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Objectives. We assessed the impact of health literacy and acculturation on oral health status of Somali refugees in Massachusetts. Methods. Between December 2009 and June 2011, we surveyed 439 adult Somalis who had lived in the United States 10 years or less. Assessments included oral examinations with decayed, missing, and filled teeth (DMFT) counts and measurement of spoken English and health literacy. We tested associations with generalized linear regression models. Results. Participants had means of 1.4 decayed, 2.8 missing, and 1.3 filled teeth. Among participants who had been in the United States 0 to 4 years, lower health literacy scores correlated with lower DMFT (rate ratio [RR] = 0.78; P = .016). Among participants who had been in the country 5 to 10 years, lower literacy scores correlated with higher DMFT (RR = 1.37; P = .012). Literacy was not significantly associated with decayed teeth. Lower literacy scores correlated marginally with lower risk of periodontal disease (odds ratio = 0.22; P = .047). Conclusions. Worsening oral health of Somali refugees over time may be linked to less access to preventive care and less utilization of beneficial oral hygiene practices.

The Centers for Disease Control and Prevention have endorsed the concept of preconception care (PCC). New tools must be developed to promote PCC.Development and testing of a health information technology system to provide PCC.An urban safety net hospital and an urban university.Community recruitment of 31 women in focus groups and 15 women participating in observed usability testing; 9 students recruited from the Office of Minority Health Preconception Peer Educators program participated in pilot testing for 2 months.Online interactive animated character ("Gabby") designed to identify and modify preconception risks.Qualitative transcripts, preconception risk assessment, server data for system usage, self-administered satisfaction surveys, and follow-up phone calls.Descriptive statistics of subjects' demographics, satisfaction, PCC risks, and system usage. Transcripts coded using NVIVO.Subjects (n = 24) reported an average of 23 preconception risks; in the pilot, 83% of risks added to the "My Health To-Do List" were addressed by the subject. Seventy-three percent of risks identified as contemplative progressed to action or maintenance. Differences were noted in effectiveness of the system based on initial stage of change for each risk.Results suggest that the PCC system could be effective in influencing positive behavior change. Adding stage of change-focused functionality might have added benefits. This system has great potential to assist in the delivery of PCC.

Inadequate health literacy and limited English proficiency are associated with poor health care access and outcomes. Despite what appears to be an interaction phenomenon--whereby the rate of inadequate health literacy is particularly high among limited English proficiency populations--researchers in health literacy and limited English proficiency rarely collaborate. As a result, few health literacy instruments and interventions have been developed or validated for smaller linguistic populations. Interventions to improve health outcomes for people with low health literacy and limited English proficiency show great potential to alleviate many of the health disparities currently experienced by some of the most disenfranchised individuals in our health care system, those from smaller linguistic minority groups, including Deaf American Sign Language users. It is critical for health literacy and limited English proficiency researchers to work together to understand how culture, language, literacy, education, and disabilities influence health disparities and health outcomes. It is important to ensure that research is collaborative and inclusive in order to broaden the reach of future interventions to smaller linguistic minority populations.

Without concerted effort, the current explosion in health information technology will further widen the digital health divide for individuals with inadequate health literacy. However, with focused investment of time and energy, technology has the potential for reducing disparities through intelligent, usable, and accessible systems that tailor information, advice, counseling, and behavioral support to an individual's need at a given time and place.

Nonadherence to cardiovascular medications such as statins is a common, important problem. Clinicians currently rely on intuition to identify medication nonadherence. The visit-to-visit variability (VVV) of low-density lipoprotein (LDL) cholesterol might represent an opportunity to identify statin nonadherence with greater accuracy. We examined the clinical and pharmacy data from 782 members of the Boston Medical Center Health Plan, seen at either the Boston Medical Center or its affiliated community health centers, who were taking statins and had ≥3 LDL cholesterol measurements from 2008 to 2011. The LDL cholesterol VVV (defined by the within-patient SD) was categorized into quintiles. Multivariate logistic regression models were generated with statin nonadherence (defined by the standard 80% pharmacy refill-based medication possession ratio threshold) as the dependent variable. The proportion of statin nonadherence increased across the quintiles of LDL cholesterol VVV (64.3%, 71.2%, 89.2%, 92.3%, 91.7%). Higher quintiles of LDL cholesterol VVV had a strong positive association with statin nonadherence, with an adjusted odds ratio of 3.4 (95% confidence interval 1.7 to 7.1) in the highest versus lowest quintile of LDL cholesterol VVV. The age- and gender-adjusted model had poor discrimination (C-statistic 0.62, 95% confidence interval 0.57 to 0.67), but the final adjusted model (age, gender, race, mean LDL cholesterol) demonstrated good discrimination (C-statistic 0.75, 95% confidence interval 0.71 to 0.79) between the adherent and nonadherent patients. In conclusion, the VVV of LDL cholesterol demonstrated a strong association with statin nonadherence in a clinic setting. Furthermore, a VVV of LDL cholesterol-based model had good discrimination characteristics for statin nonadherence. Research is needed to validate and generalize these findings to other populations and biomarkers.

Economic incentives to promote healthy behavior are becoming increasingly common and have been suggested as an approach to decreasing healthcare costs. Ethical concerns about programs with such incentives are that they may contribute to inequities, be coercive, interfere with therapeutic relationships, undermine personal responsibility for health, and decrease social solidarity. Additionally, they may be a source of stigma or discrimination, promote dependence, and be unfair for those already engaged in targeted health behaviors or those who cannot fulfill the incentivized behaviors. Incentive programs need to incorporate appropriate safeguards to monitor these risks and support fairness in offering economic incentives to promote healthy behavior.

Objective In the 30 days after hospital discharge, hospital utilisation is common and costly. This study evaluated the association between gender and hospital utilisation within 30 days of discharge. Design Secondary data analysis using Poisson regression stratified by gender. Participants 737 English-speaking hospitalised adults from general medical service in urban, academic safety-net medical centre who participated in the Project Re-Engineered clinical trial (clinicaltrials.gov identifier: NCT00252057). Main outcome measure The primary end point was hospital utilisation, defined as total emergency department visits and hospital readmissions within 30 days after index discharge. Results Female subjects had a rate of 29 events for every 100 people and male subjects had a rate of 47 events for every 100 people (incident rate ratio (IRR) 1.62, 95% CI 1.28 to 2.06). Among men, risk factors included hospital utilisation in the 6 months prior to the index hospitalisation (IRR 3.55, 95% CI 2.38 to 5.29), being unmarried (IRR 1.72, 95% CI 1.12 to 2.64), having a positive depression screen (IRR 1.53, 95% CI 1.09 to 2.13) and no primary care physician (PCP) visit within 30 days (IRR 1.64, 95% CI 1.08 to 2.50). Among women, the only risk factor was hospital utilisation in the 6 months prior to the index hospitalisation (IRR 3.08, 95% CI 1.86 to 5.10). Conclusions In our data, male subjects had a higher rate of hospital utilisation within 30 days of discharge than female subjects. For men—but not for women—risk factors were being retired, unmarried, having depressive symptoms and having no PCP visit within 30 days. Interventions addressing these factors might lower hospital utilisation rates observed among men., Article summary Article focus Early hospital readmission is a common and costly occurrence in the USA. Men often use hospital emergency departments for usual source of medical care. We aimed to study whether men are therefore more likely to be readmitted to the hospital within 30 days of an index discharge. Key messages Men have higher rates of 30-day readmission to hospital than women in this study group. Men also were less likely to complete a follow-up appointment with their primary care physician after discharge. Interventions that promote connecting men to primary care, address social isolation and screen for depressive symptoms may reduce the risk for early readmission among men. Strengths and limitations of this study This analysis was conducted with the Project RED data set, which included, and allowed controlling for certain clinical and social confounders in our analysis such as subjects' comorbidity burden, depression symptoms, homelessness, substance abuse and other similar risk factors, in our analysis. This study is limited in that it was conducted at an urban safety-net hospital and may not be generalisable to other types of hospital systems. We also relied on subject self-report of any rehospitalisation events outside of the study site, however, were able to confirm 91% of all events using our hospital electronic medical record system.

Hospital discharge may be an opportunity to intervene among patients with substance use disorders to reduce subsequent hospital utilization. This study determined whether having a substance use disorder diagnosis was associated with subsequent acute care hospital utilization.We conducted an observational cohort study among 738 patients on a general medical service at an urban, academic, safety-net hospital. The main outcomes were rate and risk of acute care hospital utilization (emergency department visit or hospitalization) within 30 days of discharge. The main independent variable was presence of a substance use disorder primary or secondary discharge diagnosis code at the index hospitalization.At discharge, 17% of subjects had a substance use disorder diagnosis. These patients had higher rates of recurrent acute care hospital utilization than patients without substance use disorder diagnoses (0.63 vs 0.32 events per subject at 30 days, P0.01) and increased risk of any recurrent acute care hospital utilization (33% vs 22% at 30 days, P0.05). In adjusted Poisson regression models, the incident rate ratio at 30 days was 1.49 (95% confidence interval, 1.12-1.98) for patients with substance use disorder diagnoses compared with those without. In subgroup analyses, higher utilization was attributable to those with drug diagnoses or a combination of drug and alcohol diagnoses, but not to those with exclusively alcohol diagnoses.Medical patients with substance use disorder diagnoses, specifically those with drug use-related diagnoses, have higher rates of recurrent acute care hospital utilization than those without substance use disorder diagnoses.

To improve the safety culture of a skilled nursing facility, we conducted multidisciplinary "Team Improvement for Patient and Safety" (TIPS) case conferences biweekly to identify causes of transfers to acute care hospitals and improvement opportunities. Staff perceptions of organizational patient safety culture were assessed with the Nursing Home Survey on Patient Safety Culture. Over the course of the year, we held 22 TIPS conferences. Mean item scores increased during the study, indicating improved staff perceptions of patient safety culture (P < .005).

BACKGROUND: Optimizing postdischarge medication adherence is a target for avoiding adverse events. Nevertheless, few studies have focused on predictors of postdischarge medication adherence. METHODS: The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study used counseling and follow-up to improve postdischarge medication safety. In this secondary data analysis, we analyzed predictors of self-reported medication adherence after discharge. Based on an interview at 30-days postdischarge, an adherence score was calculated as the mean adherence in the previous week of all regularly scheduled medications. Multivariable linear regression was used to determine the independent predictors of postdischarge adherence. RESULTS: The mean age of the 646 included patients was 61.2 years, and they were prescribed an average of 8 daily medications. The mean postdischarge adherence score was 95% (standard deviation [SD] = 10.2%). For every 10-year increase in age, there was a 1% absolute increase in postdischarge adherence (95% confidence interval [CI] 0.4% to 2.0%). Compared to patients with private insurance, patients with Medicaid were 4.5% less adherent (95% CI −7.6% to −1.4%). For every 1-point increase in baseline medication adherence score, as measured by the 4-item Morisky score, there was a 1.6% absolute increase in postdischarge medication adherence (95% CI 0.8% to 2.4%). Surprisingly, health literacy was not an independent predictor of postdischarge adherence. CONCLUSIONS: In patients hospitalized for cardiovascular disease, predictors of lower medication adherence postdischarge included younger age, Medicaid insurance, and baseline nonadherence. These factors can help predict patients who may benefit from further interventions. Journal of Hospital Medicine 2012;. © 2012 Society of Hospital Medicine

In their article, Health Literacy and Health Care Spending and Utilization in a Consumer-Driven Health Plan, Hardie et al. examine health literacy and health care spending and utilization by linkin...

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand health information, skills, and services needed to make informed health decisions and take informed actions. Narratives from Mr J, a 76-year-old man with multiple medical problems and limited health literacy, and his physician exhibit some of the difficulties experienced by patients with limited health literacy. Clinicians can help patients with limited health literacy by removing unneeded complexity in their treatment regimens and in the health care system and by using teach-back methods to assess and improve understanding. Rather than a selective screening approach for limited health literacy, a patient-based universal precaution approach for confirming patient comprehension of critical self-care activities helps ensure that all patients have their health literacy needs identified.

BACKGROUND Although pay-for-performance (P4P) compensation is widespread, questions have arisen about its efficacy in improving health care quality and consequences for vulnerable patients. OBJECTIVE To assess perceptions of general internists and P4P program leaders regarding how to implement fair and effective P4P. METHODS Qualitative investigation using in-depth interviews with P4P program leaders and focus groups with general internists. RESULTS Internists emphasized a gradual and cautious approach to P4P implementation. They strongly recommended improving P4P measure validity and had detailed suggestions regarding how. Program leaders saw a need to implement perhaps imperfect programs but with continual improvement. Both groups advocated protecting vulnerable populations and made overlapping recommendations: improving measure validity; adjusting for patient characteristics; measuring improvements in quality (vs cutpoints); and providing incentives to physicians of vulnerable populations. Internists tended to favor explicit protections, while program leaders felt that P4P might inherently protect vulnerable patients by improving overall quality. DISCUSSION Internists favored gradual P4P implementation, while P4P leaders saw an immediate need for implementation with iterative improvement. Both groups recommended specific measures to protect vulnerable populations such as improving measure validity, assessing improvements in quality, and providing special incentives to physicians of vulnerable populations.

To evaluate an intervention to improve discharge disposition from a skilled nursing unit (SNU).Historical control comparison of discharge disposition before and after implementation.Fifty-bed SNU.All patients admitted from acute care hospitals to a SNU between June 2008 and May 2010.Physician admission procedures were standardized using a template, patients with three or more hospital admissions over the prior 6 months received palliative care consultations, and multidisciplinary root-cause analysis conferences for patients transferred back to the hospital acutely were conducted bimonthly to identify problems and improve processes of care.Patients' discharge disposition (i.e., acute care, long-term care, home, or death) before and after implementation were compared.Discharge dispositions were determined for all 1,725 patients admitted during the study; 862 patients before (June-May 2008) and 863 during (June 2009-May 2010) the intervention. Discharge dispositions were significantly differently distributed across the two periods (P=.03). Readmission to acute care declined (from 16.5% to 13.3%, a nearly 20% decline). Multivariable logistic regression, controlling for age, sex, and case-mix index and adjusting for clustering due to repeated admissions of individual patients, suggests that, during the intervention period, patients were more likely than during the baseline period to die on the unit in accordance with their wishes than to be transferred out to the hospital (odds ratio=2.45, 95% confidence interval=1.09-5.5).Interventions such as the ones implemented can lead to fewer hospital transfers for SNUs.

Pressure ulcers and depression are common preventable conditions secondary to a spinal cord dysfunction. However, few successful, low-cost preventive approaches have been identified. We have developed a dynamic automated telephone calling system, termed Care Call, to empower and motivate people with spinal cord dysfunction to improve their skin care, seek treatment for depression, and appropriately use the healthcare system. Herein, we describe the design and development of Care Call, its novel features, and promising preliminary results of our pilot testing. Voice quality testing showed that Care Call was able to understand all voice characteristics except very soft-spoken speech. Importantly, pilot study subjects felt Care Call could be particularly useful for people who are depressed, those with acute injury, and those without access to quality care. The results of a randomized controlled trial currently underway to evaluate Care Call will be available in 2011.

OBJECTIVE To examine the mechanisms linking health literacy to physical activity and self-reported health. METHODS From 2005-2007, patients (N = 330) with hypertension were recruited from safety net clinics. Pathanalytic models tested the pathways linking health literacy to physical activity and self-reported health. RESULTS There were significant paths from health literacy to knowledge (r = 0.22, P < 0.001), knowledge to self-efficacy (r = 0.13, P < 0.01), self-efficacy to physical activity (r = 0.17, P < 0.01), and physical activity to health status (r = 0.17, P < 0.01). CONCLUSIONS Health education interventions should be literacy sensitive and aim to enhance patient health knowledge and self-efficacy to promote self-care behavior and desirable health outcomes.

Introduction When patients are unable to make important end-of-life decisions, doctors ask surrogate decision makers to provide insight into patients' preferences. Unfortunately, multiple studies have shown that surrogates' knowledge of patient preferences is poor. We hypothesized that a video decision tool would improve concordance between patients and their surrogates for end-of-life preferences. Objective To compare the concordance of preferences among elderly patients and their surrogates listening to only a verbal description of advanced dementia or viewing a video decision support tool of the disease after hearing the verbal description. Methods This was a randomized controlled trial of a convenience sample of community-dwelling elderly subjects (≥65 years) and their surrogates, and was conducted at 2 geriatric clinics affiliated with 2 academic medical centers in Boston. The study was conducted between September 1, 2007, and May 30, 2008. Random assignment of patient and surrogate dyads was to either a verbal narrative or a video decision support tool after the verbal narrative. End points were goals of care chosen by the patient and predicted goals of care by the surrogate. Goals of care included life-prolonging care (CPR, mechanical ventilation), limited care (hospitalization, antibiotics, but not CPR), and comfort care (only treatment to relieve symptoms). The primary outcome measure was the concordance rate of preferences between patients and their surrogates. Results A total of 14 pairs of patients and their surrogates were randomized to verbal narrative (n = 6) or video after verbal narrative (n = 8). Among the 6 patients receiving only the verbal narrative, 3 (50%) preferred comfort care, 1 (17%) chose limited care, and 2 (33%) desired life-prolonging care. Among the surrogates for these patients, only 2 correctly chose what their loved one would want if in a state of advanced dementia, yielding a concordance rate of 33%. Among the 8 patients receiving the video decision support tool, all 8 chose comfort care. Among the surrogates for these patients, all 8 correctly chose what their loved one would want if in a state of advanced dementia, yielding a concordance rate of 100%. Conclusion Patients and surrogates viewing a video decision support tool for advanced dementia are more likely to concur about the patient's end-of-life preferences than when solely listening to a verbal description of the disease.

Objective To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks. Design Randomised controlled trial conducted between 1 September 2007 and 30 May 2008. Setting Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston. Participants Convenience sample of 200 older people (≥65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women. Intervention Verbal narrative alone (n=106) or with a video decision support tool (n=94). Main outcome measures Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care. Results Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (χ2=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (κ=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (κ=0.79) (P

Patients are commonly presented with complex documents that they have difficulty understanding. The objective of this study was to design and evaluate an animated computer agent to explain research consent forms to potential research participants.Subjects were invited to participate in a simulated consent process for a study involving a genetic repository. Explanation of the research consent form by the computer agent was compared to explanation by a human and a self-study condition in a randomized trial. Responses were compared according to level of health literacy.Participants were most satisfied with the consent process and most likely to sign the consent form when it was explained by the computer agent, regardless of health literacy level. Participants with adequate health literacy demonstrated the highest level of comprehension with the computer agent-based explanation compared to the other two conditions. However, participants with limited health literacy showed poor comprehension levels in all three conditions. Participants with limited health literacy reported several reasons, such as lack of time constraints, ability to re-ask questions, and lack of bias, for preferring the computer agent-based explanation over a human-based one.Animated computer agents can perform as well as or better than humans in the administration of informed consent.Animated computer agents represent a viable method for explaining health documents to patients.

Objective To determine whether or not limited caregiver health literacy is associated with adherence to a daily multi-vitamin with iron regimen in infants. Methods 110 caregiver/infant dyads were enrolled in a prospective study to assess the relationship between caregiver health literacy and adherence to a daily multi-vitamin with iron regimen for infants. Households were contacted biweekly over a 3-month period. Adherence was based upon caregiver report. High adherence, our primary outcome, was defined as the administration of the multi-vitamin with iron on 5–7 days over the past week. Results As measured by the Short Test of Functional Health Literacy in Adults (S-TOFHLA), 18% of caregivers had limited health literacy skills. Caregivers with limited health literacy skills were more likely to have higher adherence than caregivers with adequate health literacy, after adjusting for a number of possible confounding variables (AOR = 2.13; 95% 1.20–3.78). Conclusion Caregivers with limited health literacy were twice as likely to report high adherence to a daily multi-vitamin with iron regimen in infants as caregivers with adequate health literacy in adjusted analysis. Practice implications Health literacy may exert a differential influence on adherence depending upon the complexity of the desired health behavior.

Little is known about the relationship between mental illness and literacy despite both being prevalent problems. We examine whether literacy varies by psychiatric diagnoses. Interviews and chart reviews (N = 100) were conducted in a behavioral health outpatient clinic. The relationships among sociodemographics, rapid estimate of adult literacy in medicine, measures of verbal and visual intellectual abilities, and psychiatric diagnoses were examined. The mean rapid estimate of adult literacy in medicine score was 55.9 which is equivalent to below an eighth grade literacy level. Psychotic disorder (p = 0.03) was associated with limited literacy, and substance abuse (p = 0.003) and PTSD (p = 0.07) were associated with higher literacy in bivariate analyses. These diagnoses were further examined in multivariate models. Limitations include the small sample size and the over-representation of people with high levels of education. Increasing our understanding of the relationships between health literacy and psychiatric disorders will help inform the development of appropriate psychiatric care and better outcomes.

To impute limited health literacy from commonly measured socio-demographic data and to compare it to the Short-Test of Functional Health Literacy in Adults (S-TOFHLA) for estimating the influence of limited health literacy on health status in the elderly.The Prudential Medicare Study assesses the S-TOFHLA score, leading to a "reference standard" classification of 25% of people with inadequate literacy; the National Health Interview Survey has no such assessment. We estimated a regression of S-TOFHLA on sex, age, years of schooling, and race/ethnicity in The Prudential Medicare Study data to derive a Demographic Assessment for Health Literacy (DAHL) score, and imputed inadequate literacy to the 25% with the lowest DAHL scores. Using regression, we then examined associations between several health status measures (including hypertension, diabetes, physical and mental SF-12) and inadequate literacy (imputed or test-based).Estimates of association using imputed inadequate literacy closely approximate those obtained using S-TOFHLA-based inadequate literacy for most outcomes examined.As few population surveys measure health literacy, the DAHL, a readily calculated health literacy proxy score, may be useful for expanding the scope of health literacy research in national survey data.

Limited health literacy is a significant risk factor for adverse health outcomes. Despite controversy, many health care professionals have called for routine clinical screening of patients’ literacy skills. Whereas brief literacy screening tools exist that with further evaluation could potentially be used to detect limited literacy in clinical settings, no screening program for limited literacy has been shown to be effective. Yet there is a noted potential for harm, in the form of shame and alienation, which might be induced through clinical screening. There is fair evidence to suggest that possible harm outweighs any current benefits; therefore, clinical screening for literacy should not be recommended at this time.

Limited health literacy may be a contributing factor to racial disparities in health care. This study examined the mediating effect of limited health literacy on the relationship between race and HIV-medication adherence.A total of 204 patients infected with HIV were recruited from two clinics in 2001. Structured in-person interviews were conducted to obtain information on patient demographics, medication adherence, and health literacy. Multivariate regression models were run in 2006 to examine the associations among race, literacy, and HIV-medication adherence after adjusting for relevant covariates.In an adjusted analysis that excluded literacy, African Americans were 2.40 times more likely to be nonadherent to their HIV-medication regimen than whites (95% confidence interval [CI]=1.14-5.08). When literacy was included in the final model, the effect estimates of race diminished 25% to nonsignificance. Literacy remained a significant independent predictor of nonadherence (adjusted odds ratio [AOR]=2.12, 95% CI=1.93-2.32).In this study, limited health literacy mediated the relationship between race and HIV-medication adherence. Investigators need to consider the potential utility of responding to literacy and communication barriers in health care as part of interventions to reduce racial disparities.

Low health literacy has been associated with worse adherence to antiretroviral therapy (ART) and higher HIV-RNA levels, but these relationships have not been evaluated in longitudinal analyses.We evaluated literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM) (or = 6th grade, 7th to 8th grade,or = 9th grade) in the HIV-Alcohol Longitudinal Cohort study of HIV-infected persons with a history of alcohol problems, conducted from 1997 to 2001. We tested HIV-RNA levels and administered a standardized questionnaire regarding demographics, substance use, receipt of ART, and adherence with ART, every 6 months for up to 7 occasions. Among the 235 subjects on ART, we investigated the relationship between literacy and 2 outcomes: 100% 3-day self-reported adherence and HIV-RNA suppression (500 copies).Subjects' literacy levels were the following: 14%or = 6th grade, 29% 7th to 8th grade, and 57%or = 9th grade. In 66% of the observations (478/725), subjects reported 100% 3-day adherence with ART. Of the 685 HIV-RNA assays from these subjects, 62% had500 copies. In unadjusted analyses, subjects with the lowest literacy level (or = 6th grade) had a higher odds of adherence (odds ratio [OR] 2.23, 95% confidence interval 1.15 to 4.30) and HIV-RNA suppression (OR 2.01, 95% confidence interval 1.03 to 3.90) compared with those withor = 9th grade literacy. This trend persisted but was no longer statistically significant in adjusted models of adherence (AOR 1.93, 95% confidence interval 0.86 to 4.31) and HIV-RNA suppression (AOR 1.70, 95% confidence interval 0.79 to 3.65).Contrary to our hypothesis, low literacy was not associated with a lower odds of adherence or virologic suppression in this longitudinal analysis of HIV-infected patients with a history of alcohol problems. Indeed, trends in these data suggest the possibility that low literacy may be associated with a higher odds of adherence and virologic suppression. These counterintuitive findings underscore the need to pursue a fuller understanding of the mechanisms by which literacy affects health outcomes.

The prevalence of torture among foreign-born patients presenting to urban medical clinics is not well documented.To determine the prevalence of torture among foreign-born patients presenting to an urban primary care practice.A survey of foreign-born patients.Foreign-born patients, ageor = 18, presenting to the Primary Care Clinic at Boston Medical Center.Self-reported history of torture as defined by the UN, and history of prior disclosure of torture.Of the 308 eligible patients, 88 (29%) declined participation, and 78 (25%) were not included owing to lack of a translator. Participants had a mean age of 47 years (range 19 to 76), were mostly female (82/142, 58%), had been in the United States for an average of 14 years (range 1 month to 53 years), and came from 35 countries. Fully, 11% (16/142, 95 percent confidence interval 7% to 18%) of participants reported a history of torture that was consistent with the UN definition of torture. Thirty-nine percent (9/23) of patients reported that their health care provider asked them about torture. While most patients (15/23, 67%) reported discussing their experience of torture with someone in the United States, 8 of 23 (33%) reported that this survey was their first disclosure to anyone in the United States.Among foreign-born patients presenting to an urban primary care center, approximately 1 in 9 met the definition established by the UN Convention Against Torture. As survivors of torture may have significant psychological and physical sequelae, these data underscore the necessity for primary care physicians to screen for a torture history among foreign-born patients.

To identify the educational factors associated with HIV risk behaviors among incarcerated women.We evaluated a cohort of female detainees at The Rhode Island Adult Correctional Institute between July and September 2004. Among the 423 women who participated in the study, 55% did not have a high school diploma, 29% hador = 8th grade reading capacity, 32% had a learning disability, 37% had problem drinking, and 61% (257/423) reported HIV risk behavior.In multiple logistic regression, participants who had completed high school had the lowest likelihood of HIV risk behavior (adjusted odds ratio [OR] 0.35, 95% confidence interval [CI] 0.12-1.00). There was no association between participants? literacy level and HIV risk behavior (adjusted OR 2.02, 95% CI 0.83-4.92).Correctional education programs to reduce HIV risk behavior should focus on those with low educational attainment irrespective of literacy skills.

Background: Federal regulation requires hospitals to present patients with a Notice of Privacy Practices (NPP) that contains all stipulated content items, is readable by patients, and posted on institutional web sites. Objective: The objective of this study was to determine whether the NPP texts contain the required content, if readability is influenced by local literacy rates, and if readability or the presentation of NPP texts in other languages is influenced by local rates of English proficiency. Research Design: The authors conducted a cross-sectional study of the web sites of 115 hospitals selected from the US News and World Report list: Best Hospitals in America. Measures: English NPP texts were evaluated for 18 content items and readability using the Flesch-Kincaid scale, which assigns the minimal grade level required to read a text (range, 0–16). Results: NPP texts were available for all hospitals (115 of 115). A Spanish-language NPP was available for 25% (29 of 115). All content items were evident in 76% (87 of 115) of hospitals’ NPP texts. The average grade-level readability of NPP text was 12.3 (95% confidence interval, 12.0–12.7). Readability was not associated with the rate of local literacy (P = 0.07). Hospitals with a lower local rate of English proficiency had NPP texts that were more difficult to read (P = 0.03) and did not present NPP texts in other languages more frequently (P = 0.15). Conclusions: Although NPP texts typically cover the stipulated content, they are written beyond the reading capacity of the majority of American adults. Explicit federal guidance is needed to help privacy lawyers draft NPP texts that are both comprehensive and comprehensible. The goals of the Health Insurance Portability and Accountability Act of 1996 Privacy Rule cannot be met with NPP texts patients cannot decipher.

To systematically review U.S. studies examining the prevalence of limited health literacy and to synthesize these findings by evaluating demographic associations in pooled analyses.We searched the literature for the period 1963 through January 2004 and identified 2,132 references related to a set of specified search terms. Of the 134 articles and published abstracts retrieved, 85 met inclusion criteria, which were 1) conducted in the United States withor =25 adults, 2) addressed a hypothesis related to health care, 3) identified a measurement instrument, and 4) presented primary data. The authors extracted data to compare studies by population, methods, and results.The 85 studies reviewed include data on 31,129 subjects, and report a prevalence of low health literacy between 0% and 68%. Pooled analyses of these data reveal that the weighted prevalence of low health literacy was 26% (95% confidence interval [CI], 22% to 29%) and of marginal health literacy was 20% (95% CI, 16% to 23%). Most studies used either the Rapid Estimate of Adult Literacy in Medicine (REALM) or versions of the Test of Functional Health Literacy in Adults (TOFHLA). The prevalence of low health literacy was not associated with gender (P=.38) or measurement instrument (P=.23) but was associated with level of education (P=.02), ethnicity (P=.0003), and age (P=.004).A pooled analysis of published reports on health literacy cannot provide a nationally representative prevalence estimate. This systematic review exhibits that limited health literacy, as depicted in the medical literature, is prevalent and is consistently associated with education, ethnicity, and age. It is essential to simplify health services and improve health education. Such changes have the potential to improve the health of Americans and address the health disparities that exist today.

Although differences between Internal Medicine (IM) and Family Practice (FP) physicians have been examined in terms of care outcomes and cost, there have been few studies of specialty differences in physician-patient communication.In 1995, 277 clinical encounters with 29 full-time, community-based FP physicians and 287 clinical encounters with 30 full-time, community based IM physicians were audiotaped. Communication was evaluated with the Roter Interaction Analysis System to reflect data gathering, patient education and counseling, rapport building, partnership building, verbal dominance, and patient-centeredness. Patient satisfaction was measured with an exit questionnaire.IM clinicians ask more biomedical questions (P =.02). FP clinicians engage in more psychosocial discussion (P =.02) and tend to engage in more emotionally supportive exchanges such as empathy and reassurance (P =.06). Significant interaction effects show differential treatment of patient subgroups by specialty; FP physicians were more verbally dominant with female patients (P.01) and more patient-centered in their communication style with minority patients (P =.03). Although patient satisfaction was similar for IM and FP, satisfaction was more closely linked to measures of rapport and patient-centeredness for patients of FP physicians than for patients of internists.The current work adds insight into FP and IM differences in both physician-patient communication and predictors of patient satisfaction.

Institutional review boards (IRBs) are charged with safeguarding potential research subjects with limited literacy but may have an inadvertent role in promulgating unreadable consent forms. We hypothesized that text provided by IRBs in informed-consent forms falls short of the IRBs' own readability standards and that readability is influenced by the level of research activity, local literacy rates, and federal oversight.To test these hypotheses, we conducted a cross-sectional study linking data from several public-use sources. A total of 114 Web sites of U.S. medical schools were surveyed for IRB readability standards and informed-consent-form templates. Actual readability was measured with the Flesch-Kincaid scale, which assigns a score on the basis of the minimal grade level required to read and understand English text (range, 0 to 12). Data on the level of research activity, local literacy rates, and federal oversight were obtained from organizational Web sites.The average readability score for text provided by IRBs was 10.6 (95 percent confidence interval, 10.3 to 10.8) on the Flesch-Kincaid scale. Specific readability standards, found on 61 Web sites (54 percent), ranged from a 5th-grade reading level to a 10th-grade reading level. The mean Flesch-Kincaid scores for the readability of sample text provided by IRBs exceeded the stated standard by 2.8 grade levels (95 percent confidence interval, 2.4 to 3.2; P0.001). Readability was not associated with either the level of research funding (P=0.89) or local rates of literacy (P=0.92). However, the 52 schools that had been made subject to oversight by the Office for Human Research Protections (46 percent) had lower Flesch-Kincaid scores than the other schools (10.2 vs. 10.9, P=0.005).IRBs commonly provide text for informed-consent forms that falls short of their own readability standards. Federal oversight is associated with better readability.

In this issue, Sudore et al.1 report their efforts to improve comprehension of informed consent information by using a method sometimes referred to as “teaching to goal.” In brief, the investigators standardized the informed consent process for an actual study that was evaluating patients' preferences for different types of advance directive documents. The standardized process involved reading a simplified informed consent document that was written at the sixth-grade level to the participants while they read it to themselves. The investigators then quizzed the participants to ensure comprehension of 7 selected aspects of the study. If participants were unable to answer these items correctly, the informed consent process was repeated until participants were able to answer correctly. Initially, only 28% of participants could answer all the items correctly, but this improved to 80% after a second pass at reviewing the informed consent document. Lower comprehension was associated with lower literacy and African American race. The investigators conclude that such modifications in consent might be used with minimal increase in effort. While this may be the case, a series of additional research and practical questions regarding such an approach are readily apparent. First, the 7 items selected by the investigators were limited to factual items inherent to the study protocol. While understanding these research-related procedures is important, it is unclear both in this particular case and for other types of research whether these are the right types of questions to ask. To meet the ethical goals of informed consent, it is critical that several steps of the informed consent process are satisfied. These steps include ensuring that the potential research participants have adequate decision-making capacity, that they are positioned to make a voluntary choice, that they are given relevant information about the research in a manner that is understandable to them so that they can make a decision about participation and if affirmative, give consent, either orally or by signing a consent document.2 In this study, the researchers took some efforts to screen out many of those who might lack capacity to consent, and then in common with much of the published literature on informed consent,3,4 focused their efforts on providing information about the research and ensuring that this was understood before permitting the participants to give consent. Fair enough, but it is also arguably critical for all potential participants to understand that participation is voluntary and that they can leave the research at any time. In addition, for research conducted in health care settings, potential participants need to understand that their decision will not affect their regular medical care. While there is arguably little need to evaluate comprehension of everything mentioned in a consent document, it is unclear why the investigators steered clear of the central ethical requirements that are supposed to be included in these documents (e.g., voluntariness). While the methods of standardizing informed consent and ensuring comprehension described by Sudore and colleagues are important, it is unclear whether such “big guns” should be used for minimal risk research. Although the details of the time required or nature of the questions being asked of participants in the parent study are surprisingly not found in the simplified informed consent document presented, it is hard to imagine that the study is terribly burdensome. That is, the parent study involving advance directives seems to raise few if any risks, burdens, or inconvenience to participants, save the unlikely possibility that participants may think that these issues are being raised with them because they have a specific medical indication. Nevertheless, the entire consent document is read to the participants, typically twice, and quizzing is used to ensure comprehension. Indeed, in this case, the standardized consent process seems to be more onerous than the parent study itself. That said, for research that poses clear psychosocial, economic, or physical risk to participants, such an approach might be appropriate. In research that poses such risks to participants, measures that enhance the likelihood of obtaining meaningful informed consent should be used, and a teach-to-goal strategy may be a promising approach. In order to assess whether to implement such an approach, several questions about the process itself should be examined. For example, it would be interesting to assess patients' attitudes toward having a written consent document read aloud to them. Note that U.S. federal regulations for research do not require reading consent documents to all potential participants. In fact, they stipulate that the “form may be read to the subject or the subject's legally authorized representative, but in any event, the investigator shall give either the subject or the representative adequate opportunity to read it before it is signed.”5 Regardless, reading the consent form verbatim is extraneous to the teach-to-goal process. Would it not be preferable to train research assistants to teach the information, evaluate comprehension, and continue the consent process with additional focused education until the potential subject exhibits comprehension ? Reading the text verbatim might be an easy thing to standardize among research assistants, but it only yielded 11% comprehension among subjects without adequate literacy in this study. Similarly, it would be important to elicit patients' attitudes toward quizzing. Not all patients may be comfortable being challenged by questions from those seeking their consent. Indeed, patients with low literacy might be particularly ill at ease when confronted with a test. In addition, it is unclear from the current study whether participants are simply learning to answer the specific items posed to them or are truly comprehending and appreciating the implications of their responses. Further, it will be important to assess the effects of such approaches to consent on the enrollment and retention of subjects. It is conceivable that enrollment rates may go down, but that this may be balanced by better retention that could ultimately be helpful to the quality of the study. Finally, it is necessary to examine whether the person who solicits informed consent can also validly assess comprehension. After all, the person who conducts the consent process has a stake in the outcome. Possibly, these roles should be split. If this particular approach is found to be acceptable in research that poses more than minimal risk, it will obviously be critical to measure the quality of consent. Nevertheless, developing study-specific methods assessing the quality of consent can require substantial financial and intellectual resources that may not be readily available for all researchers and institutions. Developing measures of the quality of consent alone that are reliable and valid can take years of effort. With this in mind, it may be prudent to use or modify approaches that have already have been developed and are designed to work across different types of research. For instance, the Brief Informed Consent Evaluation Protocol (BICEP) is a means of assessing the quality of informed consent, using a telephone interview immediately following consent, that has good reliability.6 Despite this array of unanswered issues, the report from Sudore and colleagues provides evidence that innovations in informed consent can be implemented in the research setting and have scope to work. That is, there is clear evidence that there was a lack of comprehensive understanding of the proposed research even when using a simplified consent form that was read aloud to potential participants. Moreover, they identified potential participants who were deemed ineligible by the fact that they were not able to pass the comprehension test, suggesting that many subjects may be enrolled in research over their own signatures without having given informed consent. In addition, their work supports the assumption found in other studies that those with low literacy are at heightened risk of having difficulty in responding to items aimed at measuring the comprehension of informed consent information. In short, these baseline findings regarding “comprehension” that the researchers found seem unacceptable and indicate that people with low literacy warrant close attention during the informed consent process. Informed consent remains one of the pillars of protection of the rights of research participants. Accordingly, researchers, research sponsors, and those charged with the oversight of research need to develop and fund initiatives aimed at enhancing the quality of consent.

In 1992, the National Adult Literacy Survey (NALS) showed that 40% to 45% of adult Americans struggled with functional literacy tasks.1 In early 2006, the results of the National Adult Assessment of Literacy indicated that the status of literacy in the United States remains much the same.2 Over 90 million adults lack the literacy skills needed to effectively function in the present health care environment.3 Low health literacy is associated with less medical knowledge, infrequent receipt of preventive services, increased hospitalization and use of emergency care, and worse control of chronic diseases.4 In 2004, the Institute of Medicine (IOM) called for additional research into the associations and consequences of low health literacy. Among the items highlighted by the IOM committee were the need to develop new measures of health literacy, approaches to improve health communication in diverse populations, interventions to reduce the negative health effects of low literacy, and ways to address health literacy in graduate medical education and the health system.3 This special issue of JGIM responds to the priority areas outlined in the IOM report by bringing together state-of-the-art research related to the role of literacy in health care. The research articles and commentaries in this issue will provide insight for clinicians, educators, researchers, administrators, and policy makers on addressing literacy in various health care settings. Among the many excellent original manuscripts featured in this special issue are several important health outcome studies. Sudore and colleagues lead off the issue with their longitudinal analysis of the Health, Aging, and Body Composition Study, demonstrating for the first time that low health literacy is an independent risk factor for mortality. In a 2-year study of patients with asthma, Mancuso and Rincon show that literacy is associated with asthma outcomes and that this relationship appears to be mediated by other variables, particularly asthma knowledge. More work like this is needed, to clarify not only the extent to which literacy is associated with disease control, but also to provide a better understanding of the potential mechanisms behind such relationships. In another longitudinal study, Lincoln and colleagues describe the association between literacy and the severity of depression among adults with alcohol and drug dependence. A particularly innovative report in this issue is a clinical trial by Weiss and colleagues, who randomized patients with depression and low literacy to receive adult literacy education as an adjunctive therapy. The groundbreaking findings of this study should serve as a call for greater collaboration between the medical and adult education communities. Given the importance of literacy in chronic disease management, it is surprising how few previously published articles had investigated the relationship between literacy and medication use. Four research papers in this issue shed some light on this area. Studies by Kripalani, Fang, and Davis indicate that literacy is associated with patients' ability to correctly identify their medicines, understand medication dosing instructions, and understand prescription bottle warning labels, respectively. However, the relationship of literacy with medication adherence and clinical parameters is less clear. Fang found no association between literacy and adherence to warfarin therapy or anticoagulation levels. By contrast, Paasche-Orlow actually found better adherence and viral load suppression among patients with low literacy and HIV, contradicting findings of prior studies.5,6 It is evident that more research is needed to clarify how literacy may impact various aspects of medication use and adherence. Two articles address the important question of whether differences in literacy contribute to racial and socioeconomic disparities in health and health care. Using data from the NALS, Sentell found that differences in literacy helped explain disparities in disability and chronic illness by race and educational attainment. Using data from a large cohort study, Howard similarly found that different literacy levels contributed to disparities in health status but not in vaccination rates. These findings raise as many questions as they answer. Other original research papers in this issue concern comprehension of informed consent, follow-up after an abnormal Pap smear, and the performance of health literacy screening questions. Baker offers a perspective on the meaning of health literacy and the challenges inherent in its measurement. Three commentaries have been included to highlight federal and other national activities, strategies for teaching about health literacy and clear communication, and guidance for health systems to adapt to the needs of low-literacy patients. Many other resources are catalogued online by the SGIM Health Literacy Interest Group.7 It has been a privilege, a pleasure, and a great learning experience to review the latest work in health literacy and compile this special issue of JGIM. We wish to thank all of the authors who submitted their manuscripts for consideration, as well as Pfizer Global Pharmaceuticals for funding the publication of this issue through an unrestricted grant. We are indebted to the staff of the journal as well as the wonderful members of the Expert Review Panel who performed many of the manuscript reviews, anchoring the peer review process. (See front matter for a complete listing.) Finally, we thank Vice Admiral Richard H. Carmona, MD, MPH, the current United States Surgeon General, for his support of this issue and for making health literacy an integral part of his public health agenda. We hope you all enjoy the issue and include efforts to improve health literacy in your own clinical practice, research, and educational activities.

In 1992, the United States enacted the Individuals with Disabilities Education Act (IDEA), which required public schools that receive federal dollars to provide free and appropriate public education for all minors, regardless of any form of disability or infirmity.1 One of the hallmarks of the IDEA was the introduction of the Individual Education Program (IEP), which is a legally binding contract between minors, their parents or guardians, and a school. Individual Education Programs outline the ways a child will need to be accommodated to be able to successfully participate in classroom activities and curriculum. The programs �must be designed for one student and must be a truly individualized document.�2

9004 Background: End-of-life decision-making is important to patients, including whether or not to attempt cardiopulmonary resuscitation (CPR). Doctors often rely solely on verbal descriptions to communicate information regarding CPR. Video decision support tools have the potential to improve patients’ understanding of CPR by providing visual images of what this intervention entails. The objective of this study was to examine the effect of a CPR video among patients with advanced cancer on their preferences and knowledge of CPR. Methods: A randomized controlled trial of 150 subjects with diverse advanced cancers (< 1-year prognosis) recruited from 4 cancer centers in the United States. Subjects were randomized to either a verbal narrative describing CPR, or to a video with verbal narrative. The video depicts CPR and reviews the success rate in advanced cancer. Study endpoints were subjects’ CPR preferences, knowledge of CPR (knowledge scores ranged from 0-4, higher score indicating more knowledge), and perceived value of the video. Chi-square tests were used to compare the distributions of categorical outcomes and two-sample t-tests were used to compare the means between the two groups. Results: A total of 150 subjects were randomized to a verbal narrative (n=80) or video with verbal narrative (n=70). Mean age was 62, 49% were women, 47% White, 34% Black, and 47% had lung or colon cancer. Among subjects receiving the verbal narrative, 38 (47.5%) preferred to have CPR attempted; 41 (51.2%) chose not to have CPR; and 1 (1.3%) was uncertain. In the video group, 14 (20%) preferred to have CPR attempted; 55 (78.6%) chose not to have CPR; and 1 (1.4%) was uncertain (P

One in 5 hospitalizations is complicated by postdischarge adverse events (1, 2), some of which may lead to preventable emergency department visits or readmissions. Despite this finding, hospital discharge procedures have not been standardized (3). In addition, the declining presence of primary care providers (PCPs) in hospitals has not been adequately accompanied by systems to ensure that patient data are transferred to subsequent caregivers (4, 5). For example, discharge summaries frequently lack critical data and are not sent to the PCP in a timely fashion (6, 7), resulting in outpatient clinicians being unaware of test results that were pending at discharge (8) and evaluations that were scheduled to be done after discharge not being completed (9). Similarly, patients are often left unprepared at discharge; many do not understand their discharge medications and cannot recall their chief diagnoses (10). With more than 32 million adult discharges in the United States each year (11), these deficiencies in the transition of care increase illness, unnecessary hospital utilization, and cost. Some peridischarge interventions have shown a reduction in hospital readmission rates and cost (12-14), emergency department visits (15), and postdischarge adverse events (16), whereas some have shown little or no effect (17-20). Peridischarge interventions have also shown improved PCP follow-up and outpatient work-ups (21) and higher patient satisfaction (15). Most of these studies have focused on specific diagnoses (14, 22, 23) or highly selected populations, such as geriatric adults (12, 13, 19, 24). Some have focused on specific aspects of the discharge, such as increasing access to primary care follow-up (25), connecting with transitional nursing services (26), or improving patients′ ability to advocate for themselves after discharge (12). To date, no study has evaluated a standardized discharge intervention that includes patient education, comprehensive discharge planning, and postdischarge telephone reinforcement in a general medical population. Context Emergency department visits and rehospitalizations are common after hospital discharge. Contribution This trial demonstrated that a nurse discharge advocate and clinical pharmacist working together to coordinate hospital discharge, educate patients, and reconcile medications led to fewer follow-up emergency visits and rehospitalizations than usual care alone. Caution The trial was conducted at a single center, and not all eligible patients were enrolled. Implication A systematic approach to hospital discharges can reduce unnecessary health service use. —The Editors In 2004, we began an in-depth examination of hospital discharge, for which we designed a package of services to minimize discharge failures—a process called reengineered discharge (RED) (Table 1) (3, 27). We did a randomized, controlled trial to evaluate the clinical effect of implementing RED among patients admitted to a general medical service. Table 1 Components of Reengineered Hospital Discharge