Low Health Literacy Linked to Mortality in CHF Patients

Asking congestive heart failure patients just three simple questions can determine their health literacy level and might just keep them alive longer, according to a study by Kaiser Permanente and other researchers in Colorado.

"Measuring health literacy is extremely helpful, because clinicians make inferences about patients' literacy levels that are not always correct," says Pamela Peterson, MD, the lead author of the report and an affiliate investigator with Kaiser Permanente Colorado Institute for Health Research in Denver.

For example, she says, "the patient could be a PhD graduate, but may not be able to function well anymore or understand how to take care of himself. Knowing what you're dealing with is important from the beginning."

That way, she says, doctors and nurses can focus precious time on those patients who need more help understanding and following instructions and medication regimens to make sure they don't wind up in the hospital in worse condition. "You may want to have more layers of support in between visits to the doctor," she says.

It's expensive, and requires more personnel time. "But I think it's worth it," she says.

In the study, 17.5% of 1,494 CHF patients who agreed to participate, or nearly one in five was found to have low health literacy. Their risk of dying from any cause during the 1.2-year average follow-up was 17.6%, much higher than the 6.3% mortality in those whose responses indicated high health literacy.

After adjusting for demographic variables, socioeconomic status, education and co-morbidities, low health literacy "remained independently associated with an increased risk of mortality," the authors wrote

The report did not say why patients with low health literacy were more likely to die in the follow-up period, but the authors speculate that these patients may have "a greater misunderstanding of medications" and therefore have less ability to perform successful self-management of their chronic disease.

The study is published in Wednesday's edition of the Journal of the American Medical Association.

The three simple questions the research recommend clinicians ask are:

1. How often do you have someone help you read hospital materials?

2. How often do you have problems learning about your medical condition because of difficulty reading hospital materials?

3. How confident are you filling out forms by yourself?

The researchers mailed questionnaires to Denver-area Kaiser enrollees who had been diagnosed and hospitalized at least once with CHF. Those who didn't respond to e-mail had the questions read to them by telephone. A total of 1,494 eligible enrollees agreed to participate. Answers were stratified in groups of five.

While patients with lower levels of literacy turned out to be older, of lower socioeconomic status, and less likely to have a high school education and higher rates of co-existing illnesses, that wasn't always the case, she says.

Previous studies attempting to measure health literacy have done so with much more complex, interviewer-administered instruments that are impractical in a busy clinic practice, they wrote. That's why this study was unique, Peterson says.

Once they've identified a patient with low health literacy, clinicians should be sure to use "teach-back" techniques, "to ensure the patient can restate what you want them to understand. You have to reinforce education over time, and continuously check for understanding. But we as clinicians aren't always taught that, or know that at a system level, we should put in place frequent structured follow-ups or check-ins."

With patients found to have low health literacy, clinicians need to be cautious, as well. "It's sensitive topic. You don't want people to be labeled that they're not smart. Just asking someone 'do you know what this means?' can make people feel insecure and points out their deficiencies. You don't want to make people feel bad."

"Assessment of health literacy should be performed with care and sensitivity, because the social implications of identifying a patient as being of low health literacy could be counterproductive," they wrote.