Health Literacy A Prescription to End Confusion (2004) / Chapter Skim
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Appendix B: Commissioned Papers
Appendix B: Commissioned Papers
Pages 255-300
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B Commissioned Papers CONTENTS The Relationship Between Health Literacy and Medical Costs David H Howard 256 Improving Chronic Disease Care for Populations with Limited Health Literacy Dean Schillinger 267 Outside the ClinicianPatient Relationship: A Call to Action for Health Literacy Barry D
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Multivariate techniques are used to adjust for underlying differences in respondents' characteristics. Data Description Health literacy data were collected as part of a survey of persons enrolling in a Prudential Medicare health maintenance organization between December of 1996 and August of 1997 in one of four locations: Cleveland, Ohio; Houston, Texas; South Florida (including Fort Lauderdale, Miami, and nearby areas)
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population of health-care consumers. The first column of the table presents summary statistics for the 3,260 responders, the second for the 3,245 nonresponders, and the third for participants of comparable age in the household component of the 1997 Medical Expenditure Panel Survey (MEPS)
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Persons with inadequate health literacy had lower incomes and fewer years of schooling. More Caucasian subjects had adequate than inadequate health literacy, while more African Americans and Spanish-speaking Hispanics had inadequate health literacy.
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and chronic condition indicators, were higher in those with inadequate health literacy, indicating worse health status overall. Somewhat surprisingly, persons with inadequate health literacy are less likely to smoke or have smoked previously and less likely to consume alcohol.
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These are constructed by computing predicted probabilities from the first stage and then multiplying these predicted probabilities by the exponentiated second-stage predicted values and a "smearing factor" (Duan, 1983) , which is needed to transform logged dollars back to constant dollars, and averaging the predicted spending levels over the entire sample.
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. Controlling for health status, predicted inpatient spending for persons with inadequate health literacy is about $450 higher than that of persons with adequate health literacy.
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In contrast to the results for inpatient spending, the predicted outpatient spending level from the basic model for persons with adequate health literacy is higher than the predicted value for persons with inadequate health literacy. Predicted spending on emergency room care is lower for persons with adequate health literacy, while the predicted values for pharmacy spending from the basic model are comparable.
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It would be incorrect in such a case to attribute the costs associated with post-stroke care to illiteracy, since the stroke caused illiteracy and not the other way around. Controlling for health status, as is done in the extended model, removes the effect of health on health literacy but also removes the effect of health literacy on disease incidence, leading to estimates of the impact of health literacy on spending that are systematically lower than the true effect.
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Results were sensitive to the inclusion of controls for health status, and the confidence intervals around predicted inpatient spending from the basic model overlapped by a small amount. Although it is impossible to prove causality, future studies should take advantage of statistical methods, such as propensity score estimators (Coyte et al., 2000; Rubin, 1997)
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1995. The Test of Functional Health Lit eracy in Adults: A new instrument for measuring patients' literacy skills.
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1994. Illit eracy among Medicaid recipients and its relationship to health care costs.
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-- George Bernard Shaw Introduction Chronic disease management is one of the major challenges facing health-care systems and patients in industrialized nations. Nearly threequarters of all health-care resources are devoted to the treatment of chronic diseases, and nearly one-half of the U.S.
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use the Chronic Care Model to consider opportunities to reduce health literacy-related disparities, and (4) reflect on strategies to develop qualityof-care indicators to promote improvement in chronic disease care for patients with limited health literacy.
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; a clinic that restructures its care delivery through multidisciplinary teams, planned visits, or home visits; or a practice that uses disease registries to track patients' progress, stratify intensity of care, promote outreach, and maintain continuity -- all would represent efforts consistent with the Chronic Care Model. Focusing on these components could foster interactions between patients Community Health System Resources and Policies Organization of Health Care Self-management Decision Delivery Clinical Support Support System Information Design Systems Informed, Prepared, Productive Activated Proactive Interactions Patient Practice Team Functional and Clinical Outcomes FIGURE B-1 Model for improvement of chronic illness care.
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. The Chronic Care Model and similar comprehensive, population-based disease management approaches may offer insights into the ways in which limited health literacy affects chronic disease care and identify potential points of intervention.
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Communication about chronic diseases during outpatient visits may be hampered by several factors. These include the relative infrequency and brevity of visits, language barriers and limited literacy, differences between providers' and patients' agendas and communication styles, lack Social Policy Health Health Policy/Incentives Enhanced Policy/Incentives Community Factors Improved · Access Expanded Provider-Patient · health coverage Home-Based Communication · provider availability Monitoring and · Economic Resources Clinical Support · Interactive, · Adult Education Participatory · Patient and Family · Environmental: Communication Empowerment · nutrition · Open Discussion of · Good Self-Management · air quality Explanatory Models Practices · physical activity · Collaborative Goal · Learning and Skill-Based · safety Setting Registries · occupational risks · Patient Recall and · Decision Support and · Trust in Health System Comprehension of Problem-Solving Skills · Power and Advocacy Advice and Instructions · Ability to Navigate System · Public Health Messages/ · Understanding of and Self-Advocate Health Promotion Disease Processes and · Maintaining Continuity Activities Treatment Options in Communication · Trust · Self-Efficacy Improved Clinical Outcomes and Better Quality of Life FIGURE B-2 Improving chronic disease care: a framework based on health literacy and related research.
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A recent study among patients with diabetes demonstrated that those patients with limited health literacy (as measured by the Short Test of Functional Health Literacy in Adults [S-TOFHLA] [Nurss et al., 1995]
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. Focus groups of patients with limited health literacy have identified health system navigation (finding resources within the health system, such as knowing whom, for
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indicate that patients with limited health literacy comprise a large sector of patients in public hospitals and community clinics that predominantly serve socioeconomically disadvantaged populations, and in private health systems that serve the elderly or those with low incomes, such as Medicare and Medicaid managed care organizations. Little work has been done exploring the relationship between limited health literacy and neighborhood characteristics, particularly those of direct relevance to chronic disease management.
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If we apply the Chronic Care Model without also attending to the unique challenges to chronic disease management posed by limited health literacy, we may improve care for many but run the risk of perpetuating disparities in outcomes for those with limited health literacy. In order to engage in more productive interactions with patients who have limited health literacy, solutions must primarily affect the nature, quality, and extent of communication.
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If all patients with chronic diseases are to benefit from emerging technologies, particularly interventions that involve the Internet, research must explore how to best design such programs for patients with limited health literacy (Robert Wood Johnson Foundation and the National Cancer Institute, 2002)
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. Measuring Progress In order to promote progress in chronic care delivery for patients with limited health literacy, quality-of-care measures must be designed to capture health literacy-related performance.
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A second approach is to develop novel measures of quality that may be less disease-specific, yet have particular relevance to patients with limited health literacy across chronic conditions. To our knowledge, relatively little work has been done in this regard.
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In order to ensure that the Chronic Care Model and increasingly sophisticated chronic disease management programs can benefit patients with limited health literacy, attention must be paid to tailor design and implementation with the involvement of patients with limited health literacy, and to expand the reach of such programs. By promoting meaningful, collaborative communication between patients and the providers and systems that serve them, such a reorganization is likely to benefit all patients with chronic diseases.
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2003. Brief questions to detect inadequate health literacy among VA patients.
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1998. Improving comprehension for cancer patients with low literacy skills: Strategies for clinicians.
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1999. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: A randomized trial.
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1998. Chronic disease management: What will it take to improve care for chronic illness?
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1992. Health status of illiterate adults: Relation between literacy and health status among persons with low literacy skills.
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Medicare's costs are heavily influenced by limited health literacy because of the high rate of limited literacy skills among elderly individuals. According to the Centers for Medicare and Medicaid Services, around 35 million persons over 65 years old currently receive Medicare benefits, and the number of beneficiaries increases annually (Figure B-3)
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Advocacy Organizations · Advocacy organizations for the elderly could provide health education courses and classes on common health problems of older persons, specifically designed for seniors with limited literacy skills. · Professional advocacy organization could create a nationwide corps of volunteer physicians and other health professionals to teach health education and prevention topics in elementary and secondary schools across the nation.
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Others · Assisted living centers for the elderly could provide health education videotapes for residents to view in their homes. · Health education messages could be displayed on the inside or bathroom stall doors in all public restrooms.
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, which indicate that 80 percent of persons over 65 have limited literacy skills, one can estimate that about 80 percent of Medicare beneficiaries -- 32 million individuals -- have limited literacy skills. Thus, most of the $240 billion annual Medicare expenditures are related to providing benefits for persons with limited literacy.
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Subjects in the study who indicated that their preferred language for reading was Spanish had their literacy skills assessed in Spanish, and their average reading level was at grade level 3.1. The limited literacy skills of Medicaid enrollees are associated with high health-care costs.
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Employers Business leaders have long recognized the need for literacy enhancement in the workforce, as workers' limited literacy skills often interfere with productivity and safety (Rockefeller Foundation Conference Proceedings, 1989)
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. To the extent that improving literacy skills will reduce health-care costs, employers would benefit substantially from initiatives that improve worker literacy.
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Given the very high rate of limited literacy among older individuals, and relationship of those limited literacy skills to health status, health-care
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. Limited literacy is one such obstacle, and the Mexican American Legal Defense and Educational Fund could participate in efforts to enhance literacy and health literacy skills of Hispanics.
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and the National Urban League. The National Medical Association, the organization that
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Other Organizations and Systems There are many other organizations and systems that provide services to groups with high rates of limited literacy. Among these are prison systems and social service agencies that work with undereducated individuals.
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Professional Associations Finally, professional associations representing health-care providers have an interest in assuring and improving health and health care for individual patients. With evidence showing that limited literacy skills are associated with poorer health status, all professional associations representing
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Persons with limited general and health literacy, on average, have poorer health knowledge, poorer health status, and higher health-care costs than do persons with higher-level literacy skills. The relationship between limited literacy and poorer health and higher costs is strong and independent of other socioeconomic factors.
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For example, because limited literacy skills are so common among the elderly, most of Medicare's $240 billion annual budget goes to providing care for persons with limited literacy. Employers, especially those that employ large numbers of undereducated service and production workers, also have a stake in health literacy.
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2004. Relationship between health care costs and very low literacy skills in a medically needy and indigent Medicaid population.
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