Health Literacy and Emergency Department Outcomes: A Systematic Review

THE PRACTICE OF EMERGENCY MEDICINE/REVIEW ARTICLE

Health Literacy and Emergency Department Outcomes: A Systematic Review Jill Boylston Herndon, PhD, Michelle Chaney, MS, Donna Carden, MD From the Department of Health Outcomes and Policy and Institute for Child Health Policy (Herndon, Chaney), and Department of Emergency Medicine (Carden), College of Medicine, University of Florida, Gainesville, FL.

Study objective: We assess emergency department (ED) patients’ health literacy, the readability of ED patient materials, and the relationship between health literacy and ED outcomes through a systematic literature review. Methods: PubMed, PsychInfo, CINAHL, Web of Knowledge, and ERIC were searched for studies published January 1, 1980, to July 15, 2010, conducted in the United States, reporting original data, and measuring ED patients’ health literacy, the readability of ED materials, or the association between health literacy and EDrelated outcomes. Two reviewers evaluated each study and abstracted information from included studies into evidence tables. Results: We identified 413 articles, and 31 met inclusion criteria. Collectively, health literacy skills were assessed at or below the eighth-grade level for approximately 40% of ED patients. In contrast, ED patient materials were typically assessed at or above the ninth-grade level. Studies of adults aged 65 years and older found that those with lower health literacy were more likely to use the ED and incur higher ED costs. Studies of pediatric ED patients did not find direct effects of caregiver literacy on ED outcomes. Conclusion: A substantial proportion of ED patients have limited health literacy, and ED materials are typically too complex for these patients. It is important for EDs to evaluate the accessibility and patient understanding of information presented. The evidence linking health literacy to ED outcomes is limited. Additional research is needed to better understand the relationship between health literacy and ED outcomes. [Ann Emerg Med. 2011; 57:334-345.] A podcast for this article is available at www.annemergmed.com. 0196-0644/$-see front matter Copyright © 2010 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2010.08.035

INTRODUCTION Health literacy is defined as “[t]he degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”1 The Institute of Medicine has recognized that health literacy not only encompasses reading and writing ability but also quantitative literacy, or “numeracy,” skills.2 Health literacy influences patients’ abilities to read and interpret health information, understand prescription labels, participate in medical decisionmaking, and undertake selfmanagement of health conditions. Results of the National Adult Literacy Survey indicate that approximately half of US adults have limited literacy that impedes their ability to successfully complete everyday activities.3,4 Equivalent nationally representative, population-based studies of health literacy do not exist. However, a pooled analysis of 85 US health literacy studies, representing 31,129 adults, found that the prevalence of low or marginal health literacy was 46%.5 Health literacy skills are particularly important for patients presenting to the emergency department (ED). The American 334 Annals of Emergency Medicine

College of Emergency Physicians defines an emergency as “any health care service provided to evaluate and/or treat any medical condition such that a prudent layperson possessing an average knowledge of medicine and health, believes that immediate unscheduled medical care is required.”6 Although what constitutes “an average knowledge of medicine and health” is ill defined, health literacy likely affects a patient’s decision to seek emergency medical care. Moreover, ED patients and their caregivers must process information about complex conditions and make critical decisions rapidly. Health literacy may integrally affect patient-physician communication and the ability to act on information provided during the ED encounter. Because preventing poor health outcomes requires compliance with medical advice and appropriate selfmanagement, health literacy also may influence ED visit-related outcomes and subsequent ED use. A systematic literature review of the relationship between health literacy and a broad range of health outcomes found limited health literacy to be associated with lower scores on global health measures, poorer health-related knowledge, and a Volume , .  : April 

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decreased likelihood of receiving recommended screenings and preventive services.7 However, no ED outcomes were reported. We undertook this review to evaluate what is known about ED patients’ health literacy, the association between health literacy and ED outcomes, and make recommendations for future research based on identified gaps in knowledge.

MATERIALS AND METHODS We conducted a systematic review of published studies that addressed the following questions: 1. What is the health literacy of patients presenting to the ED? 2. What is the readability of materials presented to patients during the ED encounter? 3. Are health literacy skills related to ED use and outcomes? We searched MEDLINE, PsychInfo, CINAHL, ISI Web of Knowledge, Cochrane Database, and ERIC, using the following search terms: (1) “literacy” or “health literacy” or “numeracy” or “wide range achievement test” or “WRAT” or “rapid estimate of adult literacy in medicine” or “test of functional health literacy in adults” or “TOFHLA” or “readability” or “reading level,” combined with (2) “emergency department” or “emergency room” or “emergency care” or “emergency utilization” or “emergency outcomes” or “emergency service, hospital” (Medical Subject Headings). We also examined the National Library of Medicine Current Bibliographies in Medicine and bibliographies of other health literacy systematic reviews to identify additional articles. Because our focus is on literacy as it pertains to current ED care and outcomes in the United States, we restricted our search to English-language articles published January 1, 1980, to July 15, 2010, and conducted in the United States. Studies that did not contain original data, were not yet published (eg, conference abstracts), or could not be located were excluded. For the first question, we included studies that measured literacy among patients presenting to the ED using a validated literacy instrument. For the second question, we included studies that assessed the readability of materials presented to ED patients. For the third question, studies that examined the relationship between ED patients’ literacy and ED use or other ED outcome measures were included, and we excluded studies that examined the effect of a literacy intervention on ED outcomes. All 3 authors (J.B.H., M.C., D.C.) conducted the original abstract reviews, with 2 reviewers assigned to each abstract. Abstracts for which the 2 reviewers did not agree were evaluated by the third reviewer and a consensus decision was reached. Articles not excluded after abstract review and those for which abstracts were not available underwent a full-text review. Two of the authors (J.B.H., D.C.) independently evaluated the full-text articles to determine which met inclusion criteria. One author (J.B.H.) extracted data from the retained articles into evidence tables, and a second (D.C.) checked the tables for accuracy. We evaluated the strength of evidence for articles addressing our third study question: are health literacy skills associated with Volume , .  : April 

Figure. Health literacy review flow diagram.

ED use or outcomes? Each study was independently graded by 2 reviewers (J.B.H., D.C.) on the following 7 dimensions adapted from West et al8 and used in previous systematic reviews7,9,10: adequacy of the study population, comparability of subjects, validity and reliability of the literacy measurement, maintenance of comparable groups, outcome measurement, appropriateness of the statistical analysis, and approaches to control for confounding. Grading was based on a 3-item scale of good (2 points), fair (1 point), or poor (0 points), and the reviewers were blinded to each other’s grades during the evaluation process. Consistent with the approach used in previous reviews,7,9 the scores were summed and averaged across the number of reviewers and the number of questions. The overall score was classified as good if equal to or greater than 1.5, fair if equal to or greater than 1.0 and less than 1.5, and poor if less than 1.0.

RESULTS A total of 413 unduplicated articles were identified, and 31 were retained for final analysis, with some addressing more than 1 question (Figure). The primary reasons for exclusion were because the study did not contain a valid health literacy measure or readability assessment or because the study did not involve an ED setting, patient population, or outcome. Two studies assessing ED patients’ health literacy11,12 were excluded because the patient samples were subsets of other included studies.13,14 Two studies were excluded from the third question because health literacy was used as a control variable rather than a Annals of Emergency Medicine 335

Health Literacy and Emergency Department Outcomes primary predictor of ED use or outcomes; however, both studies met the inclusion criteria for the first question.15,16 We retained multiple studies drawing from the same sample population if they offered insight into different aspects of health literacy or the relationship between health literacy and ED outcomes. Studies with overlapping samples are indicated in notes appended to the evidence tables. Literacy of Patients Presenting to the ED Table 1 summarizes the evidence on ED patient health literacy. Eleven studies used the Test of Functional Health Literacy in Adults (TOFHLA) or its short form (ShortTOFHLA [S-TOFHLA]) to assess health literacy, 6 used the Rapid Estimate of Adult Literacy in Medicine (REALM), and 2 used the Wide Range Achievement Test (WRAT). The TOFHLA is based on materials used in health care settings, contains 50 reading comprehension items and 17 numerical ability items, and has a timed administration of 22 minutes.32 The S-TOFHLA has 36 reading comprehension items and 4 numerical ability items, with a timed administration of 12 minutes.33 An abbreviated S-TOFHLA includes only the 36 reading comprehension items and can be administered in 7 minutes.34 The TOFHLA and STOFHLA instruments have English and Spanish versions, and test scores are divided into 3 functional health literacy categories (adequate, marginal, and inadequate). The REALM assesses adult reading ability in medical settings, includes both medical word recognition and pronunciation tests using 66 common health-related words, and takes only 1 to 2 minutes to administer.35 The WRAT is a 57-item general literacy skills test that takes less than 5 minutes to administer and is widely used in a variety of settings, including medical settings.36 The REALM and the WRAT are available in English only. The WRAT allows individuals to be assigned to specific grade-equivalent reading levels, whereas the REALM categorizes results into grade ranges (0 to 3, 4 to 6, 7 to 8, and ⱖ9). The REALM grade ranges of at or below the sixth grade, seventh to eighth grade, and at or above the ninth grade correspond to the TOFHLA/STOFHLA categories of inadequate, marginal, and adequate, respectively.37 The REALM and TOFHLA instruments were developed in the 1990s for application specifically in health care settings and were validated against the WRAT.32,35 Although the TOFHLA instruments can be administered in Spanish and have more robust health literacy measures, the REALM and WRAT allow for more rapid assessment. All 3 instruments have good validity and reliability and are well correlated with one another.37 Which test is most appropriate depends on the purpose for assessing literacy, administration logistics, and patient characteristics.37 Among the 11 studies that used the TOFHLA or STOFHLA, the percentage of patients with limited literacy (inadequate or marginal categories) ranged from 10.5% of caretakers of pediatric patients presenting to a Midwestern urban university Level I trauma center ED28 to 48% of 336 Annals of Emergency Medicine

Herndon, Chaney & Carden adults presenting to an urban public hospital ED in Atlanta.13 Studies measuring health literacy among both English and Spanish speakers (using the English and Spanish versions of the TOFLHA/S-TOFHLA, respectively) found considerably lower health literacy scores among Spanish speakers.13,14,17 Brice et al17 suggest this disparity might be explained by variations in Spanish dialects, with consequent variation in understanding of the language used in the TOFHLA/S-TOFHLA, and by lack of familiarity with US health care practices among recent immigrants. However, 2 studies reported that language was not independently associated with health literacy after adjusting for years of education.13,21 More generally, among studies that used multivariable regression models to identify the factors associated with limited health literacy among ED patients, older age and lower education were consistently found to be significant predictors.13,17,18,21 In the only study that reported TOFHLA results by sex, a higher percentage of women were found to have limited health literacy compared with men (57% versus 49%).15 There also was a range in findings among the 5 studies that used the REALM. The percentage of patients reading below the ninth-grade level ranged from 27% of parents of young children presenting to the Johns Hopkins pediatric ED29 to 88% of patients 60 years of age and older presenting to 3 rural Midwestern EDs.23 Of the 2 studies that reported literacy using the WRAT, only 1 provided a grade-level equivalence. Spandorfer et al27 reported functional illiteracy (⬍fifth-grade level) among 40% of English-speaking ED patients presenting to a Level I trauma center in Philadelphia. Because there was a wide range in findings, we used the data provided on the sample sizes in each study and the number of patients within each literacy category to estimate the overall prevalence of limited literacy in the ED population among the included studies. We excluded one study15 from the calculation that was a subsample of another included study.13 Collectively, approximately 40% of ED patients represented in the included studies were identified as having limited health literacy skills, ie, less than ninth-grade level. In addition to assessing overall literacy, Williams et al13 separately examined responses to the TOFHLA numeracy questions for patients presenting to 2 urban EDs. A substantial percentage of patients lacked the basic numeracy skills to correctly interpret health information. One fourth could not identify their next appointment, and one third did not understand how many pills of a prescription should be taken. Although we included “numeracy” as a search term, we located only 1 additional article that focused on ED patients’ numeracy skills.22 Ginde et al22 found that approximately one third of ED patients were unable to answer the most basic numeracy question and 85% could not answer the most difficult question. Although the numeracy questions were not health specific, they have been used in other medical setting studies to assess patients’ numeracy skills.38,39 Volume , .  : April 

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Table 1. Studies measuring health literacy of ED patients.

Reference

Literacy Instrument (Language of Administration)*

Brice et al, 200817

TOFHLA (English and Spanish)

Matched cohort of native English-speaking 172 subjects; 86 and native Spanish-speaking adults and matched pairs pediatric guardians ⱖ18 y and presenting to ED of a suburban, academic medical center in North Carolina for nonurgent, acute care

Derose et al, † 200115

TOFHLA (English and Spanish)

Adults ⱖ18 y, English and Spanish speakers, presenting to the ED of a public hospital in Torrance, CA, with nonurgent complaints

599 overall (387 women; 212 men) (206 English; 393 Spanish)

Adults (ⱖ18 y), English and Spanish speakers, at a Level I inner-city pediatric and adult trauma center ED (study also included patients at 3 community health clinics) Adult (ⱖ18 y), native English speaking patients and ESL patients at a Level I inner-city pediatric and adult trauma center ED

398 overall; 101 ED patients (ED patients were overwhelmingly English speakers)

Downey and Zun, S-TOFHLA (RC) 200818 (English and Spanish)

Downey and Zun, S-TOFHLA (NS) and 200719 BEST (English)

Sample Description

100 overall (52 native English, 48 ESL)

Duffy and Snyder, 199920

REALM (English)

Ginde et al, 200821

S-TOFHLA (RC) Adults (ⱖ18 y), English and Spanish 300 (English and speakers at 3 urban, university-affiliated Spanish) EDs in Boston 4 general numeracy Adults, English and Spanish speakers, 959 total (536 study 1; questions enrolled in 2 separate studies: (1) 423 study 2) (English and patients 18–54 y with acute asthma Spanish) from 26 EDs in 17 states and (2) patients ⱖ18 y with any presenting complaint at 4 EDs in Massachusetts

Ginde et al, 200822

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Adult patients or caretakers at the ED at the Medical University of South Carolina Medical Center

Sample Size

110

Health Literacy Findings English speaking (n⫽86): Distribution: 6% inadequate 1% marginal 93% adequate Spanish speaking (n⫽86): Distribution: 48% inadequate 26% marginal 26% adequate Overall (n⫽599): 36% inadequate 18% marginal 46% adequate Women (n⫽387): 38% inadequate 19% marginal 43% adequate Men (n⫽212): 34% inadequate 15% marginal 51% adequate ED site (n⫽101): 22% marginal or inadequate 78% adequate

Overall sample (n⫽100): 16% inadequate 16% marginal 68% adequate Native (n⫽52): 10% inadequate 10% marginal 81% adequate ESL (n⫽48): 23% inadequate 23% marginal 54% adequate 19% ⱕthird grade 9% fourth–sixth grade 20% seventh– eighth grade 50% ⱖninth grade 25% marginal or inadequate (range 19%–31% across 3 ED sites) 75% adequate Study 1: One numeracy question (n⫽536) 61% answered “coin flip” question correctly Study 2: 4 numeracy questions (n⫽423) 69% answered “coin flip” question correctly, 52% answered “dice” question correctly, 35% answered “big bucks” question correctly, 15% answered “sweepstakes” question correctly

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Table 1. Continued. Literacy Instrument (Language of Administration)*

Reference

Sample Description

Sample Size

23

REALM (English)

Adults ⱖ60 y, English-speaking ED patients presenting to 3 rural Midwestern EDs and classified as urgent or deferrable at triage

Hayes, 200024

REALM (English)

Adults (ⱖ18 y), English-speaking ED patients or caregivers of ED patients presenting to 3 rural Midwestern EDs, classified as urgent or deferrable at triage; patients stratified by age into young to middle-aged adults (18–59 y) and older adults (ⱖ60 y)

195 (91 18–59 y; 104 ⱖ60 y)

Joyner-Grantham et al, 200925

WRAT4 (English)

85

Murray et al, 200916

S-TOFHLA (RC) (English)

Adult (ⱖ18 y), English-speaking patients who presented to Wake Forest University Baptist Medical Center ED with a history of hypertension Adults ⱖ50 y, English-speaking patients with a diagnosis of heart failure who required an ED visit or hospitalization within a city-county health system

Sanders et al, 200726

S-TOFHLA (RC) (English and Spanish)

Hayes, 1998

Spandorfer et al, WRAT (English) 199527

Children 12 mo–12 y and their caregivers (English and Spanish speakers) who received care from a pediatric ED of an urban, public hospital in Florida English-speaking patients or their caretakers discharged from Level I trauma center ED at Temple University Hospital in Philadelphia Parents and guardians of pediatric patients who presented to a Midwestern urban university Level I trauma center ED English-speaking parents of children ⬍6 y and presenting to the Johns Hopkins Pediatric ED

Tran et al, 200828

S-TOFHLA (RC) (English)

Trifiletti et al, 200629

REALM (English)

Williams et al, 199513

TOFHLA (Atlanta: Patients ⱖ18 y, English and Spanish English; Torrance: speakers, presenting to the EDs at 2 English and urban public hospitals in Atlanta, GA, Spanish) and Torrance, CA

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60

Health Literacy Findings Mean reading level: seventh– eighth grade 23% ⱕsixth-grade level 65% seventh– eighth grade 12% ⱖninth grade Mean reading level: seventh– eighth grade Distribution: 8% ⱕsixth-grade level 54% seventh– eighth grade 38% ⱖninth grade No statistically significant differences between the 2 age groups Mean WRAT score: below average

192 total participants of All-cause ED visits (n⫽126): 68% whom 131 (126 with adequate an HL assessment) Heart failure–specific ED visits had an “all-cause” ED (n⫽21): 38% adequate visit and 23 (21 with HL assessment) had a “heart failure–specific” ED visit 290 child-caregiver Distribution: pairs; 276 with HL 18% inadequate assessment 5% marginal 77% adequate 217 Mean reading level: sixth grade 40% ⱕfourth grade (functionally illiterate) 181

59

2,659 (1,892 English; 767 Spanish)

Distribution: 3.3% inadequate 7.2% marginal 89.5% adequate Distribution: 0% ⱕthird grade 13.5% fourth–sixth grade 13.5% seventh– eighth grade 73% ⱖninth grade Atlanta: English (n⫽979): 35% inadequate 13% marginal 53% adequate Torrance: All (n⫽1,680): 26% inadequate 14% marginal 60% adequate Torrance: English (n⫽913): 13% inadequate 10% marginal 78% adequate Torrance: Spanish (n⫽767): 42% inadequate 20% marginal 38% adequate

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Table 1. Continued.

Reference Williams et al, 199830

Literacy Instrument (Language of Administration)* REALM (English)

Yin et al, 200714 TOFHLA and S-TOFHLA

Zun et al, 200631

REALM and S-TOFHLA (RC) (English)

Sample Description

Sample Size

Health Literacy Findings

Adult (ⱖ18 y) English-speaking patients at 483 overall; 273 ED ED site: an urban public hospital in Atlanta 13% ⱕthird grade presenting to the ED with an asthma 22% fourth–sixth grade exacerbation (also examined HL of 37% seventh– eighth grade patients presenting for routine care in 28% ⱖninth grade specialized asthma clinic) Caregivers (English and Spanish 292 overall; 289 with Overall sample (n⫽289): speakers) of children aged 30 days–8 y HL assessment (277 Distribution: and presenting to an urban pediatric ED TOFHLA; 12 S10% inadequate in New York City, with a nonurgent visit TOFHLA) (181 16% marginal English; 108 Spanish) 74% adequate English administered (n⫽181): 6% inadequate 13% marginal 81% adequate Spanish administered (n⫽108): 17% inadequate 20% marginal 63% adequate Adult (ⱖ18 y) patients or caregivers with 105 (98 completed REALM (n⫽98): Hispanic surnames and self-proclaimed REALM; 93 completed 5% ⱕthird grade bilingual speakers of Spanish and S-TOFHLA) 29% fourth–sixth grade English at an inner-city Level I pediatric 66% ⱖseventh grade and adult trauma ED STOFHLA (n⫽93): 17% inadequate 11% marginal 72% adequate

S-TOFHLA (RC), Short TOFHLA, reading comprehension only; S-TOFHLA (NS), Short TOFHLA, version not specified; BEST, Basic English Skills Test; ESL, English as a second language; HL, health literacy. *The TOFHLA and S-TOFHLA instruments classify scores into inadequate, marginal, and adequate categories. Approximate grade-level equivalencies are at or below sixth grade⫽inadequate; seventh to eighth grade⫽marginal; ⱖninth grade⫽adequate.37 † Derose et al15 patient sample is a subset of those in the study by Williams et al.13

Readability of ED Materials

Relationship between Health Literacy and ED Outcomes

Table 2 summarizes studies that assessed the readability of ED materials. Discharge instructions were commonly written at the ninth- to eleventh-grade level.24,27,41,45 Head-injuryspecific discharge instructions from 15 hospital EDs were assessed at an eighth-grade level on average.40 Duffy and Snyder20 analyzed 26 commonly used patient education materials and found only 1 that assessed below the ninthgrade level. A study of 88 institutional review board–approved informed consent forms from 45 emergency medicine residency programs found that 60% were written above the tenth-grade level.42 The same study found that studies involving greater risk had more complex consent forms. To assess how well clinical investigators understand the reading capacities of their patients and federal human subject protections requirements, White et al44 assessed the readability of informed consent forms as submitted (versus approved) to academic institutional review boards. The forms submitted by emergency medicine researchers were assessed at the college level.

Table 3 summarizes the 7 studies that examined the relationship between health literacy and ED outcomes. To provide the appropriate context, we have included the overall study objective and the ED-related outcome. In our quality assessment, all of the studies were evaluated as good. Three studies examined the relationship between health literacy and ED visits among Medicare enrollees aged 65 years and older46,47,49; one of these also examined ED costs.49 Baker et al46 and Howard et al49 relied on the same sample of 3,260 Medicare managed care enrollees in 4 US areas (Cleveland, OH; Houston, TX; Tampa, FL; south Florida) but used different outcome measures and analytic approaches. Baker et al46 used a multivariate polytomous logistic regression to examine the effect of health literacy on whether patients had 0, 1, or 2 or more ED visits. Medicare enrollees with marginal and inadequate (versus adequate) literacy had an adjusted relative risk of 1.44 and 1.34, respectively, of having 2 or more ED visits (P⬍.05). Howard et al49 used a 2-part regression model to measure mean differences in ED use and costs and found an increase in the probability of

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Table 2. Studies assessing the readability of ED patient materials. Reference

Readability Measurement Instrument(s)

Type of ED Material

Duffy and Snyder, 199920

Prose Readability Analyst, which computes an average using 8 readability formulas, including Fry, Fog, SMOG

26 commonly used computerized patient education materials in the ED

Fung et al, 200640

Flesch-Kincaid

Hayes, 200024

Flesch, Flesch-Kincaid

Jolly et al, 199341

Chall, Fog, Flesch, Fry SMOG

15 hospital ED head injury discharge information forms from 10 hospitals in New York State and 5 hospitals in Ontario, Canada Standard preprinted discharge instruction sheets from 3 rural Midwestern EDs 47 sets of preprinted discharge instructions from 6 EDs

Mader and Playe, 199742

RightWriter 5.0, which includes FleschKincaid, Flesch, Fog

88 IRB-approved informed consent forms from 45 accredited emergency medicine residency programs

Powers, 198843

Fry

Spandorfer et al., 199527

Flesch, Gunning-Fogg

White et al., 199644

Flesch, Flesch-Kincaid

Williams et al., 199645

Flesch

Various ED patient-directed materials, including patient education brochures and an operative consent form Preprinted discharge instruction sheets for patients discharged from a Level I trauma center ED at Temple University Hospital in Philadelphia 82 informed consent forms (8 of which were submitted by emergency medicine researchers) as submitted to 3 academic IRBs by university-affiliated community hospitals in the Midwest 10 commonly used preprinted ED discharge instructions at an urban teaching hospital in Norfolk, VA

Reading Level 1 item: eighth grade 4 items: ninth grade 6 items: 10th grade 5 items: 11th grade 4 items: 12th grade: 6 items: ⬎12th grade Average grade level: eighth Range: sixth–12th Average grade level: ninth Average grade level: ninth– tenth Range: sixth–17th Average grade level: 10th Range: third–14th Distribution: 6% ⬍sixth grade 34% sixth–10th grade 60% ⬎10th grade Average grade level by level of study risk: Low risk: ninth grade Moderate risk: 10th grade High risk: 11th grade Grade range: eighth–college

Average grade level: 11th grade

Average grade: 13.8 both for the 8 emergency medicine researchers and for all specialties overall Average grade level: ninth– 10th Range: eighth–14th

SMOG, Simple Measure of Gobbledygook; IRB, institutional review board.

ED use (0.05; 95% confidence interval [CI] 0.01 to 0.10) and higher costs ($108; 95% CI $62 to $154) for patients with inadequate (versus adequate) literacy. Both studies controlled for age, sex, race/ethnicity, income, education, health behaviors, and chronic conditions. Cho et al47 studied a sample of Medicare enrollees in Chicago, using a path analysis approach to explore potential intermediate factors (disease knowledge, health behaviors, preventive care use, and medication adherence) that were hypothesized to link health literacy to health status and utilization after controlling for sex, race/ethnicity, and education. Contrary to a priori expectations, the proposed mediators were not statistically significant; however, there was a negative, direct effect of health literacy on ED use (standardized ␤⫽⫺.35; P⬍.05). In a longitudinal study of asthmatic adults aged 18 to 62 years in New York City, Mancuso and Rincon examined the 340 Annals of Emergency Medicine

direct and indirect associations between health literacy and ED visits.50 Patients with lower health literacy were more likely to have an ED visit after controlling for asthma self-efficacy, disease severity, education, and age in multivariable analyses, but this result did not remain significant at P⬍.05 when asthma knowledge was added to the model. Thus, the authors concluded that improving health literacy may alter patients’ health care use patterns directly or indirectly by improving disease knowledge and self-management. Of note, our systematic review located no studies that examined the relationship between health literacy and ED visits among the general (ie, non– disease specific) adult population aged 18 to 64 years. Three studies examined caregiver health literacy and ED outcomes among children in Miami-Dade County, FL, North Carolina, and Rochester, NY, respectively.26,48,51 Collectively, Volume , .  : April 

Reference

Instrument (Cut Point)

Overall Study Objective

Baker et al, 200446*

S-TOFHLA (Inadequate, Marginal, Adequate)

Cho et al, 200847

S-TOFHLA (RC) To explore potential intermediate (inadequate/ factors (disease knowledge, marginal and health behaviors, preventive adequate) care use, medication compliance) that may link health literacy and health status and utilization REALM (⬍ninth To determine whether parental grade, ⱖninth literacy is related to ED visits, grade) hospitalizations, and missed school days for asthmatic children

DeWalt et al, 200748

S-TOFHLA (inadequate, marginal, adequate)

Sample Description

Sample Size Covariates

To determine whether inadequate ED visits identified New Medicare managed care 3,260 health literacy is associated in administrative enrollees ⱖ65 y in with lower rates of outpatient claims data Cleveland, Houston, Tampa, physician visits. Secondary and south Florida (English analyses were conducted to and Spanish speakers) examine the relationship between health literacy and frequency of ED visits

A, S, R, I, E, HB, HS, O

Key Results (Relationship Between Literacy and Outcome)

Quality Rating

Increased risk of ⱖ2 ED Good visits for those with marginal literacy (RR⫽1.44; 95% CI 1.01– 2.02) and those with inadequate literacy (RR⫽1.34; 95% CI 1.00– 1.79) compared with those with adequate literacy Health literacy was Good negatively associated with ED visits (standardized coefficient⫽–0.35; P⬍.05).

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Self-reported ED visits

Medicare enrollees ⱖ65 y 489 with at least 1 visit at Mercy Hospital–affiliated outpatient clinic in Chicago (English speakers)

S, R, E, DK, HB, O

Self-reported ED visits

Patients 3–12 y with asthma 150 childand their primary caregivers caregiver who visited one of 3 pairs outpatient pediatric clinics at the North Carolina Children’s Hospital (English speakers)

A, R, I, DK, Children of parents with low Good HB, HS, literacy (defined as O ⬍ninth-grade reading level) were more likely to visit the ED, but this result was not significant at P⬍.05 in adjusted analyses (IRR 1.4; 95% CI 0.97–2.0). A, S, R, I, Compared to those with Good E, HB, adequate health literacy, HS, O patients with inadequate health literacy had a higher probability of using the ED (average difference in the probability of use⫽0.05; 95% CI 0.01– 0.10) and had greater ED costs (average difference in costs⫽$108; 95% CI $62–$154). A, E, DK, Low health literacy patients Good HS were more likely to visit the ED, but this result was not significant at P⬍.05 in multivariate analyses that controlled for asthma knowledge (P⫽.07).

To examine the relationship ED visits and costs New Medicare managed care 3,260 between low health literacy and as identified in enrollees ⱖ65 y in medical utilization and costs administrative Cleveland, Houston, Tampa, claims data and south Florida (English and Spanish speakers)

To evaluate the direct and indirect Self-reported ED Mancuso and TOFHLA (inadequate/ associations between health visits Rincon, marginal and literacy and asthma outcomes 200650 adequate)

Adult patients 18–62 y with asthma in a primary care urban practice in New York City (English and Spanish speakers)

175

Health Literacy and Emergency Department Outcomes

Howard et al, 200549*

ED-Related Outcome

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Table 3. Studies examining the relationship between health literacy and ED outcomes.

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Shone et al., 200951

A, Age; S, sex; R, race/ethnicity; I, income; E, education; HB, health behavior; HS, health status; O, other; RR, relative risk; DK, disease knowledge; IRR, incidence rate ratio. *Baker et al46 and Howard et al49 used the same sample population but analyzed different ED outcomes.

Good Not applicable for No statistically significant ED-related differences in urgent care outcome; only visits by health literacy bivariate results were detected in bivariate reported comparisons. Children 3–10 y with 499 children persistent asthma and their parents in an urban school district in Rochester, NY (English speakers)

Good No statistically significant differences in ED visits and ED costs by health literacy category were detected. A, R, E, HS, O Children 12 mo–12 y and 290 childtheir caregivers (English and caregiver Spanish speakers) who pairs received care from a pediatric ED of an urban, public hospital in Florida

To assess the ED visits (overall relationship sample) and ED between caregiver costs (sample health literacy and that could be the use and cost of matched to child health Medicaid claims services data) using electronic records and claims data REALM (⬍ninth To examine the Parent-reported grade, ⱖninth association urgent care use grade) between parent (inpatient and health literacy and ED use child asthma combined) measures S-TOFHLA (RC) (inadequate, marginal, adequate) Sanders et al., 200726

Reference

Instrument (Cut Point)

Table 3. Continued.

Overall Study Objective

ED-Related Outcome

Sample Description

Sample Size

Covariates

Key Results (Relationship Between Literacy and Outcome)

Quality Rating

Health Literacy and Emergency Department Outcomes

the studies included children aged 12 months to 12 years, and 2 were restricted to asthmatic children.48,51 The outcomes included parent-reported ED visits,48 parent-reported urgent care visits (combined inpatient and ED use),51 and ED visits and costs as identified by medical records and administrative claims data.26 None of these studies found a statistically significant effect (P⬍.05) of caregiver literacy on the ED outcomes studied.26,48,51 Notably, there were no studies of the relationship between literacy and ED outcomes for teenagers. As DeWalt et al7 have pointed out, it is important to control for confounding variables in analyzing the relationship between health literacy and health service use and outcomes. All 7 studies adjusted for at least 1 demographic characteristic (eg, age, sex, or race/ethnicity), 5 included educational attainment, 3 included income, 5 included health status (eg, chronic conditions, disease severity), and 4 included health behaviors (eg, tobacco use, alcohol use). Failure to adjust for these factors risks misestimating the relationship between health literacy and the outcome of interest. However, as health literacy researchers have observed, variables commonly included in models as confounders may, in fact, mediate the relationship between health literacy and outcomes. For example, Howard et al49 observed that their estimates might be downward biased because of the inclusion of control variables, such as education and comorbid conditions, that may mediate rather than confound the relationship between health literacy and ED use and costs. DeWalt et al48 explicitly excluded education as a control variable in their analysis of caregiver health literacy and children’s asthma outcomes because they believed it to lie in the causal pathway. As noted above, 2 studies included in this review explored potential mediators,47,50 but additional research in this area is merited.

LIMITATIONS The reported findings are limited by the scope and quality of the included studies. Studies were typically conducted in single geographic locations and often at a single medical site, which limits their generalizability to the broader US population. In practice, however, there are variations in the prevalence of low literacy among different EDs because of variations in the populations served. Consequently, we have provided details about each study’s sample population and setting to facilitate interpretation of the existing literature in the context of one’s own ED (Tables 1 and 3). From a methods perspective, the studies addressing our third question varied in how they controlled for potential confounding and mediating effects of other factors that may influence ED outcomes, and the mechanisms by which health literacy affects patients’ ED use and outcomes remain poorly understood. More research is required to determine the precise pathways by which health literacy affects outcomes and whether there are variations among different populations and health conditions. The included studies are also limited by the relatively narrow populations and outcomes addressed. There is a notable gap in knowledge about the effect of health literacy on ED-related Volume , .  : April 

Herndon, Chaney & Carden outcomes among teenagers and the general adult population aged 18 to 64 years. The existing evidence on health literacy and ED outcomes has focused on ED utilization and costs. However, there are other ED outcomes that may be influenced by health literacy skills, such as compliance with discharge instructions. Finally, existing evidence is subject to the limitations of the literacy instruments themselves. Although it is important to have standardized, validated instruments to measure health literacy, these general measures of health literacy may fail to detect variations in the particular literacy skills needed to manage specific medical conditions. For example, prescription label reading skills have been associated with the risk of heart failure–related ED use.16 Moreover, it may be important to separately assess numeracy skills from reading comprehension to identify appropriate targets for interventions, but there is scant evidence on ED patients’ numeracy skills. This is a significant gap in knowledge because the ability to understand and interpret numeric information is essential for patients to weigh the risks and benefits of different treatment options and to adhere to treatment protocols.52

DISCUSSION Evidence from studies included in this review suggests that ED patient materials are often written at levels that are higher than the literacy skills of a large proportion of ED patients. This finding is consistent with broader evidence indicating a long-standing mismatch between the average reading ability of patients and the readability of health information.53 Continued efforts are necessary to make ED patient materials more accessible to low-literacy patients. One strategy is to revise materials so that they use “plain language,” eg, using common words, avoiding jargon, and using simple short sentences.53,54 There is also a growing body of literature demonstrating the effectiveness of using illustrations or pictographs to facilitate patient comprehension of health information both in the ED setting specifically55 and more broadly.56 The consistent finding of lower literacy among non–native English speakers in this review suggests that special attention should be paid to evaluating and addressing the literacy needs of these patients. Three included studies found that Medicare enrollees with limited health literacy were at increased risk of having an ED visit,46,47,49 and one also found higher ED costs49 after adjusting for demographic characteristics, education, health behaviors, and health status. Two of these studies relied on the same sample of 3,260 Medicare enrollees. Although the evidence is limited, these findings suggest that inadequate health literacy may be associated with an inefficient use of health care resources among adults aged 65 years and older. Individuals with limited health literacy may be more likely to substitute the ED for routine office visits, face increased difficulty accessing a primary care physician for acute problems, or to be referred to the ED by their physician.46 Previous research has found that individuals with inadequate health literacy possess less Volume , .  : April 

Health Literacy and Emergency Department Outcomes knowledge about their conditions and health care in general7; therefore, they may believe that immediate unscheduled medical care is required in situations in which those with higher health literacy skills would handle the acute health problem outside of the emergency care system. The lack of statistically significant effects (P⬍.05) between caregiver literacy and children’s ED use is consistent with the mixed results found in other systematic reviews of caregiver literacy and child health care use.9,10 However, there is fairly consistent evidence that lower caregiver literacy is associated with poorer health care knowledge and comprehension of health care materials.9,10 Caregivers with limited literacy are more likely to experience difficulty in understanding medication instructions and correctly dosing medications for their children.10 These findings highlight the importance of providing caregiver information in the ED at an appropriate comprehension level. Studies of literacy-sensitive interventions in improving caregiver adherence and in reducing pediatric ED use are promising. In a randomized controlled trial, Yin et al11 found that a pictogram-based intervention decreased medication dosing errors among caregivers whose children were treated at an urban pediatric ED. Educational materials designed to help low-literacy parents better manage common childhood medical conditions have been associated with reductions in ED use.57,58 Literacy interventions targeted to children themselves also may be effective. Robinson et al59 designed an intervention for lowincome asthmatic children that improved their literacy skills and asthma self-efficacy. These improvements were associated with lower odds of asthma-related ED recidivism. The existing evidence on health literacy and ED-related outcomes, as summarized in this systematic review, has focused on ED utilization and costs. However, as noted above, there are other important ED outcomes that may be influenced by health literacy skills. In addition, health literacy may affect patients’ experiences with care during the ED encounter. For example, a study of patients’ satisfaction with their ED physician included health literacy as a control variable and found that women with inadequate health literacy were less satisfied with their treating ED physician than women with higher literacy skills.15 This is an important finding because patients’ satisfaction reflects their trust in the physician, which is strongly associated with adherence to medical advice.60 In summary, it is important to recognize that a substantial proportion of ED patients have limited literacy that may influence both the reasons for seeking ED care and their EDrelated outcomes. Moreover, there is consistent evidence from the studies reviewed that the readability of ED patient materials often exceeds patients’ literacy skills. Consequently, it is important to ensure that patient health information is developed at appropriate reading levels, check patient understanding of health care information presented, and identify strategies for facilitating patient comprehension. The evidence linking health literacy to ED outcomes is limited: we identified only 7 relevant studies, which focused primarily on Annals of Emergency Medicine 343

Health Literacy and Emergency Department Outcomes Medicare enrollees and pediatric caregivers. Recommendations for future research are to focus on understudied populations (eg, teenagers and the general adult population), numeracy skills, and the pathways by which health literacy affects ED use. Addressing these gaps is critical to designing effective interventions. Supervising editor: Donald M. Yealy, MD Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Publication dates: Received for publication May 27, 2010. Revision received August 19, 2010. Accepted for publication August 25, 2010. Available online October 29, 2010. Reprints not available from the authors. Address for correspondence: Jill Boylston Herndon, PhD, Department of Health Outcomes and Policy, University of Florida College of Medicine, PO Box 100147, Gainesville, FL 32610-0147; 352-265-7216, fax 352-265-7221; E-mail [email protected].

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