beyond the knife what is health literacy and why is it ...€¦ · 08/08/2019 · possibly...

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

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)

https://doi.org/10.2337/diaclin.28.4.171

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)




12%






Nearly 9 of 10 adultshave difficulty using health information in healthcare facilities and the media.

Health Literacy Levels

Proficient

Intermediate

Basic

Below Basic




4. Predict future


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


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


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)


Low health literacy associated w ↓ QoL and recovery



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



4. Predict future


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


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



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



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


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…

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

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.


• 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


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


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



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.

“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



4. Predict future


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


Why Else Does It Matter? Health Disparities…


To reduce health disparities among Americans

To eliminate health disparities


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

Questions?

[email protected]

@DChu80

beyond the knife what is health literacy and why is it ...€¦ · 08/08/2019 · possibly...

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