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.
educational status socioeconomic factors patient admission patient readmission hospitalization
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Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: National Center for Education, US Dept of Education; 1993.Google Scholar
Williams MV, Parker R, Baker D. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995;274:1677–82.PubMedCrossRefGoogle Scholar
Baker DW, Parker RM, Williams MV, et al. The health care experience of patients with low literacy. Arch Fam Med. 1996;5:329–34.PubMedCrossRefGoogle Scholar
Powers RD. Emergency department patient literacy and the readability of patient-directed materials. Ann Emerg Med. 1988;17:124–6.PubMedCrossRefGoogle Scholar
Doak L, Doak C. Patient comprehension profiles: recent findings and strategies. Patient Couns Health Educ. 1980;2:101–6.PubMedCrossRefGoogle Scholar
Leichter S, Nieman J, Moore R, Collins P, Rhodes A. Readability of self-care instructional pamphlets for diabetic patients. Diabetes Care. 1981;4:627–30.PubMedCrossRefGoogle Scholar
Holcomb C. Reading difficulty of informational materials from a health maintenance organization. J Reading. 1981;25:130–2.Google Scholar
Boyd M, Citro K. Cardiac patient education literature: can patients read what we give them? J Card Rehab. 1983;3:513–6.Google Scholar
McNeal B, Salisbury Z, Baumgardner P, Wheeler F. Comprehension assessment of diabetes education program participants. Diabetes Care. 1984;7:232–5.PubMedCrossRefGoogle Scholar
Jaycox S. Smoking literature and literacy levels. Am J Public Health. 1989;79:1058. Letter.PubMedGoogle Scholar
Davis T, Crouch M, Willis G, Miller S, Abdehou D. The gap between patient reading comprehension and the readability of patient education materials. J Fam Pract. 1990;31:533–8.PubMedGoogle Scholar
Jackson R, Davis T, Bairnsfather L, George R, Crouch M, Gault H. Patient reading ability: an overlooked problem in health care. South Med J. 1991;84:1172–5.PubMedCrossRefGoogle Scholar
Davis T, Mayeaux E, Fredrickson D, Bocchini J, Jackson R, Murphy P. Reading ability of parents compared with reading level of pediatric patient education materials. Pediatrics. 1994;93:460–8.PubMedGoogle Scholar
Jolly B, Scott J, Feied C, Sanford S. Functional illiteracy among emergency department patients: a preliminary study. Ann Emerg Med. 1993;22:573–8.PubMedCrossRefGoogle Scholar
Spandorfer J, Karras D, Hughes L, Caputo C. Comprehension of discharge instructions by patients in an urban emergency department. Ann Emerg Med. 1995;25:71–4.PubMedCrossRefGoogle Scholar
Williams MV, Baker DW, Parker RM. Differences in disease knowledge between patients with adequate and inadequate functional health literacy. Arch Intern Med. 1998;158:166–72.PubMedCrossRefGoogle Scholar
Kitagawa EM, Hauser PM. Differential Mortality in the United States: A Study in Socioeconomic Epidemiology. Cambridge, Mass: Harvard University Press; 1973.Google Scholar
Guralnik JM, Land KC, Blazer D, Fillenbaum GG, Branch LG. Educational status and active life expectancy among older blacks and whites. N Engl J Med. 1993;329:110–6.PubMedCrossRefGoogle Scholar
Feldman JJ, Makuc DM, Kleinman JC, Cornoni-Huntley J. National trends in educational differentials in mortality. Am J Epidemiol. 1989;129:919–33.PubMedGoogle Scholar
Nelson MD Jr. Socioeconomic status and childhood mortality in North Carolina. Am J Public Health. 1992;82:1131–3.PubMedGoogle Scholar
Tofler GH, Muller JE, Stone PH, Davies G, Davis VG, Braunwald E. Comparison of long-term outcome after acute myocardial infarction in patients never graduated from high school with that in more educated patients. Multicenter Investigation Limitation Infarct Size (MILIS). Am J Cardiol. 1993;71:1031–5.PubMedCrossRefGoogle Scholar
Keil JE, Sutherland SE, Knapp RG, Lackland DT, Gazes PC, Tyroler HA. Mortality rates and risk factors for coronary disease in black as compared with white men and women. N Engl J Med. 1993;329:73–8.PubMedCrossRefGoogle Scholar
Stamler R, Hardy RJ, Payne GH. Educational level and five-year all-cause mortality in the hypertension detection and follow-up program. Hypertension. 1987;9:641–6.Google Scholar
Parikh NS, Parker RM, Nurss JR, Baker DW, Williams MV. Shame and health literacy: the unspoken connection. Patient Educ Counseling. 1996;27:33–9.CrossRefGoogle Scholar
Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25:391–5.PubMedGoogle Scholar
Kuh D, Stirling S. Socioeconomic variation in admission for disease of female genital system and breast in a national cohort aged 15–43. BMJ. 1995;311:840–3.PubMedGoogle Scholar
Weiss BD, Blanchard JS, McGee DL, et al. Illiteracy among Medicaid recipients and its relationship to health care costs. J Health Care Poor Underserved. 1994;5:99–111.PubMedGoogle Scholar
Baker DW, Parker RM, Williams MV, Clark WS, Nurss JR. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health. 1997;87:1027–30.PubMedGoogle Scholar
Parker RM, Baker DW, Williams MV, Nurss JR. The Test of Functional Health Literacy in Adults (TOFHLA): a new instrument for measuring patient’s literacy skills. J Gen Intern Med. 1995;10:537–42.PubMedCrossRefGoogle Scholar
Taylor W. Cloze procedure: a new tool for measuring readability. Journalism Q. 1953;30:415–33.Google Scholar
Ware JE. SF-36 Health Survey: Manual and Interpretation Guide. Boston, Mass: The Health Institute, New England Medical Center; 1993.Google Scholar
Stewart AL, Greenfield S, Hays RD, et al. Functional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study. JAMA. 1989;262:907–13.PubMedCrossRefGoogle Scholar
Prevalence of selected risk factors for chronic disease by education level in racial/ethnic populations—United States, 1991–1992. MMWR. 1995;1004:894–9.Google Scholar
Health Care Financing Review: Medicare and Medicaid Statistical Supplement, 1995. Baltimore, Md: Health Care Financing Administration; 1996.Google Scholar
Hussey LC. Minimizing effects of low literacy on medication knowledge and compliance among the elderly. Clin Nurs Res. 1994;3:132–45.PubMedCrossRefGoogle Scholar
Revell L. Understanding, identifying, and teaching the low-literacy patient. Semin Periop Nurs. 1994;3:168–71.Google Scholar
Berger D, Inkelas M, Myhre S, Mishler A. Developing health education materials for inner-city low literacy parents. Public Health Rep. 1994;109:168–72.PubMedGoogle Scholar
Plimpton S, Root J. Materials and strategies that work in low literacy health communication. Public Health Rep. 1994;109:86–92.PubMedGoogle Scholar
Meade CD, McKinney WP, Barnas GP. Educating patients with limited literacy skills: the effectiveness of printed and videotaped materials about colon cancer. Am J Public Health. 1994;84:119–21.PubMedCrossRefGoogle Scholar
Brown P, Ames N, Mettger W, et al. Closing the comprehension gap: low literacy and the Cancer Information Service. Monogr Natl Cancer Inst. 1993;157–63.Google Scholar
Overland JE, Hoskins PL, McGill MJ, Yue DK. Low literacy: a problem in diabetes education. Diabetic Med. 1993;10:847–50.PubMedCrossRefGoogle Scholar
Weiss BD. Identifying and communicating with patients who have poor literacy skills. Fam Med. 1993;25:369–70.PubMedGoogle Scholar
Hussey LC. Overcoming the clinical barriers of low literacy and medication noncompliance among the elderly. J Gerontol Nurs. 1991;17:27–9.PubMedGoogle Scholar
Said MB, Consoli S, Jean J. A comparative study between a computer-aided education (ISIS) and habitual education techniques for hypertensive patients. J Am Med Inform Assoc. 1994; (symp suppl): 10–14.Google Scholar
Michielutte R, Bahnson J, Dignan M, Schroeder E. The use of illustrations and narrative text style to improve readability of a health education borchure. J Cancer Educ. 1992;7:251–60.PubMedCrossRefGoogle Scholar
McCabe B, Tysinger JW, Kreger M, Currwin A. A strategy for designing effective patient education materials. J Am Diet Assoc. 1989;89:1290–5.PubMedGoogle Scholar