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The American Journal of Managed Care May 2020
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The Association of Health Literacy Domains With Hospitalizations and Mortality
Juliana Ferri-Guerra, MD; Y. Nadeem Mohammed, MD; Raquel Aparicio-Ugarriza, PhD; Douglas Salguero, MD; Aakashi Shah, MD; Dhanya Baskaran, MD; Marianne Desir, MD; and Jorge G. Ruiz, MD
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The Association of Health Literacy Domains With Hospitalizations and Mortality

Juliana Ferri-Guerra, MD; Y. Nadeem Mohammed, MD; Raquel Aparicio-Ugarriza, PhD; Douglas Salguero, MD; Aakashi Shah, MD; Dhanya Baskaran, MD; Marianne Desir, MD; and Jorge G. Ruiz, MD
Despite previous research evidence, this study did not reveal an overall association of health literacy, numeracy, and graph literacy with all-cause hospitalizations or mortality.
ABSTRACT

Objectives: To determine whether health literacy, numeracy, and graph literacy are associated with all-cause hospitalizations or mortality in community-dwelling veterans.

Study Design: Retrospective cohort study.

Methods: A total of 470 community-dwelling veterans underwent evaluations of health literacy, numeracy, and graph literacy with validated instruments in 2012 and were followed until 2018. At the end of follow-up, the associations with all-cause hospitalizations and mortality were determined with the Andersen-Gill model and Cox regression multivariate analysis, respectively.

Results: There were no associations of health literacy, numeracy, or graph literacy with all-cause hospitalization or mortality after multivariate adjustment. In subgroup analysis, subjective numeracy was associated with hospitalizations in African Americans. Higher objective and subjective numeracy were associated with future hospitalizations only for those with a history of hospitalization. Higher graph literacy was associated with lower mortality in those with a history of hospitalization.

Conclusions: This study did not show associations of health literacy, numeracy, or graph literacy scores with lower risk of all-cause hospitalization or mortality. Further research is needed with random sampling in a broader spectrum of healthcare settings to better understand what roles health literacy, numeracy, and graph literacy might play in healthcare utilization and clinical outcomes.

Am J Manag Care. 2020;26(5):200-206. https://doi.org/10.37765/ajmc.2020.43152
Takeaway Points

Despite previous research evidence, this study did not reveal an overall association of health literacy, numeracy, and graph literacy with all-cause hospitalizations or mortality.
  • Higher subjective numeracy in African Americans and both objective and subjective numeracy in individuals with a history of hospitalization were associated with lower all-cause hospitalizations.
  • Higher graph literacy was associated with lower all-cause mortality in those individuals with a history of hospitalization.
Health literacy is the capacity to obtain, process, and use basic health information and services needed to make healthcare decisions.1 Health literacy is a multidimensional process, including system demands and complexities, as well as individuals’ skills and abilities,2 and may encompass numeracy and graph literacy. Numeracy is a set of quantitative abilities needed for comprehending, managing, and manipulating numerical expressions of probability about health information,3 and graph literacy is the ability to understand basic graphical representations used to present quantitative health-related information.4 Health literacy has been linked to self-management behaviors, healthcare costs, hospitalizations, mortality, and overall health status.5 Less is known about the specific roles of numeracy and graph literacy in health.

Patients receiving care at US Veterans Health Administration (VA) facilities tend to be older, have more comorbidities, and have lower levels of function, education, employment, and socioeconomic status than patients in other facilities.6-9 Prior work has also suggested concerningly low levels of health literacy, numeracy, and graph literacy in this population, particularly among African American veterans.10 Many risk factors for poor health outcomes among VA patients might be compounded by these health literacy concerns. On the other hand, veterans have access to an integrated healthcare system that provides a range of supports for patient-provider communication, self-management, and care coordination,11,12 which might mitigate the risks implied by lower levels of health literacy, numeracy, and graph literacy. Future studies could explore the specific aspects of numeracy and graph literacy that predict mortality in high-risk, high-need individuals. Optimal numeracy and graph literacy skills may influence patient decision-making and health behaviors.13 Patients with adequate numeracy and graph literacy skills may be empowered to safely and effectively use healthcare information contained in web-based patient portals.14,15 Patient engagement in their own healthcare may in turn lead to better self-management and potentially lower risk for hospitalizations and mortality.

The aim was to determine in a sample of veterans the association of health literacy, numeracy, and graph literacy with future all-cause hospitalizations and mortality. We predicted that, after adjustment for known covariates, higher levels of health literacy, numeracy, and graph literacy would be negatively associated with all-cause hospitalizations and mortality.

METHODS

Design and Participants

The present research is based on a cross-sectional study conducted from January to February 2012 on male veterans 20 years and older receiving outpatient care at a VA medical center.10 Participants were conveniently recruited at outpatient clinics and met the following inclusion criteria: enrollment in a VA clinic, sufficient cognitive function (Mini-Cog score >3), not depressed (Patient Health Questionnaire score <3), and a minimum education level of eighth grade.10 The participants underwent evaluations of health literacy, numeracy, and graph literacy. After obtaining exempted review status from our institutional review board in 2018, we proceeded to conduct a retrospective cohort study of the veterans who had participated in the 2012 study. Data on all-cause hospitalizations and mortality from 2011 until September 30, 2018, were retrieved from the VA electronic health record.

Measures

Health literacy, numeracy, and graph literacy. The following measures were obtained in the 2012 study and were described in detail in our previous publication.10 Health literacy was assessed with the Newest Vital Sign (NVS),16 which consists of a nutritional label and 6 associated questions. Scores of 0 and 1 suggest high likelihood (≥50%) of limited literacy, 2 and 3 suggest limited literacy, and 4 to 6 indicate adequate literacy. The instrument has shown indications of reliability and internal consistency. Objective numeracy was measured with 13 items assessing the ability to compare risk magnitude, convert percentages to proportions, convert proportions to percentages, convert probabilities to proportions, and compute probabilities.17-19 The Subjective Numeracy Scale is an 8-item self-report measure of perceived ability to perform various mathematical tasks and preference for the use of numerical or prose information.20 Graph literacy was measured with a scale consisting of 13 items that measure abilities to find specific information in a graph, find relationships in the data shown on the graph, and make inferences and predictions from the data.4


 
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