Lack of Health Literacy Linked to Poor Outcomes Among Patients With Heart Failure


Heart failure is a complicated disease to manage, requiring coordination of these outcomes-related measurements: weight, blood pressure, glycemic index, and medication and diet adherence. Close to half of all patients do not reach the 5-year survival mark after the condition is diagnosed.

Heart failure is a complicated disease to manage, requiring coordination of several outcomes-related measurements: weight, blood pressure, glycemic index, and medication and diet adherence, as well as exercise and weight loss on occasion. Does patient knowledge of these measures—their health literacy—affect their health outcomes, and if so, to what extent?

This is the question a group of researchers recently tried to answer, and their study results were published in the June issue of JACC: Heart Failure. According to the data they gathered by evaluating studies published through January 1, 2019, in the MEDLINE, Embase, EBSCO CINAHL, and PsycINFO databases, the degree of a patient’s health literacy strongly influences their outcome following a diagnosis of heart failure.

For the purposes of this study, health literacy was defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” It is measured objectively, or what patients comprehend, and subjectively, or how much they think they know.

Fifteen studies were included in the analysis, and 2 levels of patient health literacy were gauged: marginal/inadequate and adequate. Mortality, hospitalization, and emergency department (ED) use were the outcomes of interest evaluated among patients 18 years and older with heart failure.

Overall, just 2 of the studies showed increased health literacy among patients originally considered to have inadequate health literacy levels, translating into 24% of patients having an inadequate or marginal level of health literacy. This led to higher unadjusted risks for the 3 outcomes measured:

  • Mortality had a risk ratio (RR) of 1.67 (95% CI, 1.18-2.36)
  • Hospitalizations had a RR of 1.19 (95% CI, 1.09-1.29)
  • ED visits had a RR of 1.17 (95% CI, 1.03-1.32)

After adjusting for potential confounders, mortality (RR, 1.41; 95% CI, 1.06-1.88) and hospitalization (RR, 1.12; 95% CI, 1.01-1.25) remained significantly associated with inadequate health literacy.

The authors suggest that the health literacy levels could be low due to social determinants of health, positing that patients who do not have adequate comprehension of their degree of illness might not seek the appropriate health care services they should or they don’t know how to discuss their condition with their physician. These barriers to care possibly contribute to feelings of shame, especially when the “educational materials provided often exceed the reading ability of a patient with inadequate health literacy,” the authors said.

“Our findings showed that an inadequate level of health literacy is associated with increased risks in mortality and hospitalization among patients with heart failure,” stated Lila J. Finney Rutten, PhD, an author of the study and professor of health services research in the Department of Health Sciences at Mayo Clinic. “Identifying health literacy as a factor that affects health outcomes and measuring its effect on patients with heart failure is essential to allocate more resources for, and research on, interventions to improve health literacy.”

Therefore, to improve the outcomes of patients with heart failure who have inadequate health literacy, the authors strongly suggest screening for this measure during clinical visits, finding out what the patients do and do not understand about their condition, and building on that knowledge base. This, in turn, can help improve their outcomes. Communication and education are key.


Fabbri M, Murad MH, Wennberg AM, et al. Health literacy and outcomes among patients with heart failure. JACC Heart Fail. 2020;8(6):451-460. doi:10.1016/j.jchf.2019.11.007

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