Darren A. DeWalt, MD, MPH Assistant Professor of Medicine

1. Addressing Health Literacy: Critical to Good Health Outcomes Darren A. DeWalt, MD, MPH Assistant Professor of Medicine University of North Carolina School of Medicine December 11, 2008

2. Patient Centered Medical Home • Patient centered requires understanding the skills and desires of the patient • Medical home implies seamless and supportive care that is coordinated • Helping the individual patient thrive • Health literacy is at the center of PCMH

3. Summary • What is health literacy? • Literacy in America • Literacy and health outcomes • Strategies to address low health literacy

4. Health Literacy “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Healthy People 2010

5. How Well Do We Read and Write?

6. National Assessment of Adult Literacy (NAAL) n = 19,714 ● Most up to date portrait of literacy in U.S. ● Scored on 4 levels ● Lowest 2 levels cannot: ◦ Use a bus schedule or bar graph ◦ Explain the difference in two types of employee benefits ◦ Write a simple letter explaining an error on a bill National Center for Education Statistics, U.S. Department of Education

7. 2003 National Assessment of Adult Literacy 13% 14% Below Basic Proficient 29% Basic 44% Intermediate Basic or Below Basic 52% of H.S. Grads 61% of Adults ≥ 65 93 Million Adults have Basic or Below Basic Literacy

8. Inadequate Literacy Increases with Age Slide by Terry Davis, PhD

10. Video • It’s hard to be a patient

11. Relationship between Literacy and Health Outcomes

12. Health Outcomes Associated with Literacy • Health Outcomes/Health Services • General health status • Hospitalization • Prostate cancer stage • Depression • Asthma • Diabetes control • HIV control • Mammography • Pap smear • Pneumococcal immunization • Influenza immunization • STD screening • Cost • Mortality • Behaviors Only • Substance abuse • Breastfeeding • Behavioral problems • Adherence to medication • Smoking • Knowledge Only • Birth control knowledge • Cervical cancer screening • Emergency department instructions • Asthma knowledge • Hypertension knowledge • Prescription labels DeWalt, et al. JGIM 2004;19:1228-1239

13. 4 3 2 1.7 1.5 1 1.2 0.7 0 < 3rd 4th-6th 7th-8th >9th Asthma Patients with Low Literacy have Poorer Metered Dose Inhaler (MDI) Skills Mean MDI Score 0 - 4 Williams et al. Chest 1998, 114(4):1008-1015.

14. Adult Hospitalization • People with low literacy have 30-70% increased risk of hospitalization • RR = 1.29 (1.07-1.55) Medicare Managed Care • RR = 1.69 (1.13-2.53) Urban Public Hospital *Adjusted for age, gender, socioeconomic status, health status, and regular source of care. Baker et al. AJPH. 2002. 92:1278. Baker et al. JGIM. 1998. 13:791.

15. Can Patients Comprehend Rx Drug Warning Labels? Davis et al. JGIM 2006; 21: 847-851

16. Simple Familiar Wording Understood by Most Patients 84% (1st grade.) Slide by Terry Davis

17. More Complex Message Limited Comprehension 59% (10th-12th grade.) Slide by Terry Davis

18. Unfamiliar Multi-step Instructions Rarely Understood 8% (12th-13th grade) Slide by Terry Davis

19. Comprehension Increased with Patient Literacy Level * p<.0001, †p<.05 <67-8>9 79% 86% 88% † 35% 66% 78% * 8% 64% 82% * 8% 18% 23% * 0% 6% 15% * In multivariate analysis only literacy and age predicted comprehension. Patients with low literacy (< 6th gd.) 3x more likely to incorrectly interpret warning labels. Davis et al. JGIM 2006; 21:847–851.

20. What does this picture mean? • “Someone swallowed a nickel” • “Indigestion” • “Bladder” • “Looks like a ghost- Casper” Slide by Terry Davis

21. “Show Me How Many Pills You Would Take in 1 Day” John Smith Dr. Red Take two tablets by mouth twice daily. Humibid LA 600MG 1 refill

22. Rates of Correct Understanding vs. Demonstration “Take Two Tablets by Mouth Twice Daily” 89 84 80 71 63 35

23. Video • It’s easy to make a mistake

24. Many things we assume people understand, they don’t.And, health outcomes are affected.

25. We have a problem and must alter systems of care • The complexity of the care system exacerbates literacy vulnerabilities • All aspects of our system can raise barriers • Appointments and referrals • Getting tests done • Paying for medicine or treatment • Understanding bills and insurance

26. The Continuum of Confusion: “Now go home and safely manage your care” PP=Prior to seeing physician

27. Skills Needed by Patient • Read • Remember • Implement • Figure out complex processes • Relentlessly pursue….

28. What Works?

29. Improving Written Health Information • Most materials written well above the average literacy of the population • Guidelines available for better clear written health information • Any letter or form we send to patients should be vetted by experts in our health system

30. All members of team: physicians, nurses, social workers, PT/OT, dentists, nutrition, health educators, phone room, front desk staff Principles of Clear Communication Limit number of points Write them down Avoid using jargon (would your mother understand?) Teach-back method Improving Communication

31. Teach-back Explain Assess Clarify Understanding

32. Ask Me 3 • What is my main problem? • What do I need to do? • Why is it important for me to do this?

33. Changing Systems of Care • Redesign how care is provided • Simplify care tasks • Make care seamless and organized • Integrate a well-trained workforce

34. Examples of System Changes

35. Planned Care Intensive Self-care Education Usual Care compared to Rothman et al. Am J Med 2005; 118:276-284. DeWalt et al. BMC Health Services Research. 6:30; 2006.

36. Heart Failure 47% lower hospitalization rate for those in planned care DeWalt et al. BMC Health Services Research. 6:30; 2006.

37. Diabetes Rothman et al. Am J Med 2005; 118:276-284.

38. Results According to Literacy Status

39. Diabetes Control: Results for Patients with Literacy Above 6th Grade Level Rothman et al. JAMA 2004, 292(14):1711-1716.

40. Diabetes Control: Results for Patients with Literacy at or Below 6th Grade Level Rothman et al. JAMA 2004, 292(14):1711-1716.

41. Patient Centered Medical Home • Success requires us to apply the principles we tested in diabetes and heart failure to all patients and all problems • This requires all staff to attend to the needs of individuals • Clear and helpful communication will help us to achieve this goal

42. Summary • Low health literacy is common and we need to consider patient understanding every time • Take health literacy into account for every initiative we do in clinic • Today: Think about whether your patient understands. Write it down for the patient. Ask them to tell you back (when appropriate).