According to the National Assessment of Adult Literacy, only 12 percent of U.S. adults are considered to have proficient health literacy (HL). Low HL can negatively affect a patient’s understanding of key treatment information including consent forms, perioperative instructions, prescription labels and appointment schedules. Low HL has been associated with increased hospitalizations and disproportionately high rates of chronic disease and mortality.
New research suggests low HL also contributes to poorer postoperative outcomes in complex abdominal surgeries. A study by Vanderbilt University Medical Center investigators, published in JAMA Surgery in October 2017, was the first to examine association of HL with postoperative outcomes in major, elective abdominal surgeries. The study evaluated the influence of HL on index hospitalization length of stay, postoperative 30-day ED visits and 90-day hospital readmission rates.
“When we began looking at this, there were very little data on how health literacy affects surgical outcomes,” said Jesse Wright, M.D., a resident in general surgery at Vanderbilt. “Since major abdominal surgeries can often be complex, we wanted to determine how important it was to recovery that patients understood every step of their treatment.”
Methodology of the Vanderbilt GI Study
From November 2010 to December 2013, 1,239 Vanderbilt patients who underwent elective gastric, colorectal, hepatic and pancreatic resections for both benign and malignant disease were retrospectively reviewed. Patient demographics, education, insurance status, procedure type, American Society of Anesthesiologists status, Charlson comorbidity index and postoperative outcomes — including index length of hospital stay (LOS), 30-day ED visits and 90-day hospital readmissions — were reviewed from EHRs.
Health literacy levels were assessed using the Brief Health Literacy Screen, a previously validated tool that was administered by nursing staff members upon hospital admission. Multivariate analysis determined the association of HL levels on postoperative outcomes, controlling for patient demographics and clinical characteristics.
Of the 1,239 patients who participated in the Vanderbilt study, 624 (50.4 percent) were women, 1,083 (87.4 percent) were white, 96 (7.7 percent) were black and 60 (4.8 percent) were of other races/ethnicities. The mean (SD) Brief Health Literacy Screen score was 12.9 (SD, 2.75; range, 3-15) and the median educational attainment was 13 years.
In an adjusted analysis, lower HL levels were independently associated with longer LOS for patients undergoing major abdominal surgery. Patients with low HL levels (BHLS 3 to 8) spent an additional median one day in the hospital compared with those with a high HL level (BHLS 15). According to the authors, this extra day could cost the hospital approximately $61,000. Notably, lower HL was not significantly associated with increased rates of 30-day ED visits or 90-day hospital readmissions. “These results show an opportunity for hospital systems to improve the inpatient experience, decrease potential adverse events and decrease overall costs,” wrote the authors.
A subsequent study of day surgery patients, reviewed by the Vanderbilt group in the August 2018 issue of JAMA Surgery, corroborates the group’s findings that low HL is associated with poor postoperative metrics.
“The role of health literacy needs to be further evaluated within surgical practices to improve health care outcomes,” said Kamran Idrees, M.D., assistant professor of surgical oncology at Vanderbilt. “Systematic development and validation of health-related instruments will allow formal measurement and monitoring of data to help us develop, identify, implement and evaluate health literacy-appropriate interventions.”