Journal of General Internal Medicine

, Volume 28, Issue 9, pp 1174–1180 | Cite as

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

  • Jia-Rong Wu
  • George M. Holmes
  • Darren A. DeWalt
  • Aurelia Macabasco-O’Connell
  • Kirsten Bibbins-Domingo
  • Bernice Ruo
  • David W. Baker
  • Dean Schillinger
  • Morris Weinberger
  • Kimberly A. Broucksou
  • Brian Erman
  • Christine D. Jones
  • Crystal W. Cene
  • Michael Pignone
Original Research



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.


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.


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.


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


heart failure outcomes literacy 



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.

Conflict of Interest

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


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Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Jia-Rong Wu
    • 1
  • George M. Holmes
    • 2
    • 3
  • Darren A. DeWalt
    • 2
    • 4
  • Aurelia Macabasco-O’Connell
    • 5
  • Kirsten Bibbins-Domingo
    • 6
  • Bernice Ruo
    • 7
  • David W. Baker
    • 7
  • Dean Schillinger
    • 6
  • Morris Weinberger
    • 3
  • Kimberly A. Broucksou
    • 8
  • Brian Erman
    • 2
  • Christine D. Jones
    • 4
  • Crystal W. Cene
    • 4
  • Michael Pignone
    • 2
    • 4
  1. 1.School of NursingUniversity of North Carolina at Chapel HillChapel HillUSA
  2. 2.Cecil G. Sheps Center for Health Services ResearchUniversity of North Carolina at Chapel HillChapel HillUSA
  3. 3.Health Policy and ManagementUniversity of North Carolina at Chapel HillChapel HillUSA
  4. 4.Division of General Internal MedicineUniversity of North Carolina at Chapel HillChapel HillUSA
  5. 5.UCLA School of NursingUniversity of California, Olive View–UCLA Medical Center Los AngelesLos AngelesUSA
  6. 6.Division of General Internal Medicine and Center for Vulnerable Populations, Department of Medicine at San Francisco General HospitalUniversity of California San FranciscoSan FranciscoUSA
  7. 7.Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  8. 8.Carolina MeadowsChapel HillUSA

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