Ask 3 Questions to Rate Patients' Health Literacy : A lack of health literacy skills can lead to delayed diagnoses and poor adherence to medical advice.


PHOENIX — Three brief screening questions enable physicians to spot patients lacking the literacy skills necessary to understand and act upon health care information, Lorraine S. Wallace, Ph.D., said at a congress sponsored by the Association for Academic Surgery and the Society of University Surgeons.

“Surgeons should consider administering these three screening items to identify patients at increased risk of having limited health literacy skills,” said Dr. Wallace of the department of family medicine at the University of Tennessee, Knoxville.

“Our results pretty much echo what other researchers have found regarding the three questions in primary care settings,” he added.

According to the Institute of Medicine's landmark 2004 report, “Health Literacy: A Prescription to End Confusion,” nearly 50% of English-speaking adults lack the literacy skills needed to adequately use the health care system.

The consequences of a lack of health literacy skills include delayed diagnoses, poor adherence to medical advice, less use of preventive services, deficient self-management skills, more hospitalizations, and worse short- and long-term health outcomes.

By one estimate, the price tag for poor health literacy adds up to $69 billion per year.

Moreover, last year the Editorial Projects in Education Research Center, supported by the Bill and Melinda Gates Foundation, reported that fully 30% of U.S. ninth graders fail to finish high school with a diploma.

Dr. Wallace noted that more than 800 published studies demonstrate that patient education materials are far too difficult for the average patient to understand. The great majority of this research has been conducted in primary care settings and has relied upon assessment tools that are too cumbersome for use in clinical practice.

Despite this large body of evidence, however, limited health literacy “still isn't even on residents' radar screens” at most academic medical centers, Dr. Wallace said.

“The first issue for physician educators is to get them to understand that the high school dropout rate across America is 29%. That's who your patient population is,” he said.

Dr. Wallace sought to determine whether the screening questions for limited health literacy previously studied in primary care are also accurate in the surgical setting.

The questions were as follows:

▸ How often do you have someone (like a family member, friend, or hospital worker) help you read hospital materials?

▸ How confident are you filling out medical forms by yourself?

▸ How often do you have problems learning about your medical condition because of difficulty understanding written information?

Patients rate their answers to each question on a 1–5 scale.

Dr. Wallace studied 100 adult patients attending a vascular surgery clinic for an initial consultation.

None of these patients had overt psychiatric illness or severe cognitive impairment. They averaged 62 years of age. Sixty-five of the patients were women. Ninety-six were Caucasian, reflecting the demographics of east Tennessee. A total of 32 had failed to complete high school.

All participants were assessed according to the Rapid Estimate of Adult Literacy in Medicine (REALM), which is considered the accepted standard for evaluating patient literacy skills. Thirty-nine patients scored in the limited or marginal health literacy range.

The area under the receiver operating characteristic curves for each of the three screening questions using REALM scores as the reference standard was 0.83–0.86. That's a favorable result. It indicates these specific questions are effective in identifying patients at greatest risk of limited health literacy.

“These questions are nonthreatening. It's not like asking, 'Can you read?' Studies have shown that patients with limited literacy skills do indeed harbor a tremendous amount of shame,” Dr. Wallace explained.

“It's information they're not about to offer to anyone, let alone their physician,” he said.

The audience pressed Dr. Wallace as to what exactly she does differently when the screening questions identify a patient with a problem.

She replied that although it's clear the clinical interaction has to be tailored accordingly, “there is not really any hard evidence to date as to what will work, unfortunately.”

Dr. Wallace and her coinvestigators hope to change that. The study that she presented is a part of a larger ongoing patient/surgeon communication project aimed at providing specific guidance to physicians.

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