What’s Important: Health Literacy in Orthopaedics

Orthopaedic surgeons have traditionally been considered poor communicators, a paradigm that is quickly changing with the shift to the patient-centric model¹. Effective communication with patients can directly result in better patient satisfaction, adherence, and outcomes, as well as lower malpractice litigation rates for the surgeon. In the same vein, a patient’s health literacy plays an equally important role in the ecosystem of health care.

The definition of health literacy has evolved over time, cumulating in multiple governmental organizations (e.g., the Centers for Disease Control and Prevention [CDC], the U.S. Department of Health and Human Services [HHS], and the Office of Disease Prevention and Health Promotion [ODPHP]) agreeing on the term: the degree to which individuals have or organizations equitably enable “the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others².” This ability is based on several domains comprised of individual aspects of health literacy, including reading and/or listening comprehension, numeracy (calculating measurements or dosages), digital health literacy, self-advocacy, oral communication, health-care navigation, health-care forms and/or documentation, medications, and critical thinking and decision-making³. Low health literacy in medicine and surgery has been directly linked to increased health-care costs, higher surgical complication rates, higher mortality, and worse patient-reported outcomes^4-8.

Health literacy in orthopaedics is not well studied, but the studies that have been performed have directly correlated it with positive patient outcomes in aspects such as less pain and better function, better treatment adherence, and greater satisfaction^9-12. Roh et al. reported on health literacy assessed using the Newest Vital Sign (NVS) screening tool in patients with acute mallet finger injuries; they found that lower health literacy correlated with poor rehabilitation adherence, resultant extensor lag, and decreased patient satisfaction¹¹. Cosic et al. performed a randomized controlled trial in orthopaedic trauma patients with lower-limb fractures. Their intervention provided patients with an additional discussion with illustrations about their fracture and its subsequent management prior to discharge, which resulted in a higher satisfaction score in patients who received the additional information (88.5% versus 69.7%). These results suggested that even small steps in addressing and improving health literacy in orthopaedic surgery can have substantial impacts on patients¹². Outside of the orthopaedic realm, many studies have linked health literacy with reduced health-care costs from readmissions, hospitalization time, and complications^4,6,13. Furthermore, according to the U.S. Census Bureau, the number of individuals with limited English proficiency (LEP) is increasing, necessitating increased communication and health literacy standards¹⁴.

Health literacy has strong associations with the social determinants of health (SDOH), specifically income, education, race and ethnicity, and even geographic location^15-17. Given that health literacy may be modifiable and/or addressed directly with interventions, there is a strong argument that focusing on health literacy will improve equity and impact patient outcomes. A focus on more immediate health literacy needs will not solve all of the core inequities for patients and communities, but it will be critical on the pathway to achieving equity within our health-care systems.

There are numerous general instruments to measure health literacy, including the Test of Functional Health Literacy in Adults (TOFHLA), the Rapid Estimate of Adult Literacy in Medicine (REALM), the Short Assessment of Health Literacy (SAHL), the NVS, and several brief health literacy screening tools. All of these instruments test several of the components of health literacy that were mentioned earlier; however, some are too brief and none are fully comprehensive, which contributes to the drawbacks of limited depth and survey fatigue, respectively. More importantly, criticisms of health literacy include the broadness and vagueness of the measurements and the generalizability; critics also believe that, at times, interventions to improve health literacy may not produce the expected positive outcomes¹⁸. These surprising results may be due to the challenges that the medical field faces in general, the chronicity of certain illnesses, or the expectations and values that patients associate with their own health¹⁹.

A notable advantage in the field of orthopaedic surgery is the specificity of our goals, which typically are centered around a patient’s pain or functional capacity^19-21. These objectives are quantifiable and follow a treatment trajectory with distinct phases, including a beginning, a middle, and an end. In contrast, chronic diseases often entail more complex and enduring treatment journeys, potentially leaving patients disheartened by the continuous burden of treatment without a clear end point²². In orthopaedic surgery, achieving pain relief and functional milestones serve as tangible end points. Unlike the more entrenched SDOH, such as education level, the Area Deprivation Index, or income, health literacy can be modified through relatively small interventions, resulting in important and meaningful improvements in patient outcomes, all while reducing health-care costs^23-25. A common example of this is a preoperative joint replacement class, where patients receive the opportunity to ask questions and receive feedback, which may enhance adherence to perioperative protocols. Likewise, modest interventions can yield substantial improvements in musculoskeletal health literacy. Therefore, we as orthopaedic surgeons have the opportunity to lead the movement in health literacy and serve as the blueprint for other specialties.

Call to Action

Given the powerful influence of health literacy on patient outcomes, orthopaedic surgeons can play a pivotal role in addressing disparities through actionable solutions in order to make a difference in outcomes²⁶. The teach-back method, also known as the “show me” or “closing-the-loop” technique, is a communication strategy that is designed to increase patient understanding of medical information and instructions. It is a valuable tool that orthopaedic surgeons can employ to ensure that patients comprehend the information they receive; it has led to greater patient knowledge, health literacy, and satisfaction, as well as better outcomes and lower complication rates^27,28. Notably, it has garnered recommendations from reputable health-care institutions such as the Agency for Healthcare Research and Quality (AHRQ), the Institute for Healthcare Improvement, The Joint Commission, and others. Furthermore, health-care team members other than orthopaedic surgeons can play a role in implementing the teach-back method^29,30.

A practice of health literacy is to simplify communication with patients in order to ensure that medical information is understandable and thereby accessible to all patients. By using plain language and presenting information in clear, digestible chunks, orthopaedic surgeons can foster better patient comprehension, which directly improves treatment adherence and patient outcome³¹. Additionally, visual aids can serve as invaluable tools to improve patients’ understanding of their condition and enable them to make more informed decisions regarding complex treatment options³².

Digital health tools offer approaches to improve health literacy in orthopaedic patients, and they have several notable advantages when compared with traditional, outdated pamphlets. These tools allow for self-paced learning and can be interactive, providing a more personalized and effective educational experience. Examples include a comprehension check regarding informed consent, video-based education and/or virtual training, and online patient engagement platforms^33-37. However, it is essential to acknowledge that these digital health tools may require a baseline level of digital literacy for the patient to be able to access and utilize them effectively.

Artificial intelligence is another emerging field within the health literacy space that shows promising results. Recent studies have reported enhanced patient education and informed consent with use of large language models, and new applications are continually emerging^38,39. However, a healthy amount of caution should be reserved because artificial intelligence can craft convincingly incorrect statements that perpetuate misinformation to the unknowing individual.

Conclusions

The evolving landscape of orthopaedic surgery emphasizes the important role of effective communication and health literacy in patient-centered care. We recognize the impact of health literacy on patient outcomes, satisfaction, and health-care costs. The strong associations between health literacy and established SDOH such as income and education also cannot be ignored. Studies in orthopaedics have demonstrated that even small educational efforts to address and improve health literacy can lead to substantial improvements in patient outcomes, particularly in terms of pain, function, and satisfaction. This underscores the need for a comprehensive musculoskeletal health literacy assessment tool that is tailored to the specific goals of orthopaedic care. As we navigate the challenges and opportunities surrounding health literacy in orthopaedics, it becomes clear that health literacy is a vital component of the strategy to enhance access, quality, and equity in musculoskeletal medicine.