EducationCan Screening Items Identify Surgery Patients at Risk of Limited Health Literacy?
Introduction
Recent reports issued by the Institute of Medicine, American Medical Association Foundation, and Agency for Healthcare Research and Quality show that nearly half of all English-speaking adults lack the literacy skills needed to fully understand and act on medical information [1, 2, 3]. Individuals with limited literacy skills have poorer health-related outcomes [4, 5], less disease-based knowledge [6, 7, 8], higher health care costs [9, 10], more hospitalizations [11], poorer communication with physicians [12], and more difficulty reading prescription labels [13, 14] than those with adequate literacy skills. Among patients undergoing ambulatory surgery, those with inadequate health literacy skills (HLS) were less likely to adhere to preoperative medication instructions compared with patients with adequate HLS [15].
Although a large number of patients have limited HLS, identifying those at greatest risk during routine clinical encounters is challenging. Patients with limited HLS harbor a tremendous amount of shame [16, 17] and, perhaps because of this, go to great lengths to hide their inability to read. Simply asking patients about educational attainment does not accurately predict reading ability, since it is not unusual for individuals to read several grade levels lower than the highest grade completed [18]. Furthermore, both resident [7, 19, 20] and attending [21] physicians tended to overestimate patients’ actual literacy levels based on information discussed during the clinical encounter.
Valid and reliable health literacy assessment instruments are available [22, 23, 24, 25]; however, the time required to administer these tools precludes their use in busy clinical settings. Accordingly, Chew et al. [26] developed and tested the performance of screening items for detecting inadequate HLS in a preoperative Veterans’ Administration (VA) population. Wallace et al. [27] subsequently administered Chew’s screening items in a sample of primary care patients and found them to be predictive of patients’ HLS. The purpose of this study was to provide further evidence of the utility of these screening items [26] in identifying patients with limited or marginal HLS in the vascular surgery setting. A study such as this one is especially important because patients typically do not have an on-going, established relationship with their vascular surgeon, making communication paramount to the foundation of the patient-surgeon relationship. Easier identification of patients likely to have poor HLS may potentially prevent costly and dangerous misunderstandings between patients and their surgeons.
Section snippets
Setting and Study Sample
This cross-sectional study was nested in an on-going, descriptive patient-surgeon communication project. We recruited a convenience sample of English-speaking patients (≥21 years of age) attending a university-based vascular surgery clinic for an initial consultation. Patients were considered ineligible if the research assistant identified him/her as having at least one of the following conditions: (1) inability to speak English, (2) severely impaired vision, (3) severely impaired hearing, (4)
Results
Demographic characteristics of the study sample (n = 100) are summarized in Table 1. Patients ranged in age from 22 to 89 years (mean age = 62.0 ± 12.9), 65 were female and 64 were currently married. Patients’ HLS were as follows: limited (n = 18), marginal (n = 21), and adequate (n = 61).
Individual and combinations of 2 and 3 health literacy screening items had significant AUROC curves for detecting limited and limited/marginal HLS (Table 2). However, combinations of 2 and 3 health literacy
Discussion
Similar to national estimates of adults’ HLS [31], one-third of patients in our study had limited or marginal HLS. Because patients with inadequate HLS are at increased risk for a wide array of poor medical-related consequences [1, 2, 3], identifying those with limited or marginal HLS is paramount in improving patient-surgeon communication. Given the nature of surgical practice, with the surgeon usually a consultant whose role with the patient is limited to the referral problem, initial
Acknowledgments
The authors thank Beth Littmann, B.S., and Lindsay M. Newman, M.P.H., M.S.N., for assisting with data collection for this study.
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