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To assess racial differences in the use of oral anticoagulant therapy for patients with heart failure, we conducted a cohort study of 30 hospitals in northeast Ohio. For 12,911 Medicare enrollees consecutively admitted in 1992 through 1994 with heart failure, crude and adjusted odds of being on oral anticoagulation were determined. The crude and adjusted odds of being African Americans on oral anticoagulant therapy relative to whites were 0.57 (95% confidence interval 0.47-0.69) and 0.55 (95% confidence interval 0. 45-0.67), respectively. African-Americans with heart failure were much less likely than whites to receive oral anticoagulant therapy, even after adjusting for other variables associated with anticoagulant use.

Background: Improved understanding of the reasons for underuse of diagnostic tests and treatments for congestive heart failure (CHF) may be helpful for designing future interventions to improve quality of care., Methods: To determine differences between family physicians' and cardiologists' practice styles for diagnosis and treatment of CHF, a random sample of family physicians and cardiologists were surveyed with standardized case scenarios., Results: Survey respondents were 182 family physicians and 163 cardiologists. Family physicians were less likely than cardiologists to rate measurement of left ventricular ejection fraction as "very important" for patients with new CHF, less likely to order an echocardiogram or test for ischemia, and much less likely to identify diastolic dysfunction as a cause of CHF. Family physicians were more likely to prescribe digoxin when it was not indicated (diastolic dysfunction) and less likely to prescribe digoxin and an angiotensin-converting enzyme (ACE) inhibitor when they were indicated (moderately to severely reduced left ventricular ejection fraction). Family physicians expressed more concern over the risks of ACE inhibitors in patients with blood pressure of 100/70 mm Hg or serum creatinine of 2.0 mg/dL and were less likely to prescribe an ACE inhibitor in these settings. Family physicians overestimated the risks of warfarin use for atrial fibrillation and were therefore less likely to prescribe warfarin., Conclusions: Family physicians appear to have less understanding of CHF pathophysiology (ie, systolic versus diastolic dysfunction) and how treatment differs according to the underlying disease process. Overestimation of the risk of ACE inhibitor and warfarin use may result in underprescribing these medications.

We describe the development of an abbreviated version of the Test of Functional Health Literacy in Adults (TOFHLA) to measure patients' ability to read and understand health-related materials. The TOFHLA was reduced from 17 Numeracy items and 3 prose passages to 4 Numeracy items and 2 prose passages (S-TOFHLA). The maximum time for administration was reduced from 22 minutes to 12. In a group of 211 patients given the S-TOFHLA, Cronbach's alpha was 0.68 for the 4 Numeracy items and 0.97 for the 36 items in the 2 prose passages. The correlation (Spearman) between the S-TOFHLA and the Rapid Estimate of Adult Literacy in Medicine (REALM) was 0.80, although there were important disagreements between the two tests. The S-TOFHLA is a practical measure of functional health literacy with good reliability and validity that can be used by health educators to identify individuals who require special assistance to achieve learning goals.

Background: It is not known whether quality of care for congestive heart failure (CHF) at rural hospitals is similar to that in larger, urban hospitals., Methods: We reviewed hospital charts for 310 Medicare patients hospitalized with CHF at six hospitals in rural Georgia., Results: Of the 310 patients, 101 (33%) had left ventricular systolic dysfunction, and 60 (19%) had preserved systolic function. Information on left ventricular function was not available for 48% (range, 29% to 87% across the six hospitals). Among patients with systolic dysfunction, 77% were prescribed an angiotensin converting enzyme (ACE) inhibitor at discharge, and 73% were prescribed digoxin. However, the mean daily ACE inhibitor dose was only 48% of the recommended target dose. Only 30% of all patients with atrial fibrillation were prescribed warfarin., Conclusions: Overall quality of care for CHF at rural hospitals appears similar to that in other settings, though many patients may not receive evaluation of ventricular function.

Context: Elderly patients may have limited ability to read and comprehend medical information pertinent to their health., Objective: To determine the prevalence of low functional health literacy among community-dwelling Medicare enrollees in a national managed care organization., Design: Cross-sectional survey., Setting: Four Prudential HealthCare plans (Cleveland, Ohio; Houston, Tex; south Florida; Tampa, Fla)., Participants: A total of 3260 new Medicare enrollees aged 65 years or older were interviewed in person between June and December 1997 (853 in Cleveland, 498 in Houston, 975 in south Florida, 934 in Tampa); 2956 spoke English and 304 spoke Spanish as their native language. MAIN OUTCOME MEASURE; Functional health literacy as measured by the Short Test of Functional Health Literacy in Adults., Results: Overall, 33.9% of English-speaking and 53.9% of Spanish-speaking respondents had inadequate or marginal health literacy. The prevalence of inadequate or marginal functional health literacy among English speakers ranged from 26.8% to 44.0%. In multivariate analysis, study location, race/language, age, years of school completed, occupation, and cognitive impairment were significantly associated with inadequate or marginal literacy. Reading ability declined dramatically with age, even after adjusting for years of school completed and cognitive impairment. The adjusted odds ratio for having inadequate or marginal health literacy was 8.62 (95% confidence interval, 5.55-13.38) for enrollees aged 85 years or older compared with individuals aged 65 to 69 years., Conclusions: Elderly managed care enrollees may not have the literacy skills necessary to function adequately in the health care environment. Low health literacy may impair elderly patients' understanding of health messages and limit their ability to care for their medical problems.

Objective: To examine the relationship between reading ability and family planning knowledge and practices among Medicaid managed care enrollees., Methods: A total of 406 women age 19-45 years enrolled in TennCare and members of Prudential HealthCare Community Plan in Memphis, Tennessee were interviewed to determine their methods of contraception, desire for additional information about contraceptives, and knowledge about the time in menstrual cycle they are at highest risk for pregnancy. Patient reading ability was assessed by an abbreviated version of the Test of Functional Health Literacy of Adults. The independent associations between reading ability, desire for additional contraceptive information, and knowledge about the highest risk time for pregnancy were assessed with logistic regression., Results: Almost 10% of the respondents had low reading skills. Women who had used an intrauterine device, douching, rhythm, or levonorgestrel implants as methods of birth control had higher rates of low reading skills than women who used other methods of birth control. Compared with women with good reading skills, women with low reading skills were 2.2 times (95% confidence interval [CI] 1.1, 4.4) more likely to want to know more about birth control methods and 4.4 times (95% CI 2.2, 9.0) more likely to have incorrect knowledge about when they were most likely to get pregnant. These relationships were significant even after controlling for age, race, and marital status., Conclusion: Health providers and organizations that serve historically underserved populations must understand that some individuals have a low level of reading ability that limits family planning education.

Objective: To determine the association between patient literacy and hospitalization., Design: Prospective cohort study., Setting: Urban public hospital., Patients: A total of 979 emergency department patients who participated in the Literacy in Health Care study and had completed an intake interview and literacy testing with the Test of Functional Health Literacy in Adults were eligible for this study. Of these, 958 (97.8%) had an electronic medical record available for 1994 and 1995., Measurements and Main Results: Hospital admissions to Grady Memorial Hospital during 1994 and 1995 were determined by the hospital information system. We used multivariate logistic regression to determine the independent association between inadequate functional health literacy and hospital admission. Patients with inadequate literacy were twice as likely as patients with adequate literacy to be hospitalized during 1994 and 1995 (31. 5% vs 14.9%, p <.001). After adjusting for age, gender, race, self-reported health, socioeconomic status, and health insurance, patients with inadequate literacy were more likely to be hospitalized than patients with adequate literacy (adjusted odds ratio [OR] 1.69; 95% confidence interval [CI] 1.13, 2.53). The association between inadequate literacy and hospital admission was strongest among patients who had been hospitalized in the year before study entry (OR 3.15; 95% CI 1.45, 6.85)., Conclusions: In this study population, patients with inadequate functional health literacy had an increased risk of hospital admission.

The objective was to determine physicians' ratings of the clinical importance of common adult symptoms and to use these ratings to develop a new measure of symptom-specific use of health care services. We developed a list of common symptoms using the National Ambulatory Medical Care survey. We surveyed a random sample of internists, family physicians, general practitioners and emergency medicine physicians from the American Medical Association's Physician Masterfile and asked them to rate symptoms' seriousness, impact on quality of life and urgency of need for medical attention. The symptoms' prevalences were determined in a general population survey (National Access to Care Survey). Eleven items were classified as "serious" (median seriousness ratings of 7 or higher on scale from 1 to 10); most of these also were judged to have high impact on quality of life. Another 12 items that were not judged "serious" had median quality of life impact scores of 7 or higher and were classified as "morbid". Sixteen items did not meet criteria for either "serious" or "morbid" symptoms and were classified as "intermediate". Six other items had median seriousness and quality of life impact scores of 3 or less and were classified as "benign". A total of 24 of these items (7 "serious", 8 "morbid", 8 "intermediate" and 1 "benign") were selected to form the symptom-response measure. In the national survey, 26.3% reported one or more serious symptom, 30.6% reported one or more morbid symptom and 29.6% reported one or more intermediate symptom. This new instrument expands on earlier "symptom-response" measures by including a larger number and a broader spectrum of symptoms. This measure should be useful to assess differences in patterns of health care use for particularly serious or morbid conditions; such variations may indicate problems with access to medical care.

Study Objectives: To determine the relationship of literacy to asthma knowledge and ability to use a metered-dose inhaler (MDI) among patients with asthma., Design: Cross-sectional survey., Setting: Emergency department and asthma clinic at an urban public hospital., Patients: Convenience sample of 273 patients presenting to the emergency department for an asthma exacerbation and 210 patients presenting to a specialized asthma clinic for routine care., Interventions: Measurement of literacy with the Rapid Estimate of Adult Literacy in Medicine, asthma knowledge (20 question oral test), and demonstration of MDI technique (six-item assessment)., Measurements and Results: Only 27% of patients read at the high-school level, although two thirds reported being high-school graduates; 33% read at the seventh- to eighth-grade level, 27% at the fourth- to sixth-grade level, and 13% at or below the third-grade level. Mean asthma knowledge scores (+/-SD) were directly related to reading levels: 15.1+/-2.5, 13.9+/-2.5, 13.4+/-2.8, 11.9+/-2.5, respectively (p < 0.01). Patient reading level was the strongest predictor of asthma knowledge score in multivariate analysis. Poor MDI technique (< or =3 correct steps) was found in 89% of patients reading at less than the third-grade level compared with 48% of patients reading at the high-school level. In multivariate regression analyses, reading level was the strongest predictor of MDI technique., Conclusions: Inadequate literacy was common and strongly correlated with poorer knowledge of asthma and improper MDI use.

Objectives: Many patients have limited English proficiency and require an interpreter. The authors evaluated the effect of current interpreting practices on Spanish-speaking patients' satisfaction with the patient-provider relationship., Methods: A cross-sectional survey was conducted of 457 patients seen in a public hospital emergency department. Measures were satisfaction with the provider's friendliness, respectfulness, concern, ability to make the patient comfortable, and time spent for the exam., Results: A total of 237 patients communicated adequately with their provider without the use of an interpreter (group 1), 120 patients communicated through an interpreter (88% of whom were ad hoc interpreters; group 2), and 100 patients communicated directly with the provider but said an interpreter should have been called (group 3). Compared with patients in group 1, patients who communicated through an interpreter (group 2) rated their provider as less friendly, less respectful, less concerned for the patient as a person, and less likely to make the patient comfortable. Patients who said an interpreter should have been called (group 3) had the lowest satisfaction ratings; compared with group 2, they were less satisfied with their provider's friendliness, concern for the patient as a person, efforts to make the patient comfortable, and amount of time spent., Conclusions: Patients who communicated through an interpreter or who did not have an interpreter when they thought one was necessary were less satisfied with the patient-provider relationship. Further efforts are needed to ensure interpreter availability and proper interpretation technique.

Background: The I1307K (T3920 --> A) variant of the APC gene has been identified as a potential risk factor for colorectal cancer and is present in 6% of Ashkenazi Jews. Screening for this mutation may allow identification of people at elevated risk who would benefit from increased surveillance. Methods and Results: We designed an assay to detect the T3920 --> A allele using a primer mismatched at the 3 < 9 terminal nucleotide in the polymerase chain reaction (PCR) to generate a recognition site for the restriction enzyme Mse I. After optimization of the PCR for magnesium ion concentration and annealing temperature, the amplicon did not cut completely with the restriction enzyme in each of four tested DNAs. Sequence analysis of the PCR product that was resistant to digestion revealed that the T3920 --> A variant was not present. The artifact was caused by a single nucleotide loop-out in the genomic DNA template under the 3 < 9 region of the primer, which allowed the 3 < 9 terminal base of the primer to hybridize properly. As a result, the mismatched primer created a modified product different from that originally planned. At a magnesium ion concentration below the optimum for product yield, most of the product was digested by Mse I. Sequence analysis showed that, under these conditions, the intended product was produced. Conclusions: Mismatched primers can produce unintended products in a PCR due to looping out of a nucleotide in the template or the primer. The magnesium ion concentration can influence the sequence and amount of the product.

Objective: To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use., Design: Cohort observational study., Setting: A public hospital in Atlanta, Georgia., Patients: Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years., Measurements and Main Results: Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was O (mean 1.1) with only 90 (26%) of the patients having any primary care clinic visits. The 58 patients (16.6%) who had more than 10 subsequent ED visits accounted for 65.6% of all subsequent ED visits. Overall, patients received 55% of their subsequent ambulatory care in the ED, with only 7.5% in a primary care clinic. In multivariate regression, only access to a telephone (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.39, 0.60), hospital admission (OR 5.90; 95% CI 4.01, 8.76), and primary care visits (OR 1.68; 95% CI 1.34, 2.12) were associated with higher ED visit rates. Regular source of care, insurance coverage, and health status were not associated with ED use. From clinical record review, 74.1% of those with high rates of use had multiple chronic medical conditions, or a chronic medical condition complicated by a psychiatric diagnosis, or substance abuse., Conclusions: All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs.

Objectives: The authors examine the reliability and validity of English and Spanish versions of a patient satisfaction measure, the Interpersonal Aspects of Care (IAC) Examiner Scale., Methods: The examiner scale was administered to 234 Spanish-speaking and 250 English-speaking patients seen in the emergency department of a large public hospital. Reliability and validity coefficients were calculated for both administrations. Differences in item and scale response distributions were compared using two methods of response dichotomization., Results: In general, the examiner scale was reliable and valid. However, the Spanish version of the scale was significantly less reliable and valid. Depending on the method of item response dichotomization, significant differences between Spanish-speaking and English-speaking patients were found for the majority of the individual scale items. This was due primarily to a tendency for Spanish-speaking patients to respond "good" to items more frequently than did English-speaking patients., Conclusions: The results bring into question the use of certain types of response formats and the practice of dichotomizing responses when evaluating patient satisfaction in Spanish-speaking patients.

Background: Inadequate functional health literacy is common, but its impact on patients with chronic diseases is not well described., Objective: To examine among patients with hypertension or diabetes the relationship between their functional health literacy level and their knowledge of their chronic disease and treatment., Methods: We conducted a cross-sectional survey of patients with hypertension and diabetes presenting to the general medicine clinics at 2 urban public hospitals. Literacy was measured by the Test of Functional Health Literacy in Adults. Knowledge of their illness was assessed in patients with diabetes or hypertension using 21 hypertension and 10 diabetes questions based on key elements in educational materials used in our clinics., Results: A total of 402 patients with hypertension and 114 patients with diabetes were enrolled. Mean (+/- SD) knowledge scores for patients with hypertension with inadequate (n = 189), marginal (n = 49), or adequate (n = 155) literacy were 13.2 +/- 3.1, 15.3 +/- 2.2, and 16.5 +/- 2.3, respectively (range, 4-20; P < .001). A total of 92% of patients with hypertension and adequate literacy levels knew that a blood pressure reading of 160/100 mm Hg was high compared with 55% of those in the lowest reading level (P < .001). Mean (+/- SD) knowledge scores for patients with diabetes with inadequate (n = 50), marginal (n = 13), or adequate (n = 51) literacy were 5.8 +/- 2.1, 6.8 +/- 1.9, and 8.1 +/- 1.6, respectively (range, 1-10; P < .001). A total of 94% of patients with diabetes and adequate functional health literacy knew the symptoms of hypoglycemia compared with 50% of those with inadequate literacy (P < .001)., Conclusions: Inadequate functional health literacy poses a major barrier to educating patients with chronic diseases, and current efforts to overcome this appear unsuccessful.

Congenital adrenal hyperplasia due to deficiency of steroid 21-hydroxylase (CYP21) is most frequently due to mutations that arise from the nearby CYP21 pseudogene. The mechanism involves either unequal crossing over, which deletes part of the CYP21 functional gene, or gene conversion which puts a mutation from the pseudogene into the functional gene. We have devised an assay to rapidly screen for five known mutations that are due to gene conversion within an 1,800 bp region of the CYP21 gene--I172N, V281L, Q318X, R356W, and a cluster of mutations in exon 6 (I236N, V237E, M239K). This method is based on a set of nested allele-specific polymerase chain reactions done simultaneously in one tube, for which we suggest the acronym NASA, for nested allele-specific amplification. The assay is capable of detecting the mutations individually as well as all combinations of mutations tested.

This article examines the use of population-based healthcare data at the interface among radiology, healthcare informatics, and health services research for the purposes of healthcare quality management. To illustrate these concepts, we draw on experience with Health Care Financing Administration's Medicare Health Care Quality Improvement Program (HCQIP). We present two HCQIP efforts that have identified opportunities to improve the delivery of imaging services, specifically studies of the diagnosis and management of congestive heart failure and cerebrovascular disease. The examples demonstrate from a population-level perspective that there are opportunities to enhance the quality of imaging practice by reducing the magnitude of imaging practice variability, implementing evidence-based guidelines, and optimizing the communication of imaging study findings to physicians who are responsible for subsequent diagnostic and therapeutic decisions. Additional research is required in specific clinical domains of radiology to determine if implementation of evidence-based imaging guidelines and enhanced clarity in the interpretation and communication of diagnostic imaging will improve health outcomes.

Objectives: This study examined the relationship of functional health literacy to self-reported health and use of health services., Methods: Patients presenting to two large, urban public hospitals in Atlanta, Ga, and Torrance, Calif, were administered a health literacy test about their overall health and use of health care services during the 3 months preceding their visit., Results: Patients with inadequate functional health literacy were more likely than patients with adequate literacy to report their health as poor. Number of years of school completed was less strongly associated with self-reported health. Literacy was not related to regular source of care or physician visits, but patients in Atlanta with inadequate literacy were more likely than patients with adequate literacy to report a hospitalization in the previous year., Conclusions: Low literacy is strongly associated with self-reported poor health and is more closely associated with self-reported health than number of years of school completed.

Objectives: Previous studies have found that health-status measures may be unable to detect clinically important changes for patients whose baseline health is poor (the "floor phenomenon"). It is not known whether this inability to detect change is confined to patients in very poor baseline health or whether the sensitivity of health-status instruments varies across the entire range of health states. The goals of this study were to see how changes in physical health, mental health, and overall health (1) depend on baseline (usual) health and (2) compare with patients' global assessment of changes in their health., Methods: Stable, ambulatory patients presenting to the emergency department of a public hospital retrospectively rated their usual physical health (eight items), mental health (three items), and overall health (one item); their health on the day of study entry using these same items; and their global assessment of the change in their health compared with baseline. Complete information on these items was available for 1,005 patients. Baseline scores on the physical and mental health subscales and the overall health item were divided into five categories: 81 to 100 (best), 61 to 80, 41 to 60, 21 to 40, and 0 to 20 (worst)., Results: The mean difference in health from baseline to emergency department presentation decreased as the baseline health category worsened, as follows: physical health, -26.0, -35.9, -15.1, -9.5, +1.0; mental health, -23.0, -16.1, -9.6, 0.0, 6.6; overall health -64.0, -45.3, -28.4, -8.4, 10.4, respectively. However, patients' global assessment of health change showed the opposite trend; the proportion of patients rating their health as "much worse" than baseline increased as baseline health worsened. When only patients whose physical health score declined less than 10 points were analyzed, 14% of those in the best baseline health said their health was "much worse," whereas 74% of those with the worst baseline physical health said their health was "much worse" than baseline., Conclusions: These findings suggest that the sensitivity of health-status measures to change and the meaning of an incremental change in physical health or mental health vary depending on baseline health. This may result from noninterval properties of response options or from patients being at the lowest health state (the "floor") of individual questions. If health-status measures similar to this are to be used to compare the outcomes of treatment across diseases and for patients in a wide variety of baseline health states, weighting schemes may be needed to account for these effects.

Study Objective: To determine whether race/ethnicity is an important determinant of emergency department use., Methods: We conducted a cross-sectional survey in a public ED to determine self-reported ED visits over the preceding 3 months. The study group comprised consecutive ambulatory patients (N = 1,049) with nonemergency medical problems., Results: Blacks, whites, and Hispanics were equally likely to report one or more visits to an ED in the 3 months before study enrollment. Blacks were the most likely to report two or more ED visits in the preceding 3 months (19.0%), followed by whites (13.5%) and Hispanics (11.4%) (P = .01; unadjusted odds ratio, 1.82 for blacks versus Hispanics). In multivariate analysis, older age (P < .001), health insurance coverage (P < .001), regular source of care (P < .001), and difficulty obtaining transportation to a physician's office (P = .011) were positively associated with two or more previous ED visits. After adjustment for these variables, race/ethnicity was not significantly associated with ED use (P = .23; adjusted odds ratio for blacks versus Hispanics, 1.48 [95% confidence interval, .95 to 2.30])., Conclusion: Race/ethnicity was not an important determinant of ED use after adjustment for age, health insurance coverage, regular source of care, and barriers to health care. Population-based studies of ED use should be conducted to further evaluate whether racial/ethnic differences in ED use exist that are not explained by differences in demographics, health, socioeconomic status, access to care, or other determinants of ED use.

Objective: To describe what is known about the relation of literacy skills to contraceptive use and to suggest directions for future research. An overview of what is known about the literacy skills of Americans and the prevalence of inadequate functional health literacy is presented. Information about reading requirements for various methods of contraception and advice from health educators on dealing with low-literate populations are described., Data Sources: MEDLINE, PsychInfo, and ERIC searches for the last 20 years were completed using the terms literacy, literacy and health, family planning, health status, educational status, risk factors, contraception, and pregnancy., Methods of Study Selection: The primary literature searches identified 125 articles. After reviewing abstracts for these articles, we excluded 79, because they contained no specific mention of literacy or educational status relating to contraception. TABULATION INTEGRATION, AND RESULTS: We were unable to identify and study specifically devoted to the relation between functional literacy and actual use of contraceptives. Forty-six with relevant background or related information were identified: literacy and health (19), adult literacy (nine), literacy and contraception (11), and literacy and family planning (seven). Over one-third of English-speaking and 62% of Spanish-speaking patients had inadequate or marginal functional health literacy in a study conducted at two urban public hospitals. Studies by health educators have demonstrated that information for many types of contraceptives is frequently above the patient's reading level. Available epidemiologic information on the relation between educational status and unplanned pregnancy is also presented., Conclusions: Although no study has specifically addressed how functional health literacy affects contraceptive use, it is reasonable to hypothesize that functional health literacy influences contraceptive knowledge, attitudes, and behaviors. Future research should focus on the relation between functional health literacy and actual use of various contraceptives.

Objectives: To understand the difficulties that patients with poor reading ability have interacting with the health care system and to identify the coping mechanisms they use to deal with these problems., Design: Focus groups and individual interviews with patients who are illiterate and patients with low literacy., Setting: Two large, urban public hospitals., Participants: Sixty patients with marginal to poor reading abilities as measured by the Rapid Estimate of Adult Literacy in Medicine were interviewed in focus groups or individual interviews., Measurements and Main Results: Patients with low literacy harbor a deep sense of shame, which is reinforced by hospital staff who become frustrated or angry when someone cannot complete a form or read instructions. Seeking medical care is intimidating for patients with low literacy because they cannot understand signs and registration forms. Many patients recounted serious medication errors resulting from their inability to read labels. To cope with these problems, the patients with low literacy rely heavily on oral explanations, visual clues, and demonstrations of tasks to learn new material. Most also use a friend or family member as a surrogate reader., Conclusions: Patients with poor reading ability have important problems accessing the health care system, understanding recommended treatments, and following the instructions of providers. Because of their shame, patients with low literacy may be unwilling to disclose their problem to health care providers, and screening tests of reading ability may be necessary to identify those who need special assistance. Patients' coping mechanisms give insight into possible interventions that may improve their interactions with the health care system.

Background: In 1992, under the sponsorship of the U.S. Agency for Health Care Policy and Research, RAND assembled an expert panel to develop the Heart Failure Clinical Practice Guideline. Phase II of the effort was intended to identify which of the guideline's recommendations the panel felt were suitable for use in retrospective utilization review and quality assessment programs and to develop review criteria, performance measures, and standards of quality for use in monitoring compliance with those recommendations., Selection of Recommendations: Selecting guideline recommendations for translation into review criteria and ultimately into standards of care was a multistep process comprising (1) identification of 34 recommendations from the guideline, (2) rating them on the basis of importance to quality of care and feasibility of monitoring, (3) review by a subcommittee and the full guideline panel, (4) translation into review criteria, and (5) further review and input by panelists and peer and pilot reviewers. Finally, standards of care (the minimum proportion of cases expected to be in accordance with guideline recommendations) were determined to be 90%-95% for six of the final criteria and 75%-80% for the other two., Conclusion: Despite some reservations, physicians and other health care professionals agreed to be held accountable for following a core set of guideline recommendations for the treatment of heart failure. Substantial progress was made in identifying recommendations that panelists and reviewers were willing to endorse in utilization review activities, including adoption of improved documentation standards. The review criteria's major impact may be the knowledge that the criteria are in place and that care is being monitored based on those standards.

Objective: To determine how often interpreters were used for Spanish- speaking patients, patients' perceived need for an interpreter, and the impact of interpreter use on patients' subjective and objective knowledge of their diagnosis and treatment., Design: Cross-sectional survey., Setting: Public hospital emergency department., Patients: A total of 467 native Spanish-speaking and 63 English-speaking Latino patients presenting with nonurgent medical problems., Main Outcome Measures: Patients' report of whether an interpreter was used, whether one was needed, self-perceived understanding of diagnosis and treatment, and objective knowledge of discharge instructions., Results: An interpreter was used for 26% of Spanish-speaking patients. For 52%, and interpreter was not used but was not thought to be necessary by the patient. A total of 22% said an interpreter was not used but should have been used. When both the patient's English and the examiner's Spanish were poor, an interpreter was not called 34% of the time, and 87% of the patients who did not have an interpreter thought one should have been used. Nurses and physicians interpreted most frequently (49%), and professional interpreters were used for only 12% of patients. Patients who said an interpreter was not necessary rated their understanding of their disease as good to excellent 67% of the time, compared with 57% of those who used an interpreter and 38% of those who thought an interpreter should have been used (P<.001). For understanding of treatment, the figures were 86%, 82%, and 58%, respectively (P<.001). However, when objective measures of understanding diagnosis and treatment were used, the differences between these groups were smaller and generally not statistically significant. There were no differences between English-speaking Latinos and native Spanish-speakers who said they did not need an interpreter., Conclusions: Interpreters are often not used despite a perceived need by patients, and the interpreters who are used usually lack formal training in this skill. Language concordance and interpreter use greatly affected patients' perceived understanding of their disease, but a high proportion of patients in all groups had poor knowledge of their diagnosis and recommended treatment.

Illiteracy is a well known national crisis, yet relatively little research has focused on how low literacy affects patients' health care experiences. The purpose of this study was to determine the relationship between shame and low functional literacy in the health care setting. It hypothesized that many patients with low literacy may not admit they have difficulty reading because of shame. Patients who presented for acute care at a large, public hospital in Atlanta, Georgia were interviewed. A total of 202 predominately indigent African-American patients completed a demographic survey, the Test of Functional Health Literacy in Adults (TOFHLA) and answered questions about difficulty reading and shame. Of the 202 patients interviewed, 42.6% had inadequate or marginal functional health literacy. Patients with low literacy were more likely to be male (P < 0.05), have less than a high school education (P < 0.01) and be over the age of 60 (P < 0.01). Of those patients with low literacy, 67.4% admitted having trouble reading and understanding what they read. Almost 40% (n = 23) of patients with low functional literacy who acknowledged they have trouble reading admitted shame. Of the 58 patients who had low functional health literacy and admitted having trouble reading, 67.2% had never told their spouses, and 53.4% had never told their children of their difficulties reading. Nineteen percent of patients had never disclosed their difficulty reading to anyone. Many patients with reading problems are ashamed and hide their inability to read. Shame is a deeply harbored emotion that plays an important role in understanding how low literate patients interact with health care providers. Further research is needed to understand how providers should deal with the shame associated with low literacy.

Objective: To determine the ability of patients to complete successfully basic reading and numeracy tasks required to function adequately in the health care setting., Design: Cross-sectional survey., Setting: Two urban, public hospitals., Patients: A total of 2659 predominantly indigent and minority patients, 1892 English-speaking and 767 Spanish-speaking, presenting for acute care., Main Outcome Measure: Functional health literacy as measured by the Test of Functional Health Literacy in Adults (TOFHLA), an instrument that measures ability to read and understand medical instructions and health care information presented in prose passages and passages containing numerical information (eg, prescription bottle labels and appointment slips)., Results: A high proportion of patients were unable to read and understand written basic medical instructions. Of 2659 patients, 1106 (41.6%) were unable to comprehend directions for taking medication on an empty stomach, 691 (26%) were unable to understand information regarding when a next appointment is scheduled, and 1582 (59.5%) could not understand a standard informed consent document. A total of 665 (35.1%) of 1892 English-speaking patients and 473 (61.7%) of 767 Spanish-speaking patients had inadequate or marginal functional health literacy. The prevalence of inadequate or marginal functional health literacy among the elderly (age > or = 60 years) was 81.3% (187/230) for English-speaking patients and 82.6% (57/69) for Spanish-speaking patients, and was significantly higher (P < .001) than in younger patients., Conclusions: Many patients at our institutions cannot perform the basic reading tasks required to function in the health care environment. Inadequate health literacy may be an important barrier to patients' understanding of their diagnoses and treatments, and to receiving high-quality care.

Objective: To develop a valid, reliable instrument to measure the functional health literacy of patients., Design: The Test of Functional Health Literacy in Adults (TOFHLA) was developed using actual hospital materials. The TOFHLA consists of a 50-item reading comprehension and 17-item numerical ability test, taking up to 22 minutes to administer. The TOFHLA, the Wide Range Achievement Test--Revised (WRAT-R), and the Rapid Estimate of Adult Literacy in Medicine (REALM) were administered for comparison. A Spanish version was also developed (TOFHLA-S)., Setting: Outpatient settings in two public teaching hospitals., Patients: 256 English- and 249 Spanish-speaking patients were approached. 78% of the English- and 82% of the Spanish-speaking patients gave informed consent, completed a demographic survey, and took the TOFHLA or TOFHLA-S., Results: The TOFHLA showed good correlation with the WRAT-R and the REALM (correlation coefficients 0.74 and 0.84, respectively). Only 52% of the English speakers completed more than 80% of the questions correctly. 15% of the patients could not read and interpret a prescription bottle with instructions to take one pill by mouth four times daily, 37% did not understand instructions to take a medication on an empty stomach, and 48% could not determine whether they were eligible for free care., Conclusions: The TOFHLA is a valid, reliable indicator of patient ability to read health-related materials. Data suggest that a high proportion of patients cannot perform basic reading tasks. Additional work is needed to determine the prevalence of functional health illiteracy and its effect on the health care experience.

Study Objective: To determine emergency department patients' perceptions of their illness urgency, their attempts to get care elsewhere, and the proportion of patients referred to the ED., Design: Cross-sectional design with self-administered questionnaires or interviews., Setting: Public hospital in Los Angeles County, California., Participants: Consecutive ambulatory patients totaling 1,190., Results: Most patients thought that they required immediate medical attention, even if they said that their condition was not serious, painful, or debilitating. Half of all patients sought care elsewhere before coming to the ED, and 38.2% had seen a doctor. Forty-four percent of all patients said they were referred to the ED by a doctor or a nurse. Referred patients had illness acuteness similar to that of patients who came to the ED on their own., Conclusion: In addition to their lack of access to other providers, patients' perceived need for immediate care and referrals by health professionals contribute to ED use for nonemergency conditions.

Objective: This article reviews the incidence of arterial thromboembolism in patients with heart failure who are not receiving anticoagulants. We also examine whether more severe ventricular dysfunction increases this incidence and the efficacy and risks of anticoagulation for patients in sinus rhythm., Data Sources: English-language studies referenced in MEDLINE or EMBASE (January 1966 to September 1993) were reviewed. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with the terms anticoagulation, cerebrovascular disorders, stroke, and thromboembolism., Study Selection: All studies with separate data for patients with chronic heart failure not receiving anticoagulants were included. Articles addressing valvular heart disease or heart failure secondary to acute myocardial infarction or Chagas' disease were excluded. Studies of the occurrence of left ventricular mural thrombi were also reviewed., Data Extraction and Synthesis: Inclusion and exclusion criteria, prevalence of atrial fibrillation, mean follow-up, and the occurrence of arterial thromboembolic events were extracted. If the incidence was not given, this was estimated using the proportion of patients with events divided by the mean follow-up., Conclusion: The incidence of arterial thromboembolism ranged from 0.9 to 5.5 events per 100 patient-years, with the largest studies reporting incidence of 2.0% and 2.4%. Findings regarding the relationship between ventricular function and thromboembolic events are contradictory. No controlled trial has assessed the efficacy or risks of anticoagulation for patients with heart failure and sinus rhythm, and reported efficacy in case series ranged from 0% to 100%. Until adequate studies are performed, anticoagulation should be discouraged for patients with heart failure who are in sinus rhythm.

Objective: This article reviews the benefits and risks of coronary artery bypass grafting and angioplasty for patients with moderate or severe left ventricular systolic dysfunction and summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline., Data Sources: Data were obtained from studies published in English and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with the terms coronary artery bypass grafting and angioplasty., Study Selection: All cohort studies and case series that provided separate outcomes data on a subgroup of patients with a left ventricular ejection fraction less than 0.40 were reviewed., Data Extraction and Synthesis: Studies were reviewed for inclusion and exclusion criteria, survival, and functional status measures using a standardized form. Cohort studies were assessed on eight aspects of study quality using a defined list of study flaws., Conclusion: Coronary artery bypass grafting improves 3-year survival by approximately 30% to 50% and physical functioning by approximately one New York Heart Association class in patients with moderate to severe left ventricular dysfunction and limiting angina. However, the operative mortality ranges from 5% to 30% depending on patients' ejection fractions and comorbidity. It is not clear whether patients whose predominant symptom is heart failure rather than angina benefit from bypass surgery or how much ischemia is required to justify surgical intervention. Clinical outcomes after angioplasty have not been adequately studied to determine the relative risks and benefits compared with bypass grafting.

Objective: This article reviews the role of counseling, education, dietary modifications, and exercise for patients with heart failure due to left ventricular systolic dysfunction., Data Source: We reviewed studies published in English between 1966 and 1993 and referenced in MEDLINE or EMBASE. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with terms for the specific areas of interest. Where data were lacking, we relied on opinions of panel members and peer reviewers. STUDY SELECTION AND DATA SYNTHESIS: Studies were reviewed to determine whether patients had heart failure due to systolic dysfunction (left ventricular ejection fraction, < 0.35 to 0.40) and whether clinical outcomes were reported. Studies that reported only intermediate outcomes (eg, hemodynamics) were not reviewed., Conclusion: Counseling and education can improve patient outcomes and decrease unnecessary hospitalizations. Patients with mild to moderate heart failure should be restricted to 3 g/d of sodium initially. Those who are unresponsive to this dosage or who have more severe disease should be advised to consume 2 g/d or less. Patients should be strongly advised to drink no more than 30 mL/d of alcohol or, preferably, to abstain completely. Exercise training is safe and can improve exercise duration and symptoms. Adherence to the treatment plan should be stressed and monitored at each visit. Clinicians should inform patients of the seriousness of their disease and their prognosis, but they should emphasize that patients can continue to remain active and enjoy a reasonable quality of life.

Objective: This review of the pharmacologic treatment of heart failure due to left ventricular systolic dysfunction summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline. It provides specific advice to help guide practitioners through clinical decision making., Data Sources: Data were obtained from English-language studies and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with terms for the specific treatments. Where data were lacking, we relied on opinions of panel members and peer reviewers., Study Selection: Only large prospective trials were used to estimate treatment efficacy. Smaller trials, case series, and case reports were reviewed for the incidence of adverse effects., Data Extraction and Synthesis: Randomized clinical trials were reviewed for inclusion and exclusion criteria, patient outcomes, adverse effects, and eight categories of study quality using a defined list of study flaws., Conclusion: Angiotensin-converting enzyme (ACE) inhibitors should be given to all patients unless specific contraindications exist. Diuretics should be used judiciously early in treatment to prevent excessive diuresis that could prevent titration of ACE inhibitors to target doses. Digoxin has not been shown to affect the natural history of heart failure and should be reserved for patients who remain symptomatic after treatment with ACE inhibitors and diuretics. Isosorbide dinitrate and hydralazine hydrochloride should be tried in patients who cannot tolerate ACE inhibitors or who have refractory symptoms.

Objective: To determine the regular source of care and the relationship between usual provider and use of medical services among ambulatory emergency department patients., Design: Cross-sectional survey., Setting: A public hospital in Los Angeles County, California., Patients: A total of 1190 stable, ambulatory adults presenting to the emergency department during a 2-week period., Main Outcome Measures: Self-reported regular source of care, usual health status, and recent physician visits., Results: A total of 16% of the patients identified an emergency department as their regular source of care. One fourth of this group reported fair or poor health. African Americans and Latinos were more likely than whites to identify an emergency department as their regular source of care. Patients who identified an emergency department as their regular source of care had 25% fewer physician visits and were less likely to have seen a physician during the preceding 3 months than patients who were usually seen in an office or clinic (relative risk, 0.45; 95% confidence interval, 0.28 to 0.70). Of all patients, 56% identified a regular source of care other than an emergency department, but 24% to 36% of all their recent physician visits still occurred in an emergency department., Conclusion: Our patients rely heavily on emergency departments for ambulatory physician visits, regardless of their reported regular source of care. However, patients who identify an emergency department as their regular source of ambulatory care used physician services less frequently than patients with access to providers in other settings. These issues require further evaluation with population-based surveys.

Study Objectives: To determine the hospital characteristics associated with patients leaving emergency departments prior to physician evaluation., Design: Cross-sectional design with data collection by mail and telephone survey., Setting: Los Angeles County, California., Type of Participants: Convenience sample of four public and 26 private hospital EDs with a combined monthly volume of 92,570., Interventions: None., Results: Questionnaires were returned from 83% of EDs surveyed. During 1990, 4.2% of patients at these EDs left without being seen by a physician. In all, 7.3% of public hospital patients left without being seen, and 2.4% of private hospital patients left without being seen (P < .001). The percentage of patients who left without being seen was significantly higher at EDs with longer waiting times, higher fraction of uninsured patients, and at hospitals with accredited residency training programs (P < .001 for each comparison). A logistic regression model, used to simultaneously evaluate the effects of multiple correlated factors, revealed that waiting time, fraction of patients uninsured, and teaching status had independent positive associations with patients who left without being seen., Conclusion: More than 4% of patients who seek care at EDs in Los Angeles County leave without being seen by a physician. A greater proportion of patients leave without medical evaluation from EDs with long waiting times for ambulatory patients and from those that serve uninsured populations. These findings should be interpreted in light of existing data on the health consequences faced by patients who leave hospital EDs without treatment.

Objective: To determine whether patients who sought care at a public hospital emergency department and left without being seen by a physician needed immediate medical attention and whether they obtained care after leaving., Design: Follow-up study of patients who left without being seen and of patients who waited to be seen by a physician., Setting: A public hospital's emergency department in Torrance, Calif., Patients: All patients who registered for care and left without being seen (n = 186) and a 20% random sample of patients who waited until they were seen (n = 211) in a 2-week period during spring 1990., Main Outcome Measures: At time of presentation: triage nurse urgency assessment, clinical acuity rating, and self-reported health status. At follow-up: hospitalization rates., Results: Patients who left reported that they had waited 6.4 hours before leaving; those who stayed reported a 6.2-hour wait before being seen. There were no differences between those who left and those who stayed in chief complaint, triage nurse assessment, acuity ratings, or self-reported health status. Forty-six percent of those who left were judged to need immediate medical attention, and 29% needed care within 24 to 48 hours. Eleven percent of those who left were hospitalized within the next week, and three patients required emergency surgery. Nine percent of those who waited to be seen were hospitalized. Forty-nine percent of patients who left did not see a physician during the 1-week follow-up period., Conclusion: Overcrowding in this public hospital's emergency department restricts access to needed ambulatory medical care for the poor and uninsured.

On the basis of principles that are similar to (but differ slightly from) those that underlie M mode and two dimensional techniques, pulsed Doppler echocardiography permits evaluation of intracardiac blood flow noninvasively. This technique is helpful in the diagnosis and management of patients with valvular and congenital heart disease, and in some circumstances provides information not available from M mode or two dimensional imaging. Despite several notable limitations, pulsed Doppler echocardiography is a useful diagnostic technique whose clinical application is likely to increase as future technologic improvements occur.

Sixty-five patients were studied for the presence of aortic insufficiency by auscultation, conventional M mode echocardiography (echo), range-gated pulse Doppler flowmeter (Doppler), and supravalvular aortic angiography. Aortic insufficiency was demonstrated angiographically in 49 patients, of which eight (16%) were missed by auscultation. Echo missed 20 (41%), and Doppler missed seven (14%). Only two (4%) were missed by auscultation and Doppler combined. All methods were highly specific, but the combination of auscultation and Doppler was the most sensitive noninvasive method for detecting aortic insufficiency.