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      The impact of health literacy on shared decision making before elective surgery: a propensity matched case control analysis

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          Abstract

          Background

          Poor health literacy affects over 90 million Americans. The primary aim of the study was to evaluate a possible association between health literacy and decision conflict in surgical patients.

          Methods

          Patients undergoing a diverse number of elective surgeries were enrolled in the study. Health literacy was measured using the Newest Vital Sign instrument and decision conflict using the low literacy version of the Decision Conflict Scale.

          Results

          200 patients undergoing elective surgeries were included in the study. Patients who had greater health literacy scores had lower decision conflict scores, Spearman’s rho = − 0.43, P < 0.001. Following propensity-score matching to account for potential covariates, the median (IQR) decision conflict score was 20 (0 to 40) for patients with poor health literacy compared to 0 (0 to 5) for patients with adequate literacy, P < 0.001.

          Conclusions

          Poor health literacy is associated with greater decision conflict in patients undergoing elective surgical procedures. Strategies should be implemented to minimize decision conflict in poor health literacy patients undergoing elective surgical procedures.

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          Addressing health literacy in patient decision aids

          Kirsten J McCaffery, Margaret Holmes-Rovner, Sian K Smith … (2013)
          Background Effective use of a patient decision aid (PtDA) can be affected by the user’s health literacy and the PtDA’s characteristics. Systematic reviews of the relevant literature can guide PtDA developers to attend to the health literacy needs of patients. The reviews reported here aimed to assess: 1. a) the effects of health literacy / numeracy on selected decision-making outcomes, and b) the effects of interventions designed to mitigate the influence of lower health literacy on decision-making outcomes, and 2. the extent to which existing PtDAs a) account for health literacy, and b) are tested in lower health literacy populations. Methods We reviewed literature for evidence relevant to these two aims. When high-quality systematic reviews existed, we summarized their evidence. When reviews were unavailable, we conducted our own systematic reviews. Results Aim 1: In an existing systematic review of PtDA trials, lower health literacy was associated with lower patient health knowledge (14 of 16 eligible studies). Fourteen studies reported practical design strategies to improve knowledge for lower health literacy patients. In our own systematic review, no studies reported on values clarity per se, but in 2 lower health literacy was related to higher decisional uncertainty and regret. Lower health literacy was associated with less desire for involvement in 3 studies, less question-asking in 2, and less patient-centered communication in 4 studies; its effects on other measures of patient involvement were mixed. Only one study assessed the effects of a health literacy intervention on outcomes; it showed that using video to improve the salience of health states reduced decisional uncertainty. Aim 2: In our review of 97 trials, only 3 PtDAs overtly addressed the needs of lower health literacy users. In 90% of trials, user health literacy and readability of the PtDA were not reported. However, increases in knowledge and informed choice were reported in those studies in which health literacy needs were addressed. Conclusion Lower health literacy affects key decision-making outcomes, but few existing PtDAs have addressed the needs of lower health literacy users. The specific effects of PtDAs designed to mitigate the influence of low health literacy are unknown. More attention to the needs of patients with lower health literacy is indicated, to ensure that PtDAs are appropriate for lower as well as higher health literacy patients.
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            Decision aids for patients facing a surgical treatment decision: a systematic review and meta-analysis.

            Anouk Knops, Dink Legemate, Astrid Goossens … (2013)
            To summarize the evidence available on the effects of decision aids in surgery. When consenting to treatment, few patients adequately understand their treatment options. To help patients make deliberate treatment choices, decision aids provide evidence-based information on the disease, treatment options, and their associated benefits and harms. Although decision aids are not designed to direct patients toward a particular treatment option, it is possible that their introduction will change the proportion of patients that opt for surgery. We searched electronic databases for studies that evaluated a decision aid in patients offered both surgery and alternative treatment options, regarding the effect on the actual treatment choices made. In addition, we documented effects on knowledge, decisional conflict, anxiety, quality of life, patient involvement, satisfaction, mortality, morbidity, and costs. Seventeen studies were included. Overall, methodological study quality was good. Patients in the decision aid group less often chose to undergo invasive treatment [risk ratio = 0.80; 95% confidence interval, 0.67-0.95), had more knowledge about treatment options [mean difference = 8.99; 95% confidence interval, 3.20-14.78), and experienced less decisional conflict (mean difference = -5.04; 95% confidence interval, -7.10 to -2.99). Levels of anxiety and quality of life were similar. Offering a decision aid increases the number of patients who prefer conservative or less invasive treatment options. As decision aids improve patient knowledge and lower decisional conflict without raising anxiety levels, they have a place in surgery to help surgeons and patients achieve well-considered and shared treatment decisions.
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              Health literacy and 30-day postdischarge hospital utilization.

              Suzanne Mitchell, Ekaterina Sadikova, Brian Jack … (2012)
              Low health literacy is associated with higher mortality, higher rates of hospitalization, and poor self-management skills for chronic disease. Early, unplanned hospital reutilization after discharge is a common and costly occurrence in U.S. hospitals. Still, few studies have examined the relation between health literacy and 30-day hospital reutilization rates. The authors examined the association between health literacy and 30-day reutilization of hospital services (readmission or return to the emergency department) in an urban safety net hospital, and conducted a secondary analysis of data from the control arm subjects of the Project RED and the RED-LIT trials. Health literacy was measured using the REALM tool. The primary outcome was rate of 30-day reutilization. The authors used multivariate Poisson regression analysis to control for potential confounding. Of the 703 subjects, 20% had low health literacy, 29% had marginal health literacy, and 51% had adequate health literacy. Sixty-two percent of subjects had a 12th-grade education or less. Subjects with low health literacy were more likely to be insured by Medicaid (p < .001); Black non-Hispanic (p < .001); unemployed, disabled, or retired (p < .001); low income (p < .001); and less educated (high school education or less, p < .001). The fully adjusted incidence rate ratio for low health literacy compared with adequate health literacy was 1.46 (CI [1.04, 2.05]). Low health literacy is a significant, independent, and modifiable risk factor for 30-day hospital reutilization after discharge. Interventions designed to reduce early, unplanned, hospital utilization after discharge should include activities to mitigate the effect of patients' low health literacy.
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                Author and article information

                Contributors
                Gildasio S. De Oliveira Jr: 401-444-4943 , Gildasio-DeOliveira@lifespan.org , Gildasio.deoliveira@lifespan.org
                Martin Errea: erream@gmail.com
                Jane Bialek: jbiale2@uic.edu
                Mark C. Kendall: Mark.kendall@lifespan.org
                Robert J. McCarthy: Robert_J_McCarthy@rush.edu
                Journal
                Journal ID (nlm-ta): BMC Health Serv Res
                Journal ID (iso-abbrev): BMC Health Serv Res
                Title: BMC Health Services Research
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1472-6963
                Publication date (Electronic): 12 December 2018
                Publication date PMC-release: 12 December 2018
                Publication date Collection: 2018
                Volume: 18
                Electronic Location Identifier: 958
                Affiliations
                [1 ]ISNI 0000 0004 1936 9094, GRID grid.40263.33, Department of Anethesiology, Alpert School Of Medicine, , Brown University, ; 593 Eddy Street, Davol 129, Providence, Rhode Island USA
                [2 ]ISNI 0000 0004 1936 9094, GRID grid.40263.33, Department of Health Services Research, Practice and Policy, School of Public Health, , Brown University, ; Providence, Rhode Island USA
                [3 ]ISNI 0000 0001 2299 3507, GRID grid.16753.36, Department of Radiology, , Northwestern University, Feinberg School of Medicine, ; Chicago, Illinois USA
                [4 ]ISNI 0000 0001 2175 0319, GRID grid.185648.6, University of Illinois at Chicago, School of Medicine, ; Chicago, Illinois USA
                [5 ]ISNI 0000 0001 0705 3621, GRID grid.240684.c, Department of Anesthesiolgy, , Rush University Medical Center, ; Chicago, Illinois USA
                [6 ]ISNI 0000 0004 1936 9094, GRID grid.40263.33, Department of Surgery, , Alpert School of Medicine, Brown University, ; Providence, Rhode Island USA
                Article
                Publisher ID: 3755
                DOI: 10.1186/s12913-018-3755-9
                PMC ID: 6292056
                PubMed ID: 30541541
                SO-VID: bc046d69-1f40-425d-ac76-d74f78e17292
                Copyright © © The Author(s). 2018
                License:

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 17 May 2018
                Date accepted : 22 November 2018
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100000133, Agency for Healthcare Research and Quality;
                Award ID: K08HS024158
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2018

                ScienceOpen disciplines: Health & Social care
                Keywords: health literacy decision conflict elective surgery
                Data availability:
                ScienceOpen disciplines: Health & Social care
                Keywords: health literacy decision conflict elective surgery

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