beyond the knife what is health literacy and why is it ...€¦ · 08/08/2019 · possibly...
TRANSCRIPT
Beyond the Knife
What is Health Literacy and Why is it Important?
Daniel I. Chu MD FACS FASCRS
Associate Professor
Department of Surgery
Florida Hospital Association | Thursday August 8 2019
@DChu80 [email protected]
• I do not have any relevant financial relationships with any commercial interest that pertains to the content of my presentation.
Work supported from:
K23 MD013903 NIH Career Development Award (2019-2022)
K12 HS023009 AHRQ Mentored Career Development Award (2017-2019)
James A. Pittman MD Scholar Award (2018-2023)
UAB Health Services Foundation General Endowment Fund (2018-2020)
SSAT Health Disparities Research Award (2016-2018)
VA Office of Health Equity (2017-2018)
ASCRS Medical Student Research Initiation Grant (2017)
Disclosures
1. Define the problem
2. Show why health literacy matters
4. Predict future
3. Share work in Alabama
1. Define the problem
2. Show why health literacy matters
4. Predict future
3. Share work in Alabama
What is health literacy?
The degree to which individuals have the capacity to
obtain, process and understand
basic health information/services to make appropriate health decisions.
Nielsen-Bohlman L, Institute of Medicine . Committee on Health L. Health literacy : a prescription to end confusion. Washington, D.C. :: National Academies Press; 2004.US Department of Human and Health Services. Healthy People 2010: Understanding and Improving Health. In. 2nd ed. Washington, DC: U.S. Government Printing Office; 2000.
Why is health literacy important?
All of this applies in medicine (and in my case, surgery too).
Getting access Analyze risk/benefit Calculate dosages Evaluating credibility NavigatingCommunication Interpret test results
What do any of these words mean?
How do I do this
again?
I’m going home
today!?
I don’t understand anything…
I heal with steel. Discharge!
Sign here.
You need surgery.
Read this.
Where and how do your patients obtain, process and understandhealth information during the surgical journey?
v
Dimensions of health literacy
Print literacy (reading/writing)
Oral literacy(speaking/listening)
Quantitative literacy(numeracy)
https://doi.org/10.2337/diaclin.28.4.171
Technology literacy(operate computer)
Information literacy(obtain and apply)
Visual literacy(understand graphics)
Health literacy is measurable w validated instruments
https://healthliteracy.bu.edu
>133 instruments
1991 REALM1995 TOFHLA1999 S-TOFHLA2004 BHLS (3-item)2005 NVS2006 SILS (1-item)2007 REALM-SF2012 BRIEF (4-item)
Health literacy is measurable w validated instruments
https://healthliteracy.bu.edu
>133 instruments
1991 REALM1995 TOFHLA1999 S-TOFHLA2004 BHLS (3-item)2005 NVS2006 SILS (1-item)2007 REALM-SF2012 BRIEF (4-item)
Measure # of Items Health Lit Levels
S-TOFHLA 40-items (36 prose, 4 num)
BHLS 3-items
1-item (SILS)
4-items (BRIEF)
NVS 6-items
REALM-SF 7-items
* Inadequate, marginal, adequate
http://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf
Major institutional efforts to address health literacy
National Assessment of Adult Literacy (2003 NAAL)
National Assessment of Adult Literacy (NAAL): National Center for Educational Statistics, U.S. Dept. of Education, 2003
Below Basic Basic Intermediate Proficient
Determine time to take medicine based on label.
Determine when okay to drink before a medical test based on short instructions.
Circle date on doctor’s appointment slip.14%
22%
53%
12%Calculate share of health insurance based on table.
N=19,000 adults, 152 tasks (28 health-related)
National Assessment of Adult Literacy (2003 NAAL)
National Assessment of Adult Literacy (NAAL): National Center for Educational Statistics, U.S. Dept. of Education, 2003
Below Basic Basic Intermediate Proficient
12%
N=19,000 adults, 152 tasks (28 health-related)
National Assessment of Adult Literacy (2003 NAAL)
National Assessment of Adult Literacy (NAAL): National Center for Educational Statistics, U.S. Dept. of Education, 2003
Below Basic Basic Intermediate Proficient
N=19,000 adults, 152 tasks (28 health-related)
Nearly 9 of 10 adultshave difficulty using health information in healthcare facilities and the media.
Health Literacy Levels
Proficient
Intermediate
Basic
Below Basic
National Assessment of Adult Literacy (2003 NAAL)
Health Literacy Levels
Proficient
Intermediate
Basic
Below Basic
National Assessment of Adult Literacy (2003 NAAL)
1. Define the problem
2. Show why health literacy matters
4. Predict future
3. Share work in Alabama
Health literacy is a determinant of health outcomes
Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107.
Mortality
HospitalizationsPreventative services
Readmissions
Emergency room visits
Medication adherence
Health literacy is a determinant of health outcomes
Adapted from: Paasche-Orlow MK & Wolf MS (2007). Am J Health Behavior 31 Suppl 1: S19-26.
An Example: Low health literacy and diabetes
https://www.ncbi.nlm.nih.gov/pubmed/12132978
Implications
1. Low health literacy is associated with worse diabetes outcomes (HbA1c)
2. Represents an opportunity for action
An Example: Taking action on health literacy & diabetes
https://www.ncbi.nlm.nih.gov/pubmed/15479936
Intervention• One-on-one counseling by pharmacists • Evidence-based treatment algorithms• Care barriers addressed by care coordinator
• Improved communication techniques• Verbal education• Simplified explanations + pictures• Teach-back
REALM
Data suggests:
1. Health lit-based interventions work2. ↑ benefits for low literacy patients.
Major work on health literacy in non-surgical fields
COPD CHF HIV ESRD Surgery
Current state of health literacy research in surgery
Adjusted Model of Readmission
Patients with possibly inadequate HL are at 53% higher odds of being readmitted as compared to patients with adequate health literacy.
Unadjusted Most Parsimonious*
OR (95% CI) p-value OR (95% CI) p-value
Adequate Ref. Ref
Possibly Inadequate 1.83 (1.23-2.73) 0.003 1.53 (1.01-2.31) 0.04
* Adjusted for Charlson Comorbidity Index, Health Survey Physical Component Score and Mental Component Score at the time of discharge
Low health literacy associated w ↑ readmissions
https://www.ncbi.nlm.nih.gov/pubmed/28979989
Implications:
1. Low health literacy may affect surgical outcomes.2. To improve surgical outcomes, we need to consider
addressing health literacy.
Low health literacy associated w ↑ LOS
Associations of health lit with poor surgical outcomes
0
10
20
30
40
50
60
POCs Organ space infections Prolonged ventilations Readmissions
Limited Marginal Adequate*
*
*
* p<0.05
These data suggest:
1. Low health literacy exists in colorectal patients2. Associated with more post-op complications (POCs)
https://www.ncbi.nlm.nih.gov/pubmed/29710226
Low health literacy associated w ↓ QoL and recovery
Low health literacy associated w ↓ QoL and recovery
https://www.ncbi.nlm.nih.gov/pubmed/29710226
Low health literacy associated w ↓ QoL and recovery
https://www.ncbi.nlm.nih.gov/pubmed/29710226
Low health literacy associated w ↓ QoL and recovery
https://www.ncbi.nlm.nih.gov/pubmed/29710226
Implications:
1. Low health literacy tied to quality of recovery and quality of life2. Addressing health literacy may have effects on patient-centered outcomes
Why should health literacy matter to you?
Valuex Patient Satisfaction
Cost=
Quality x Safety
It is the right thing to do for our patients.
x Equitable carex Health of communitiesx Care experience of patients and providers
1. Define the problem
2. Show why health literacy matters
4. Predict future
3. Share work in Alabama
A Story from Alabama(how we got to health literacy)
https://assets.americashealthrankings.org/app/uploads/2018ahrannual_020419.pdf
"I think it's very uncommon in the FirstWorld. This is not a sight that onenormally sees. I'd have to say that Ihaven't seen this."
Philip Alston
U.N. Special Rapporteur
on extreme poverty and human rights
University of Alabama at Birmingham (UAB)
African-Americans have particularly worse outcomes
Why does this happen… and what can we do about it?
Several studies @ UAB on surgical disparities…
*LOS equal or greater than the 75th percentile for each procedure. Reference group: white patients.https://insights.ovid.com/pubmed?pmid=26501490
Procedure Adjusted OR of Prolonged LOS for Black Patients* Actual Days
Prostatectomy 1.41
+1 dayPancreatectomy 1.25
Colectomy 1.36
Hysterectomy 1.82
Lung Resection 1.52
One type of disparity: length-of-stay
+ 0.4 days longer
https://www.ncbi.nlm.nih.gov/pubmed/28624035
One type of disparity: length-of-stay
The Problem
African-Americans have worse surgical outcomes including LOS.
What is KnownERAS reduces LOS.
HypothesisERAS would reduce racial disparities in LOS.
Goals of ProjectDetermine if and how ERAS reduces surgical disparities.
The thought process…
2010-2014
Pre-ERAS
2015
ERAS
vs.
Post-op LOS
1. LOS disparities eliminated with ERAS2. We weren’t doing something before…
What do ERAS patients experience?
ERAS eliminates racial disparities in post-op LOS
Interview Guides
47 patients6 focus groups
Whiten=23
Blackn=24
AnalysisUsed Grounded TheoryIdentify ThemesAchieve Thematic SaturationDevelop Better UnderstandingInform next steps
1. LOS disparities eliminated with ERAS2. We weren’t doing something before…
What do ERAS patients experience?
47 patients6 focus groups
Whiten=23
Blackn=24
AnalysisUsed Grounded TheoryIdentify ThemesAchieve Thematic SaturationDevelop Better UnderstandingInform next steps
Interview GuidesProcessing
Differences on quality of information
ObtainingVariety of methods
and sources
UnderstandingDependent on the provider(s) & team
Common finding
#1. Patients desired and valued information
But, African-Americans described experiences of:
• Having no expectations about surgery• Being provided inconsistent information• Needing more info on diet/exercise• Relying on family as info sources
1. LOS disparities eliminated with ERAS2. We weren’t doing something before…
What do ERAS patients experience?
But, African-Americans described experiences of:
• Having no expectations about surgery• Being provided inconsistent information• Needing more info on diet/exercise• Relying on family as info sources
ProcessingDifferences on quality
of information
ObtainingVariety of methods
and sources
UnderstandingDependent on the provider(s) & team
Common finding
#1. Patients desired and valued information
Framing an approach to health literacy in surgery…
Identify Understand / Addressing
Adapted from: Paasche-Orlow MK & Wolf MS (2007). Am J Health Behavior 31 Suppl 1: S19-26.
REALM-SFS-TOFHLA
NVS20
17
BRIEF(4-items)2
01
8 1. How often do you have someone help you read hospital materials?2. How often do you have problems learning about your medical condition
because of difficulty understanding written information?3. How often do you have a problem understanding what is told to you about
your medical condition?4. How confident are you filling out medical forms by yourself?
Max 45 secondsMax 7 minutesMax 3 minutes
Average 7 minutes
White
Black
Low health literacy exists in the surgical population…
White
Black
Low health literacy exists in the surgical population…
Literacy in surgical pts varies by race, sex and age…
These data suggest:
1. Low health literacy exists in IBD patients2. More common in African-Americans 3. Older African-American males with IBD may be at
particularly high-risk for low health literacy
Literacy in surgical pts varies by race, sex and age…
Red flags for individuals w/ low health literacy
Menendez, van Hoorn, Mackert. Clin Orthop Relat Res. 2017
Are trying not to act dumb
Vacant lookIncomplete forms
Missed appointments“I don’t have my glasses.”
“I’ll go home and read this.”Lack of follow-up with referrals
Ask fewer (or no) questionsCannot give coherent, sequential history
Health Literacy and Patient Safety: Help Patients Understand – A Manual for Clinicians. 2nd edition. Chicago: AMA Foundation and AMA, 2007. www.ama-assn.org/ama1/pub/upload/mm/367/healthclinicians.pdf
Adapted from: Paasche-Orlow MK & Wolf MS (2007). Am J Health Behavior 31 Suppl 1: S19-26.
Identify Understand / Addressing
Framing an approach to health literacy in surgery…
Adapted from: Paasche-Orlow MK & Wolf MS (2007). Am J Health Behavior 31 Suppl 1: S19-26.
Identify Understand / Addressing
Framing an approach to health literacy in surgery…
System-Level: Readability of surgery education material
System-Level: Readability of surgery education material
Methods
Understandability Actionability
System-Level: Readability of surgery education material
• Instead try: Hard (3.4), Heavy lifting (8.4)
“Strenuous” 21 FKGL
• Instead try: Put you to sleep (2.2)
“Anesthesia” 26 FKGL
• Instead try: Pain meds (3)
“Narcotic” 22 FKGL
• Instead try: Scar (2)
“Incision” 17 FKGL
System-Level: Intervening on Health Ed/Readability
https://ww2.mc.vanderbilt.edu/patienteducation/26031
College reading levelWith the onset of nausea, diarrhea or other gastrointestinal disturbances, consult your physician immediately.
12th Grade reading levelIf you experience nausea, diarrhea or other stomach or bowel problems, call your physician immediately.
8th Grade reading levelIf you start having nausea, loose bowel movements or other stomach problems, call your doctor immediately.
4th Grade reading levelIf you start having an upset stomach, loose bowel movements, or other problems, call your doctor right away.
Best – 3rd gradeCall your doctor right away if you have:
- Upset stomach- Loose bowel movements- Other stomach problems.
System-Level: Intervening on Health Ed/Readability
• Use visual aids
• At least 12-point font
• Keep words short (<2 syllables)
• Layout (include white space)
• Keep stem short, petals simple (bullets)
• Include blanks, check-lists
• Get patients to use rather than read it
System-Level: Intervening on Health Ed/Readability
Print Communication
Rating (PCR)
• Use visual aids
• At least 12-point font
• Keep words short (<2 syllables)
• Layout (include white space)
• Keep stem short, petals simple (bullets)
• Include blanks, check-lists
• Get patients to use rather than read it
System-Level: Intervening on Health Ed/Readability
Print Communication
Rating (PCR)
• Use visual aids
• At least 12-point font
• Keep words short (<2 syllables)
• Layout (include white space)
• Keep stem short, petals simple (bullets)
• Include blanks, check-lists
• Get patients to use rather than read it
System-Level: Intervening on Health Ed/Readability
Print Communication
Rating (PCR)
Short stem, simple petals
InteractiveVisual aids
Short words
12-pt font
White space
Simple layout
Using information design to improve written material
System-Level: Intervening on Health Ed/Readability
9.5
6.6
9th
7th
Version 1.0 Version 2.0 Version 3.0
Contrast Alignment Repetition Proximity
Lesson LearnedYou can make print material more understandable.
System-Level: Intervening with Support Technology
Records PROs
Real-time
Engaging
System-Level: Intervening with Support Technology
System-Level: Intervening with Support Technology
System-Level: Intervening with Support Technology
0
20
40
60
80
100
120
Survey 1 Survey 2 Survey 3 Survey 4 Survey 5
Response Rate, n (%)
High Intermediate High Intermediate Low
0
10
20
30
40
50
60
70
Survey 1 Survey 2 Survey 3 Survey 4 Survey 5
Days from Sign-up to Survey Completion
High Intermediate High Intermediate Low
1. Patients with low health literacy use apps.2. May provide a platform for engagement and education.
Adapted from: Paasche-Orlow MK & Wolf MS (2007). Am J Health Behavior 31 Suppl 1: S19-26.
Identify Understand / Addressing
Framing an approach to health literacy in surgery…
“A doctor can make you or break you. They can make you feel like you’re an idiot, and talk above your head.”
This young doctor, he just broke it down so smooth. I can understand a lot of stuff, but he made it so simple.”
“There should’ve been a little bit more education … it’s really just thrown at you at once.”
v
Provider-Level: Barriers and facilitators
Providers are important barriers and
facilitators to adequate understanding.
https://www.nytimes.com/2018/09/05/world/europe/doctors-plain-english.html?action=click&module=Discovery&pgtype=Homepage
• Avoid using words such as “chronic.”
• When describing diagnoses, instead of “renal,” use “kidney.”
• Instead of “acute,” use “sudden” or “short-term.”
• Instead of “atrial fibrillation,” use “irregular pulse.”
Provider-Level: Barriers and facilitators
215.53
197.81
215.42
191.88
150.00
170.00
190.00
210.00
230.00
250.00
Surgeon 1 Surgeon 2 Surgeon 3 Surgeon 4
Ave
rage
Sp
ee
ch R
ate
(w
ord
s/m
in)
Speech Rate by Surgeon
79.88
81.28
74.06
79.41
70.00
72.00
74.00
76.00
78.00
80.00
82.00
Surgeon 1 Surgeon 2 Surgeon 3 Surgeon 4
Ave
rage
Fle
sh K
inca
id E
ase
Sco
re
Flesh Kincaid Ease Score by Surgeon
4.00
4.624.89
0.00
1.00
2.00
3.00
4.00
5.00
6.00
Limited Marginal Adequate
Ave
rage
Pat
ien
t U
nd
ers
tan
din
g
Patient Understanding by Health Literacy
328.50
667.46720.34
0.00
100.00
200.00
300.00
400.00
500.00
600.00
700.00
800.00
Limited Marginal Adequate
Ave
rage
Le
ngh
t o
f V
isit
(se
con
ds)
Average Length of Visit by Health Literacy
• Teach-back or show-back
• Tell me your understanding
• How will you describe this to your family?
• Ask Me 3 ® (aim to answer these questions)
• What is my main problem? [diagnosis]
• What do I need to do? [treatment]
• Why is it important that I do this? [benefits/context]
• Slow down
• Use plain language, pictures and teaching tools
Avoid askingDo you understand?
Do you have any questions?
Provider-Level: Intervening on Communication
Adapted from: Paasche-Orlow MK & Wolf MS (2007). Am J Health Behavior 31 Suppl 1: S19-26.
Identify Understand / Addressing
Framing an approach to health literacy in surgery…
1. Define the problem
2. Show why health literacy matters
4. Predict future
3. Share work in Alabama
Equip each level of surgical care with best-evidence health literacy practices
Optimize education material
Teach-back,Improve consent
Improve discharge process
Targeted follow-up
Improve family updates
Health literacy matters and opportunities exist to make our care of patients and families more health literate.
Takehome Point
Why should health literacy matter to you?
Valuex Patient Satisfaction
Cost=
Quality x Safety
It is the right thing to do for our patients.
x Equitable carex Health of communitiesx Care experience of patients and providers
http://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf
Why Else Does It Matter? Health Disparities…
To reduce health disparities among Americans
To eliminate health disparities
http://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf
To achieve health equity, eliminate disparities, and improve the health… of ALL groups
Why Else Does It Matter? Health Disparities…
• Low health literacy is common in the population
• Health literacy plays a role in health outcomes and experiences
Health literacy matters and opportunities exist to make our care of patients and families more health literate.
Summary Points
Bottom Line
Keep it simple Teach-back method Visual aids