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Low Literacy Is Associated with Increased Risk of Hospitalization and Death Among Individuals with Heart Failure

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ABSTRACT

BACKGROUND

Low literacy increases the risk for many adverse health outcomes, but the relationship between literacy and adverse outcomes in heart failure (HF) has not been well studied.

METHODS

We studied a cohort of ambulatory patients with symptomatic HF (NYHA Class II-IV within the past 6 months) who were enrolled in a randomized controlled trial of self-care training recruited from internal medicine and cardiology clinics at four academic medical centers in the US. The primary outcome was combined all-cause hospitalization or death, with a secondary outcome of hospitalization for HF. Outcomes were assessed through blinded interviews and subsequent chart reviews, with adjudication of cause by a panel of masked assessors. Literacy was measured using the short Test of Functional Health Literacy in Adults. We used negative binomial regression to examine whether the incidence of the primary and secondary outcomes differed according to literacy.

RESULTS

Of the 595 study participants, 37 % had low literacy. Mean age was 61, 31 % were NYHA class III/IV at baseline, 16 % were Latino, and 38 % were African-American. Those with low literacy were older, had a higher NYHA class, and were more likely to be Latino (all p < 0.001). Adjusting for site only, participants with low literacy had an incidence rate ratio (IRR) of 1.39 (95 % CI: 0.99, 1.94) for all-cause hospitalization or death and 1.36 (1.11, 1.66) for HF-related hospitalization. After adjusting for demographic, clinical, and self-management factors, the IRRs were 1.31 (1.06, 1.63) for all-cause hospitalization and death and 1.46 (1.20, 1.78) for HF-related hospitalization.

CONCLUSIONS

Low literacy increased the risk of hospitalization for ambulatory patients with heart failure. Interventions designed to mitigate literacy-related disparities in outcomes are warranted.

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References

  1. Evangelista LS, Rasmusson KD, Laramee AS, Barr J, Ammon SE, Dunbar S, Ziesche S, Patterson JH, Yancy CW. Health literacy and the patient with heart failure-implications for patient care and research: a consensus statement of the Heart Failure Society of America. J Card Fail. 2010;16:9–16.

    Article  PubMed  Google Scholar 

  2. Kutner M, Greenberg E, Baer J. A first look at the literacy of america’s adults in the 21st century. Baltimore: US Department of Education; 2005.

    Google Scholar 

  3. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155:97–107.

    Article  PubMed  Google Scholar 

  4. Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19:1228–39.

    Article  PubMed  Google Scholar 

  5. Herndon JB, Chaney M, Carden D. Health literacy and emergency department outcomes: a systematic review. Ann Emerg Med. 2011;57:334–45.

    Article  PubMed  Google Scholar 

  6. DeWalt DA, Broucksou KA, Hawk V, Baker DW, Schillinger D, Ruo B, Bibbins-Domingo K, Holmes M, Weinberger M, Macabasco-O’Connell A, Pignone M. Comparison of a one-time educational intervention to a teach-to-goal educational intervention for self-management of heart failure: design of a randomized controlled trial. BMC Heal Serv Res. 2009;9:99.

    Article  Google Scholar 

  7. Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, Ferguson TB, Ford E, Furie K, Gillespie C, Go A, Greenlund K, Haase N, Hailpern S, Ho PM, Howard V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott MM, Meigs J, Mozaffarian D, Mussolino M, Nichol G, Roger VL, Rosamond W, Sacco R, Sorlie P, Stafford R, Thom T, Wasserthiel-Smoller S, Wong ND, Wylie-Rosett J. Heart disease and stroke statistics–2010 update: a report from the american heart association. Circulation. 2010;121:e46–215.

    Article  PubMed  Google Scholar 

  8. van Jaarsveld CH, Ranchor AV, Kempen GI, Coyne JC, van Veldhuisen DJ, Sanderman R. Epidemiology of heart failure in a community-based study of subjects aged > or = 57 years: incidence and long-term survival. Eur J Heart Fail. 2006;8:23–30.

    Article  PubMed  Google Scholar 

  9. Young JB. The global epidemiology of heart failure. Med Clin North Am. 2004;88:1135–43. ix.

    Article  PubMed  Google Scholar 

  10. Giamouzis G, Kalogeropoulos A, Georgiopoulou V, Laskar S, Smith AL, Dunbar S, Triposkiadis F, Butler J. Hospitalization epidemic in patients with heart failure: risk factors, risk prediction, knowledge gaps, and future directions. J Card Fail. 2011;17:54–75.

    Article  PubMed  Google Scholar 

  11. Riegel B, Moser DK, Anker SD, Appel LJ, Dunbar SB, Grady KL, Gurvitz MZ, Havranek EP, Lee CS, Lindenfeld J, Peterson PN, Pressler SJ, Schocken DD, Whellan DJ. State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association. Circulation. 2009;120:1141–63.

    Article  PubMed  Google Scholar 

  12. Laramee AS, Morris N, Littenberg B. Relationship of literacy and heart failure in adults with diabetes. BMC Heal Serv Res. 2007;7:98.

    Article  Google Scholar 

  13. Murray MD, Tu W, Wu J, Morrow D, Smith F, Brater DC. Factors associated with exacerbation of heart failure include treatment adherence and health literacy skills. Clin Pharmacol Ther. 2009;85:651–8.

    Article  PubMed  CAS  Google Scholar 

  14. Dewalt DA, Schillinger D, Ruo B, Bibbins-Domingo K, Baker DW, Holmes GM, Weinberger M, Macabasco-O’Connell A, Broucksou K, Hawk V, Grady KL, Erman B, Sueta CA, Chang PP, Cene CW, Wu JR, Jones CD, Pignone M. Multisite randomized trial of a single-session versus multisession literacy-sensitive self-care intervention for patients with heart failure. Circulation. 2012;125:2854–62.

    Article  PubMed  Google Scholar 

  15. Nurss JR, Parker RM, Baker DW. Test of functional health literacy in adults. Snow Camp: Peppercorn Books and Press, Inc; 2001.

    Google Scholar 

  16. DeWalt DA, Schillinger D, Ruo B, Bibbins-Domingo K, Baker DW, Holmes GM, Weinberger M, Macabasco-O’Connell A, Broucksou K, Hawk V, Grady KL, Erman B, Dupree C, Chang P, Cene CW, Wu JR, Jones CD, Pignone M. A multisite randomized trial of a single- versus multi-session literacy sensitive self-care intervention for patients with heart failure. Circulation. 2012;125(23):2854–62

    Google Scholar 

  17. Baker DW, Brown J, Chan KS, Dracup KA, Keeler EB. A telephone survey to measure communication, education, self-management, and health status for patients with heart failure: the improving chronic illness care evaluation (icice). J Card Fail. 2005;11:36–42.

    Article  PubMed  Google Scholar 

  18. Kroenke K, Spitzer RL, Williams JB. The phq-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13.

    Article  PubMed  CAS  Google Scholar 

  19. Ackermann RT, Rosenman MB, Downs SM, Holmes AM, Katz BP, Li J, Zillich AJ, Carney CP, Inui TS. Telephonic case-finding of major depression in a medicaid chronic disease management program for diabetes and heart failure. Gen Hosp Psychiatry. 2005;27:338–43.

    Article  PubMed  Google Scholar 

  20. Macabasco-O’Connell A, Dewalt DA, Broucksou KA, Hawk V, Baker DW, Schillinger D, Ruo B, Bibbins-Domingo K, Holmes GM, Erman B, Weinberger M, Pignone M. Relationship between literacy, knowledge, self-care behaviors, and heart failure-related quality of life among patients with heart failure. J Gen Intern Med. 2011;26:979–986.

  21. Baker DW, Dewalt DA, Schillinger D, Hawk V, Ruo B, Bibbins-Domingo K, Weinberger M, Macabasco-O’Connell A, Grady KL, Holmes GM, Erman B, Broucksou KA, Pignone M. The effect of progressive, reinforcing telephone education and counseling versus brief educational intervention on knowledge, self-care behaviors and heart failure symptoms. J Card Fail. 2011;17:789–96.

    Article  PubMed  Google Scholar 

  22. Ni H, Nauman D, Burgess D, Wise K, Crispell K, Hershberger RE. Factors influencing knowledge of and adherence to self-care among patients with heart failure. Arch Intern Med. 1999;159:1613–9.

    Article  PubMed  CAS  Google Scholar 

  23. Mathew J, Wittes J, McSherry F, Williford W, Garg R, Probstfield J, Yusuf S. Racial differences in outcome and treatment effect in congestive heart failure. Am Heart J. 2005;150:968–76.

    Article  PubMed  Google Scholar 

  24. Lafata JE, Pladevall M, Divine G, Ayoub M, Philbin EF. Are there race/ethnicity differences in outpatient congestive heart failure management, hospital use, and mortality among an insured population? Med Care. 2004;42:680–9.

    Article  PubMed  Google Scholar 

  25. Prisant LM, Thomas KL, Lewis EF, Huang Z, Francis GS, Weaver WD, Pfeffer MA, McMurray JJ, Califf RM, Velazquez EJ. Racial analysis of patients with myocardial infarction complicated by heart failure and/or left ventricular dysfunction treated with valsartan, captopril, or both. J Am Coll Cardiol. 2008;51:1865–71.

    Article  PubMed  CAS  Google Scholar 

  26. Alexander M, Grumbach K, Remy L, Rowell R, Massie BM. Congestive heart failure hospitalizations and survival in California: patterns according to race/ethnicity. Am Heart J. 1999;137:919–27.

    Article  PubMed  CAS  Google Scholar 

  27. Brown DW, Haldeman GA, Croft JB, Giles WH, Mensah GA. Racial or ethnic differences in hospitalization for heart failure among elderly adults: medicare, 1990 to 2000. Am Heart J. 2005;150:448–54.

    Article  PubMed  Google Scholar 

  28. Deswal A, Petersen NJ, Urbauer DL, Wright SM, Beyth R. Racial variations in quality of care and outcomes in an ambulatory heart failure cohort. Am Heart J. 2006;152:348–54.

    Article  PubMed  Google Scholar 

  29. Philbin EF, DiSalvo TG. Influence of race and gender on care process, resource use, and hospital-based outcomes in congestive heart failure. Am J Cardiol. 1998;82:76–81.

    Article  PubMed  CAS  Google Scholar 

  30. Rathore SS, Foody JM, Wang Y, Smith GL, Herrin J, Masoudi FA, Wolfe P, Havranek EP, Ordin DL, Krumholz HM. Race, quality of care, and outcomes of elderly patients hospitalized with heart failure. JAMA. 2003;289:2517–24.

    Article  PubMed  Google Scholar 

  31. Kutner M, Greenberg EA, Jin Y, Paulsen C. The health literacy of America’s adults: results from the 2003 national assessment of adult literacy (nces 2006–483). Washington DC: National Center for Education Statistics; 2006.

    Google Scholar 

  32. DeWalt DA, Malone RM, Bryant ME, Kosnar MC, Corr KE, Rothman RL, Sueta CA, Pignone MP. A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [isrctn11535170]. BMC Heal Serv Res. 2006;6:30.

    Article  Google Scholar 

  33. Murray MD, Young J, Hoke S, Tu W, Weiner M, Morrow D, Stroupe KT, Wu J, Clark D, Smith F, Gradus-Pizlo I, Weinberger M, Brater DC. Pharmacist intervention to improve medication adherence in heart failure: a randomized trial. Ann Intern Med. 2007;146:714–25.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The project described was supported by Award Number R01HL081257 from the National Heart, Lung, And Blood Institute and a supplement to that grant provided under the American Recovery and Reinvestment Act of 2009 (ARRA). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, And Blood Institute or the National Institutes of Health.

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The authors declare that they do not have a conflict of interest.

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Correspondence to Jia-Rong Wu PhD, RN.

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Wu, JR., Holmes, G.M., DeWalt, D.A. et al. Low Literacy Is Associated with Increased Risk of Hospitalization and Death Among Individuals with Heart Failure. J GEN INTERN MED 28, 1174–1180 (2013). https://doi.org/10.1007/s11606-013-2394-4

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  • DOI: https://doi.org/10.1007/s11606-013-2394-4

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