. Ann Intern Med. 2003;138:372–82.

    PubMed  Google Scholar 

  61. Krichbaum K, Aarestad V, Buethe M. Exploring the connection between self-efficacy and effective diabetes self-management. Diabetes Educ. 2003;29:653–62.

    PubMed  Google Scholar 

  62. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd edn. Baltimore, MD: Williams & Wilkins; 1996.

    Google Scholar 

  63. Lachs MS. Screening for family violence: what’s an evidence-based doctor to do? Ann Intern Med. 2004;140:399–400.

    PubMed  Google Scholar 

  64. Grimes DA, Schulz KF. Uses and abuses of screening tests. Lancet. 2002;359:881–4.

    Article  PubMed  Google Scholar 

  65. Roter DL, Russell NK. Validity of physician self-report in tracking patient education objectives. Health Educ Q. 1994;21:27–38.

    PubMed  CAS  Google Scholar 

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Correspondence to Dean Schillinger MD.

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The authors have no conflicts of interest, financial or otherwise, to report for this article or this research.

See editorial by Montori, p. 1071

Dr. Seligman was supported by a DHHS-HRSA Research Fellowship Grant 5 D14HP00178-03-00. Dr. Piette is a VA Research Career Scientist. Dr. Schillinger was supported by a NIH Mentored Clinical Scientist Award K-23 RR16539-03, UCSF Hellman Family Research Award, and a Pfizer Inc. Health Literacy Research Award Electronic data were made available through the San Francisco General Hospital GCRC grant M01RR00083-42.

An erratum to this article is available at http://dx.doi.org/10.1111/j.1525-1497.2005.00309.x.

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Seligman, H.K., Wang, F.F., Palacios, J.L. et al. Physician notification of their diabetes patients’ limited health literacy: A randomized, controlled trial. J GEN INTERN MED 20, 1001–1007 (2005). https://doi.org/10.1111/j.1525-1497.2005.00189.x

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  • DOI: https://doi.org/10.1111/j.1525-1497.2005.00189.x

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