Low "Health Literacy" Increases Hospitalizations

December 04, 1998

People who have trouble reading and understanding health-related materials are more than twice as likely to wind up in a hospital as those who have adequate health literacy, according to a study at a large inner-city Atlanta hospital.

A two-year study of 979 persons who used the emergency department and walk-in clinic at Atllanta's Grady Memorial Hospital revealed that 31.5 percent of the patients with inadequate health literacy were hospitalized at least once during that period, more than double the 14.9 percent of those who had adequate health literacy.

All participants took a test that measured their ability to read and understand health-related written materials such as a standard informed-consent application, and to comprehend directions for taking medicines, monitoring blood glucose levels, and keeping clinical appointments.

Hospital admissions are a major factor in health care costs, according to David W. Baker, MD, of Case Western Reserve University and MetroHealth Medical Center in Cleveland, and his colleagues at Emory University School of Medicine and Rollins School of Public Health, both in Atlanta. Their findings are reported in the December issue of the Journal of General Internal Medicine.

"After adjusting for other factors, health illiteracy appears to increase the risk of hospital admission by 50 percent," Baker said. He and his colleagues note that their findings have broad implications for millions of Medicare beneficiaries and the Medicare program itself, citing the 1993 National Adult Literacy Survey that classified 44 percent of adults aged 65 and older as functionally illiterate.

"There were approximately 16 million functionally illiterate Medicare beneficiaries (in 1993)," they report. "If these individuals have higher than expected hospital costs, and if these excess hospitalizations could have been prevented by improved communication and education, then Medicare hospital costs could be reduced substantially."

"The results of this study are not entirely unexpected, based on previous studies showing that better educated people have better health," Baker said in an interview. "But we really don't know why patients with limited reading skills were more likely to be hospitalized. It may be that people with inadequate literacy are less aware of when they need to seek medical care, so they seek it later, when their conditions have become more severe.

"We also know from previous studies that they are less likely to know how to take care of themselves and how to take care of their chronic conditions. This may be why they are more likely to get worse and have to be hospitalized."

In an accompanying editorial, Debra Roter, DrPH, of the Johns Hopkins School of Hygiene and Public Health, and colleagues point out that low literacy has further health care consequences. It is too often assumed, they write, that health care is accessible once a patient walks through the examining room door, but access to care "requires more than the patient's presence: it also requires that the patient engage in the process of care. Low literacy, though not so obvious a barrier as cost or transportation, limits access by preventing patients from engaging fully in the process of care."

Roter and colleagues also noted that stereotypes get in the way of identifying those with low literacy skills because most identify illiteracy with persons who are slow learners, poor, immigrants, and minorities, while in fact "most people with low literacy skills are of average intelligence and function reasonably well by compensating for their lack of reading skills."

They call for "patient centered interviewing skills (that) can help transcend the social, cultural, educational, and emotional barriers between patients and their physicians."
The Journal of General Internal Medicine, a monthly peer-reviewed journal of the Society of General Internal Medicine, publishes original articles on research and education in primary care. For information about the Journal, contact: Margo Glen Alderton, 215-823-4471.

Posted by the Center for the Advancement of Health . For information about the Center, contact Richard Hebert, 202-387-2829

Center for Advancing Health

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