The More Your Patients Know

Institute Promotes Texans' Health Literacy

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Public Health Feature — July 2014

Tex Med. 2014;110(7);45-50.

By Kara Nuzback
Reporter

As a physician, you always try to do the right thing for your patients, but you can't do everything for them. 

What if your patients don't understand a diagnosis, their risk for certain diseases, or your prescription instructions? 

In February, the Texas Institute of Health Care Quality and Efficiency (TIHCQE) released its strategic plan to guide the institute's activities for the next five years, including an initiative to improve health literacy in the state. 

The U.S. Department of Health and Human Services defines health literacy as "the ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions."

Houston family physician Patrick Carter, MD, who serves on the TIHCQE Board of Directors and on the Texas Medical Association Council on Legislation, says one of the biggest problems in his daily practice is communicating with patients who don't understand their disease or its consequences on their health.

"Often a patient will say, 'I feel fine. These medications you're giving me don't make me feel any better,'" he said. 

But patients don't always feel the effects of diabetes or high blood pressure, Dr. Carter says. They might then see an advertisement or an article that shows their prescribed medication in a negative light and choose to stop taking it.

"A lot of information is available. Figuring out what is accurate or meaningful, that's the hard part," Dr. Carter said. "The more people know about health care, the more they will be able to be an important part of the decisionmaking."

Dr. Carter says an uninformed patient is more likely to do things that will harm his or her health, whereas a knowledgeable patient is less likely to spend health care dollars on treatments with little or no impact. 

According to TIHCQE's strategic plan, "low health care literacy and ineffective health care communication contribute to poor health outcomes and generate hundreds of billions of dollars in wasteful spending each year."

The annual cost of low health literacy ranges from $106 billion to $238 billion, according to a 2007 George Washington University Milken Institute School of Public Health report.

"When one accounts for the future costs of low health literacy that result from current actions (or lack of action), the real, present day cost of low health literacy is closer in range to $1.6 trillion to $3.6 trillion," the authors wrote.

TIHCQE Board of Directors member Alan Stevens, PhD, says the quality of patient care also suffers, which is clear when you look at the national rate of hospital readmissions.

U.S. hospitals readmit about 20 percent of Medicare beneficiaries within 30 days of discharge, costing the public an estimated $15 billion per year, according to a May 2013 article published in the American Heart Association journal Circulation: Cardiovascular Quality and Outcomes.

Dr. Stevens is director of the Center for Applied Health Research at Baylor Scott and White Health, where he conducts research on ways to improve care and health outcomes for older adults.

"There's no bad question when a patient is engaged in a discussion of his or her health. Questions suggest that a patient is ready to change to healthier behaviors," he said.

The Texas Legislature created TIHCQE in 2011 to identify and promote evidence-based approaches to improve health care quality, accountability, education, and cost containment in Texas. Dr. Stevens says the institute took up health care literacy as an initiative because it embodies all these goals.

"This is a topic that gathers traction very easily," he said. "It's an issue that we can actually improve."

Promoting Health Literacy

TMA is helping doctors promote health literacy outside the office by participating in the national Walk With a Doc program, which promotes patient-physician communication and healthy lifestyles.

Round Rock plastic surgeon Susan Pike, MD, chair of TMA's Patient-Physician Advocacy Committee, says as the traditional health care model changes, physicians need to think of new ways to approach patient care. Physicians can no longer meet the needs of all patients during a 15-minute office visit, she says.

Dr. Pike was one of the first TMA physicians to hold a Walk With a Doc event in 2012, and she continues to lead regular walks in Georgetown.

Dr. Pike says she typically starts each event with an informal, five- to 10-minute talk about a specific health topic. 

"Then we all go out and walk," she said. "Basic exercise, something as simple as walking, can reduce your risk of heart disease, cancer, and diabetes, and elevate mood and lower blood pressure."

The walk takes about 45 minutes, during which patients can engage the physician about specific topics or talk about general health issues. Dr. Pike says many patients are less intimidated outside the office and talk more freely about their health. 

"I think it's really valuable for people to see physicians look and dress normal," she said. "Physicians need to do the same things to stay healthy as the rest of the community does."

Dr. Pike says the program is a simple, effective, and easily reproducible way to promote health literacy. Anyone can join, and patients don't need any equipment, just a pair of walking shoes.

In November, the TMA Foundation (TMAF), the association's philanthropic arm, received $40,000 in funding from the Aetna Foundation to expand Walk With a Doc events in Texas. TMAF added $20,000 of its own funds to help bolster the program. 

TMA physicians now lead 11 walks in six areas of the state, and there's a waiting list for physicians who want to start more, Dr. Pike says. 

To donate or get involved in Walk With a Doc and other TMAF projects, visit the TMA Foundation webpage.  

In addition, TIHCQE is pursuing a pilot project with the Choosing Wisely® campaign to improve Texans' health care literacy. Choosing Wisely is a national initiative of the ABIM Foundation that encourages physicians to rethink the necessity of commonly administered tests and medications.

Dr. Stevens says the pilot program would give patients the tools to question procedures that might be medically unnecessary. He says the program would include key talking points for patients to take to their physicians, such as the risks associated with recommended tests or procedures and less costly alternatives to a recommended procedure. 

TIHCQE is hoping to team up with Choosing Wisely and launch the health literacy project in 2015.

"We're excited about our beginning, and we're really gaining traction fast," Dr. Stevens said.

Robyn Jacobson, chief operating officer of Entrust, Inc., health benefit consultants and administrators, and a member of the TIHCQE board, says while the institute refines its Choosing Wisely program, the board will explore opportunities to launch a broader health literacy awareness campaign.

Ms. Jacobson says the institute hopes to collaborate with The University of Texas, the Literacy Coalition of Central Texas, the Texas Workforce Commission, and other educational and medical groups "circling around this issue."

Ms. Jacobson says that TIHCQE is well-suited to launch an awareness campaign to a wide audience and that the initiative must grab patients' attention.

"There is so much information for patients to consider," she said. "In addition to their health issues, patients have to navigate the complexities of health care reform as well as the terms involved in their health plans, which can be just as overwhelming."

Ms. Jacobson said simple things, such as reading the instructions on a prescription bottle correctly, can help lower hospital readmission rates and improve patient care. 

Getting a Head Start

Dr. Carter says the Choosing Wisely partnership allows physicians to play a key role in the institute's health care literacy campaign "by not ordering and recommending things that cost a lot of money that have not proven to be effective."

In the meantime, many physicians are taking steps to improve health literacy among their patients. Dr. Carter says he tries to establish a level of trust with his patients so they look to him as a source for medical information and advice, rather than to a controversial website.

"After that, we can start to try to educate during every visit," he said.

In a 2006 report, The Health Literacy of America's Adults: Results of the 2003 National Assessment of Adult Literacy, the National Center for Education Statistics measured the health literacy of U.S. adults using four performance levels. Fourteen percent of those measured had a below basic understanding of health care, 22 percent had a basic understanding, 53 percent had an intermediate understanding of health care, and only 12 percent of the population was rated proficient. (See "U.S. Adult Health Literacy Rate, 2003.") 

Emergency medicine physician Parin Shah, MD, a 2013 graduate of TMA's Leadership College, says these statistics left him speechless. 

"I was astonished to find out that our national adult health literacy rate is only 12 percent. That means nine out of 10 people will walk out of a doctor's office not understanding the health concern," he said. "That's completely changed the way I've practiced."

Dr. Shah, past president of the Fort Bend County Medical Society, says he is thrilled TIHCQE chose to promote health literacy.

In his own practice, Dr. Shah goes the extra mile to make sure patients don't just nod their head and walk out the door when he gives them a diagnosis.

"It really boils down to communication," he said. 

Understanding each patient's culture plays a large role, as does knowing most patients will not make major health care decisions in a doctor's office but at home with their families, he says.

"It may be fear of the setting. It may be fear they have a health problem, and they don't want to come to terms with it," he said. "It might not be until later that they come to terms with what the health issues are and think about questions they should have asked."

Dr. Shah says the solution is as easy as taking a few extra minutes to make sure the patient understands what's going on. He says physicians need to realize a concept that is simple to them is not always easy for a patient to grasp.

Physicians should sit patients down, look them in the eye, and really try to make sure they understand the health concern, he says. Dr. Shah recently took the position of emergency department medical director at Resolute Health in New Braunfels. He says health literacy promotion is a major mission there. 

Resolute Health not only acts as a hospital but also offers wellness programs for the community, from training patients to manage their diabetes to offering nutrition therapy classes. Resolute Health also houses a fitness center, offers interactive cooking classes, and employs a bilingual staff.

Dr. Shah says the organization helps patients understand health care by creating a unified network of health care professionals so the patients' social workers, specialists, and physicians can collaborate to ensure patients understand their health needs.

TIHCQE board member Elena Marin, MD, chief executive officer at Su Clinica Familiar, a nonprofit health clinic in the Lower Rio Grande Valley, says communication is the key to health care literacy, and it often correlates to health disparity. She says minorities and patients with low levels of education are less likely to understand the importance of taking medicine for high blood pressure or watching out for early symptoms of stroke, for example.

"More minorities die or are disabled by strokes or heart attacks," she said. "Health literacy is an important component to address in these populations."

Dr. Marin facilitates communication with her patients by holding educational events at Su Clinica, such as medication therapy management, during which patients with multiple prescriptions meet one-on-one with a pharmacist to discuss dose schedules, side effects, and drug interactions.

"What we have found is that patients are not taking their medications the way they are prescribed on the bottle," she said. 

Sometimes, patients can't afford to refill the medication as often as they should; other times, patients just can't read the instructions, she says.

Dr. Marin says when patients sit face-to-face with a pharmacist, they are more likely to open up and admit they are not following the recommended dosage. Medication therapy management allows pharmacists to explain doctors' instructions and the risks patients run if they do not take the drugs correctly.

Taking Responsibility

Outreach programs like Walk With a Doc promote health literacy and encourage patients to take some responsibility for their health, Dr. Pike says. 

"We can't go home and make sure patients eat right," she said. "And yet nobody has really found a way to make patients accountable or responsible for their health."

TMA President Austin King, MD, an Abilene otolaryngologist, says most of his patients are tobacco users, and many refuse to take responsibility for their health by quitting smoking. He says if he berates a patient about tobacco use throughout the whole visit, the patient may not follow up on treatment, which can be very dangerous. On the other hand, if Dr. King seems aloof about the tobacco use, the patient is unlikely to quit.

Dr. King says if he can't convince a patient to stop smoking, he sometimes refers that patient to another physician, which shocks the patient into realizing the severity of his or her condition.

Dr. King says the Internet greatly changed patients' ability to become health literate. "Some of it's for the good, and some of it's for the bad," he said.

Modern medicine has become so complex patients must conduct some of their own research about their conditions to really comprehend what a physician says during an office visit, but it is difficult for patients to gauge which websites offer credible information, Dr. King says.

Physicians can help steer patients toward the correct information with clear communication. (See "Health Literacy Tools.")

"Often the physician has to really do an in-depth explanation of what he thinks is wrong with the patient and why and the therapy he's recommending," he said.

Kara Nuzback can be reached by telephone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.

 SIDEBAR

July 14 TM Public Health Sidebar

SIDEBAR

Health Literacy Tools

Physicians and nurses can use certain tools to screen patients quickly for health illiteracy. The Newest Vital Sign (NVS) is a screening tool developed by a team of professors and physicians to quickly evaluate a patient's level of understanding.

According to "Quick Assessment of Literacy in Primary Care: The Newest Vital Sign," a 2005 study published in the Annals of Family Medicine, NVS is quicker than other literacy screening tools and is available in English and Spanish.

Using NVS, a physician or nurse presents patients with a health-related scenario, then asks questions about the scenario to prove their understanding of the information. For example, a nurse using NVS might give a patient a nutrition label from an ice cream container, then ask six questions about the label, such as "If you eat the entire container, how many calories will you eat?"

According to the report, the average test takes three minutes. 

Other health literacy tests specialize in specific areas of health, such as diabetes, nutrition, and dental care. The North Carolina Program on Health Literacy offers several online tests.

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