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Literacy, Health Communication, and Diabetes Care

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Title: Literacy, Health Communication, and Diabetes Care


1
Literacy, Health Communication, and Diabetes Care
  • Dean Schillinger, MD UCSF Professor of Medicine
    in Residence
  • Director, Center for Vulnerable Populations SF
    General Hospital
  • Chief, California Diabetes Program

2
Vulnerabilities Cluster within Individuals and
Neighborhoods
3
Objectives
  • Review definitions and statistics re literacy and
    health literacy
  • Describe research on relationship between
    literacy and diabetes outcomes
  • Focus on health communication as one mechanism
  • Interventions in primary care and public health

4
What is Health Literacy?
  • The degree to which individuals have the
    capacity to obtain, process, and understand basic
    health information and services needed to make
    informed health decisions.
  • -Institute of Medicine, 2004

5
1st National Assessment of Health
Literacy n19,714
  • Below Basic Circle date on doctors appointment
    slip
  • Basic Give 2 reasons a person with no symptoms
    should get tested for cancer based on a clearly
    written pamphlet
  • Intermediate Determine what time to take Rx
    medicine based on label
  • Proficient Calculate employee share of health
    insurance costs using table

National Center for Educational Statistics, U.S.
Department of Education, 2003
6
1st Health Literacy Assessment
n19,714 U.S. Adults
12
Proficient
14
Below Basic
53
Intermediate
Hispanic
Basic
22
Average
National Assessment of Adult Literacy (NAAL)
National Center for Educational Statistics, U.S.
Department of Education, 2003.
Medicare
7
Self-reported chronic conditions among an elderly
cohort, by literacy (N2, 512)
Sudore, Schillinger JGIM 2006
8
Patients with Diabetes and Low Literacy Less
Likely to Know Correct Management
Need to Know symptoms of low blood
sugar (hypoglycemia) Need to Do
correct action for hypoglycemic symptoms
Low
Moderate
High
Low
Moderate
High
Percent
Williams 1998
Williams et al., Archive of Internal Medicine,
1998
9
Literacy is Associated with Glycemic Control,
N408
Adjusted OR2.03, p0.02
Adjusted OR0.57, p0.05
(Tight Control HbA1c?7.2)
(Poor Control HbA1cgt9.5)
Schillinger JAMA 2002
10
Adjusted odds of self-reported diabetes
complications, for patients with inadequate vs.
adequate literacy (N408)
Schillinger JAMA 2002
11
Limited Health Literacy Patients Experience more
Hypoglycemia N16,000
P for alllt0.001
Sarkar, Adler, Schillinger, in review
12
Could poor communication be a mechanism?
  • High self-management demands
  • Increasing reliance on technology
  • Large mismatch in training between health
    professionals and target populations (health
    literacy)
  • Counterbalance role of mass media in consumerist
    society
  • Strong inverse relationship between educational
    attainment and chronic illness burden
  • Communication can be powerful motivator for
    change

13
How Does Limited Literacy Affect (Verbal)
Clinical Interactions?
  • Impedes understanding of technical information
    and explanations of self-care
  • Impairs shared decision-making
  • Speed of dialogue, extent of jargon, lack of
    interactivity determinants of effectiveness of
    communication
  • Impairs medication communication, jeopardizing
    patient safety (medication discordance)
  • Interaction between limited Eng proficiency and
    limited literacy

Fang et al. 2006 JGIM Schillinger et al. 2004 Pt
Ed and Counseling Castro et al, Am J Health Beh
2007 Schillinger et al. 2003 Arch Int
Med Schillinger et al 2004. AHRQ Advances in
Patient Safety
14
Diabetes Patients with Limited Literacy
Experience Poorer Quality Communication, N408
Schillinger 2004
OR1.9p0.04
OR3.2plt0.01
OR3.3p0.02
OR2.4p0.02
32
33
26
21
20
13
13
13
(Often/Always)
(Often/Always)
(Often/Always)
(Never/Rarely/ Sometimes)
15
Medical Jargon
GLUCOMETER HEMOGLOBIN A1c DIALYSIS ANGINA RISK
FACTORS CREATININE
16
Jargon Terms
  • unclarified
  • Glucometer
  • Immunizations
  • Weight is stable
  • Microvascular complication
  • System of nerves
  • HbA1c
  • EKG abnormalities
  • Dialysis
  • Wide Range
  • Risk factors
  • Kidney function
  • Interact
  • clarified
  • Angina
  • Microalbuminuria
  • Ophthalmology
  • Genetic
  • Creatinine
  • Symptoms
  • washed out of your system
  • receptors
  • short course
  • renal clinic
  • blood cells
  • increase your R
  • screening
  • vaccine
  • CAT scan
  • blood count
  • correlate
  • stool was negative
  • stool
  • baseline
  • respiratory tract
  • polyp
  • from Patients own visit
  • benign
  • blood drawn
  • blood count

17
Function of Jargon
Assess Symptoms
10
Provide
Deliver Test Results
Recommendations
24
37
Provide Health
Education
29
n 60
Castro, Schillinger AJHB 2007
18
Dialysis Do you know what the number one cause
for people in this country being on dialysis is?
Diabetes
19
  • Ensures info understood/integrated into
    memorychecks for lapses
  • Opens dialogue re health beliefs reinforces and
    tailors health messages
  • Promotes a common understanding elicits patient
    participation

20
Closing the Loop, aka Teach-Back
  • Physicians assessed recall or comprehension for
    15/124 new concepts (12)
  • When new concepts included patient assessment,
    patient provided incorrect response half the time
    (7/1547)
  • Visits using interactive communication loop not
    longer (20.3 min. vs. 22.1 min)
  • Application of loop associated with better HbA1c
    (AOR 9.0, p.02)

Schillinger Arch Int Med 2003
21
IDEALL Project Improving Diabetes Efforts
Across Language and Literacy
  • Community Health Network of SF/DPH
  • AHRQ
  • CMWF, TCE, CHCF

Schillinger Diab Care 2009
22
Automated Telephone Diabetes Self-Management
Support (ATSM)
  • Interactive health technology, touch tone
    response
  • Weekly surveillance health education (39
    weeks9 mos)
  • In patients preferred language (English, Spanish
    or Cantonese)
  • Generates weekly reports of out of range
    responses
  • Live phone follow-up through a bilingual nurse
    -gtbehavioral action plans

23
Group Medical Visits (GMVs)
Primary Care Provider Health
Educator Pharmacist
Monthly Group Medical Visits
Cantonese-Speaking Groups
English-Speaking Groups
Spanish-Speaking Groups
  • 6-10 patients in monthly group meetings (9
    months)
  • In patients preferred language ( English,
    Spanish, or Cantonese)
  • Facilitated by a bilingual health educator and a
    primary care provider
  • A pharmacist present at end of each group visit
  • Encourage patients to become active in self-care
    through participatory learning and peer education
    -gtbehavioral action plans

24
Key Findings of IDEALL Program Estimating Public
Health Reach of Programs
  • Composite reach product
  • ATSM GMV
  • Overall 22.1 4.8
  • English 20.0 6.4
  • Chinese 22.0 2.7
  • Spanish 24.3 4.0
  • Adequate Literacy 15.6 7.6
  • Limited Literacy 28.0 3.6

Schillinger, et al.Health Ed and Behavior 2007
25
ResultsStructure and Process Measures
pre post
Plt.05.
26
Results Functional Outcomes
OR 0.37 vs UC
Rate ratio 0.5 vs UC, 0.35 vs GMV

pre post
Plt.05
27
Results Physiologic Outcomes
pre post
28
Automated telephony provides safety surveillance
function
Preventability
  • 111 participants, 54 inadequate health literacy
  • 264 events among 93 participants (86)
  • 111 AEs and 153 PotAEs

Sarkar, Murphy, Schillinger et al. 2008 JGIM
29
Health System Findings Cost-Effectiveness
Health Plans
  • Based on functional improvements, we estimated
    that the cost per QALY for ATSM was
  • gt65,000 for both set-up and ongoing costs
  • gt 32,000 for ongoing costs only
  • Cost effectiveness could be further improved with
    (a) scaling up or (b) metabolic outcomes improved
  • A large majority of CA Medicaid health plans
    reported an interest in employing ATSM-like
    technology

Handley, Schillinger, in press Ann Fam Med
2008 Goldman, Schillinger et al. Am J Man Care
2007
30
Current Project
  • Partner with a local Medicaid health plan San
    Francisco Health Plan
  • SFHP care managers will make ATSM response calls
  • Test effectiveness when implemented in
    real-world
  • Compare ATSM-ONLY with ATSM-PLUS (medication
    activation)
  • ATSM-PLUS involves merging pharmacy claims data
    with ATSM data to enable care manager counseling

31
Spanish
32
SFHP Wallet-Size CardEnglish, Spanish and
Cantonese
33
Inform, Educate and Empower
  • Health Commxn Vehicles for Diabetes Prevention
  • Partnerships with
  • Ethnic Media
  • Youthspeaks
  • Adult Literacy/ESL classrooms for health
    messages, skill-building, and peer leadership
    development

34
Develop policies and plans
  • States pursuing medication labeling legislation
  • In CA literacy and language (SB472)

35
Food for ThoughtPublic Health Literacy
  • Degree to which individuals and groups can
    obtain, process, understand, evaluate, and act
    upon information needed to make public health
    decisions that benefit the community
  • Target populations The public
  • Purpose Improve the health of the public
  • Aims Engage more stakeholders in public health
    efforts address determinants of health
  • Multidimensional conceptual foundations,critica
    l skills civic orientation

D Freedman et al AJPM 2009
36
Literacy and DiabetesConclusions
  • Mechanisms by which limited literacy affect
    diabetes outcomes likely multiple
  • Apparent that improving literacy levels can
    achieve important public health objectives and
    reduce disparities
  • Communication characteristics of health care
    system contribute to sub-optimal health care
  • Re-structuring health care system (increasing
    interactivity, employing appropriate technology)
    can improve reach and effectiveness of health
    care, enhance quality, promote safety
  • Public health is uniquely positioned to
    contribute to solutions

37
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