Health Literacy Research: Opportunities to Improve Population Health. Panel for the 4 th Annual Health Literacy Research Conference
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1 Health Literacy Research: Opportunities to Improve Population Health Panel for the 4 th Annual Health Literacy Research Conference
2 Conflict of Interest Dr. Sanders chairs a scientific board for Mercurian,, Inc., which is developing patient portals for families of children with chronic conditions. The Panelists have no other conflicts of interest to disclose
3 Goals 1. Review the associations between HL and population health outcomes. 2. Explore policy-relevant strategies to address literacy-sensitive health inequities. 3. Discuss implications for health system reform.
4 Our Panel Lee M. Sanders, MD, MPH Stanford University Diane Levin-Zamir Zamir,, PhD, MPH Clalit Health Services, Tel Aviv, Israel Jean Rafael, MD, MPH Baylor College of Medicine Joseph Selby, MD, MPH Patient Centered Research Institute
5 Questions 1. How can health literacy research best guide efforts to reduce health disparities? 2. How can health literacy research best guide efforts to improve the effectiveness and efficiency of health-care systems?
6 1. Review the associations between HL and population health outcomes. 2. Explore policy-relevant strategies to address literacy-sensitive health inequities. 3. Discuss implications for health system reform.
7 Aliyah PMH: Down syndrome, prematurity (ex week), chronic lung disease, GERD, gastrostomy tube Social Hx: Unemployed mother with limited English proficiency; recently divorced; 2 other children; no preschool / child care. Problem: Mother gets conflicting instructions from GI, pulmonary, cardiology, nutritionist, speech pathology, and school nurse. How can HL research help solve a problem like Aliyah s?
8 Health Literacy Framework Skills / ability Health Literacy Demands / complexity Parker, Ruth. WHCA Health Literacy Action Guide 2009.
9 Health Literacy Skills US adult population (millions) Below Basic Basic Intermediate Proficient Below Basic Skills Use the dosage chart on over-the the-counter medicine. Understand an appointment slip. Enter names / DOB on health insurance form 78 million (36%) Basic Skills Interpret a growth chart Follow a prescription to take medicine on an empty stomach Determine when a child s next vaccine is due, using a CDC vaccine schedule
10 Health Information Complexity Health Websites 10th-grade Insurance Enrollment 10 grade (7 12 ) v Patient handouts 10 -grade (6th - 16th) Medication Labels 8 -grade US Adult Reading Level 8 -grade (median) Vaccine information 7 -grade (5-10 th 16th) ii,iii,iv,vi,vii th ) viii,ix [i] D Allesandro DM, et al [ii] Davis TC, et al [iii] Arnold CL, et al [iv] Farrell M, et al [v] Sanders L, et al [vi] Davis TC, et al [vii] Davis TC, et al. 1990;31: [viii] IPV.txt; ; [x] Lokker,, et al Public Health Malpractice? Roter D 2008
11 Poor Health Outcomes Associated with Low Adult Health 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 DeWalt, et al. JGIM 2004;19: Behaviors Substance abuse Violent behavior Breastfeeding Behavioral problems Adherence to medication Smoking Knowledge Birth control knowledge Cervical cancer screening ED instructions Asthma knowledge Diabetes knowledge Hypertension knowledge
12 Poor Child Health Outcomes Associated with Low Parent Literacy Child / Family Health Behaviors Tobacco use* Substance use Decreased breastfeeding* Poor nutritional choices** Adolescent STDs Violence / Injury Maternal / Child Health Outcomes Maternal depression** Injury-prone behaviors* Child developmental / behavioral problems* Worse control of child chronic illness* Family-Centered Medical Home Uninsurance** Increased ED use* Decreased usual source of care ** Decreased Access to WIC, TANF** Worse Care Coordination *Adj. for SES; **Strong association Sanders, et al. Archives Ped Adol Med, 2009.
13 % Subjects Child Health Insurance and Parent HL All Children with Health Insurance 3% 100 5% % Proficient Health Literacy (2003 NAAL) 95% Intermediate Health Literacy At Least One Child with No Health Insurance 11% 89% Basic Health Literacy p < % 76% Below Basic Health Literacy Yin HS, Johnson M, Mendelsohn AL, Abrams MA, Sanders L, Dreyer BP. The health literacy of parents in the US: A nationally representative study. Pediatrics 2009; 124: S
14 Literacy and Child Urgent Care Use * * Relative Risk Literate Low Literate 0 Literate Low Literate N = 276 All Children Children < 5 years old * p=.06, adjusted for parent and child age, gender; parent educational status, and English-language proficiency Sanders, et al. Pediatrics 2006
15 Cost of Health Literacy Estimated $ billion in preventable costs per year associated with low literacy $10,000 per adult per year 7 to 17% of all healthcare expenditures Friedland 2002; Vernon 2007
16 Leading health agencies have identified Health Literacy as a priority issue for addressing quality of care and patient safety IOM AHRQ Healthy People 2020 AMA AAP Joint Commission CDC FDA NIH Health Literacy: Health Policy Response
17 IOM Roundtable: Attributes of a Health-Literate System Schillinger 2012
18 Communication Tools 1. Teach Back 2. Limited Messages 3. Clear Language 4. Visual Aids Schillinger 2012
19 Innovative Tools (example) R01 NICHD (Rothman, Sanders, Yin, Perrin)
20 Hospital and Clinic Policies 1. Include HL in Patient Safety 2. AHRQ Universal Precautions 3. HL in informed consent and d/c planning, and other care transitions Schillinger 2012
21 Universal Precautions Toolkit Access Knowledge Behavior Transportation Medical Information Self-efficacy Insurance Scheduling Communication Understanding Adherence Self-care Improved Health Outcomes Support Systems Language/Culture Social Reinforcement Tools to Improve Tools to Improve Tools to Improve Supportive Spoken and Written Self-management Systems Communication and Empowerment
22 Workforce Composition/Training 1. Navigators/Coordinator s 2. Interpreters 3. Diverse staff 4. HL Training and Goals Schillinger 2012
23 Information Technology 1. Patient Portals 2. Clear, Customized Information: - Services - Costs - Risks - Plans Schillinger 2012
24 ehealth Literacy: Mobile Devices Pew Research Center, 2011
25 National Leadership 1. Incentives for Pt. Understanding 2. Assess HL Needs Schillinger 2012
26 US DHHS National Action Plan #1 Accessible, actionable health information #2 Health care system change #3 Health and science curricula in child care and education #4 Adult education and culturally/linguistically appropriate services in the community #5 Partnerships, guidance, and policy change #6 Research on practices / interventions to improve health literacy #7 Disseminate evidence-based health literacy practices / interventions US DHHS 2010
27 Policy-focused Goals #1 Accessible, actionable health information #2 Health care system change #3 Health and science curricula in child care and education #4 Adult education and culturally/linguistically appropriate services in the community #5 Partnerships, guidance, and policy change #6 Research on practices / interventions to improve health literacy #7 Disseminate evidence-based health literacy practices / interventions US DHHS 2010
28 Health Literacy Research: Assessing the U.S. Health Policy Roadmap? Better Access healthcare.gov Better Quality AHRQ toolkit Lower Costs CAHPS HL items Rehospitalization Koh H, et al, Health Affairs 2012
29 1. Review the associations between HL and population health outcomes. 2. Explore specific, policy-relevant strategies to address literacy-sensitive health inequities. 3. Discuss implications for health system reform.
30 Guiding Questions 1. How can health literacy research best guide efforts to improve population health by reducing health disparities? 2. How can health literacy research best guide efforts to improve patient care by improving the effectiveness and efficiency of health-care systems?
31 Our Panel Diane Levin-Zamir Zamir,, MD Health behavior research Jean Rafael, MD Chronic illness research Joseph Selby, MD Health services research
32
33 Policy Solutions: Beyond Low-Literacy Literacy Handouts Regulation / Standardization Medication dosing (Yin, Sanders 2010) Insurance enrollment forms (Sanders 2007) Informed Consent Documents (Paasche( Paasche-Orlow 2003) Advanced Directives (Sudore( 2007) Payment Reform Institutional incentives connected to the patient s s ability to understand. Fully informed choices in Health Insurance Exchanges Innovation Health navigators: real and virtual (Murphy 1996; Lorig KR 2001; Flores 2005) Interactive patient portals (Meade 1994; Davis 1998; Wydra 2001)
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