Abstract
Purpose
Youth with special health care needs (YSHCN) face challenges transitioning from pediatric to adult health care. Understanding possible mechanisms contributing to poor health care transition could improve care. This study explores associations between health literacy (HL), transition readiness, and health care utilization.
Methods
YSHCN 12–18 years were recruited from a Medicaid Accountable Care Organization (2012–2017). Outcome measures included transition readiness (Transition Readiness Assessment Questionnaire, TRAQ), and health care utilization (any well-check, hospitalization, emergency department (ED) visit, or ambulatory sensitive condition (ASC) ED visit). Multivariate regression analyses examined whether HL (adequate vs. inadequate) predicted outcomes, after adjusting for covariates. Models were then created to examine whether the effect of HL on health care utilization was mediated by transition readiness.
Results
Among 417 YSHCN, 67.1% reported adequate HL. Relative to inadequate HL, teens with adequate HL had significantly higher average TRAQ20 scores (β=0.34, p<0.001). Controlling for covariates, HL was a significant predictor of having an ASC ED visit and having any ED visits neared significance. There was a positive transition readiness mediation effect on having an ED visit, with higher transition readiness being associated with higher odds of having any ED visit in the mediation analysis.
Conclusion
HL is independently associated with higher transition readiness and lower ASC ED use, but pathways of action require further study.
Keywords: transition readiness, chronic conditions, health literacy
1. Introduction
Youth face a variety of health care challenges as they reach mid-adolescence and begin taking ownership of their health care, especially youth with special health care needs (YSHCN) who have “chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally” (1). These youth must assume more responsibilities for self-management of their health conditions when transitioning from pediatric to adult health care (2, 3). The competence to successfully navigate this transition is referred to as transition readiness. Despite wide consensus about the importance of providing appropriate transition-related services to youth that support the development of transition readiness, rates of receipt of transition-related care remain low (4–6). Previous studies have identified lower socioeconomic status and lack of access to a medical home as important barriers to receiving transition-related services (7, 8).
Beyond the receipt of transition-related services, health literacy (HL) is also an essential tool for developing transition readiness and making health care use decisions (9, 10). Manganello’s framework for adolescent health literacy posits that health literacy is the product of individual traits, family and peer influences, and information inputs (e.g., mass media, education system, health system) and that health literacy resulting from these inputs influences health behaviors, health services use, and health cost (11). Research has established the expected association between health literacy and health services use. Low HL has been associated with higher utilization of the emergency department and a higher number of returns within 14 days (12). Lower teen HL is also associated with lower self-management (13) as well as higher rates of acute care utilization (12, 14).
The pathway through which the relationship between HL and utilization is affected is less well understood. We hypothesize that HL contributes to differences in receipt of recommended health care for teens during the health care transition stage by impacting their transition readiness. Lower health literacy could be a barrier to understanding and applying the information needed to build transition readiness. Additionally, clinicians may feel less effective in communicating with adolescents who have lower HL and patients with lower HL report having worse health care communication than patients with adequate HL (15–18). Thus, having lower HL could impede or delay important discussions of transition to adult care among YSHCN and their providers, resulting in lower receipt of recommended preventive care, and greater use of ED or inpatient care. A number of studies have assessed the relationship between HL and transition readiness (19–22). and most have found that lower levels of HL are associated with lower levels of transition readiness (18, 20).
While data supports the pathway from HL to transition readiness, the relationship between transition readiness and health care utilization is less clear. Higher levels of transition readiness are associated with higher levels of self-reported medication adherence, suggesting that transition readiness should be associated with reduced hospitalizations and emergency department visits (23, 24). Studies looking directly at the relationship between transition readiness and hospitalizations have not found this (23, 25–27). These previous studies did not account for transition readiness and health literacy concurrently. To date no study has explored a mediated pathway from HL to health care use through transition readiness.
The present study uses a sample of mid-adolescent YSHCN (age 12–18) to explore the relationship between HL, transitional readiness and health care utilization (any well-check, hospitalization, emergency department visit (ED), or ambulatory sensitive condition (ASC) ED visit). We test the hypotheses that HL is positively associated with transition readiness and with well-checks, but negatively associated with hospitalizations, ED visits and ASC ED visits. We also test whether any relationship between HL and any ASC ED visit or any ED visit is mediated by transition readiness.
2. METHODS
2.1. Study and setting
YSHCN (12–18 years) and their caregivers participated in the “Teen Literacy in Transition” study, which was designed to explore the relationship among transition measures, caregiver and teen HL, and racial disparities in adolescents with special health care needs. Caregivers were defined as individuals with primary health care responsibility for teens, such as parents, grandparents, or other custodial caregivers. Caregiver-teen dyads were recruited during 2012–2017 from a Medicaid accountable care organization (ACO), Partners For Kids (PFK), called all remaining caregivers of potentially eligible teens and described the study. If caregivers expressed interest in participating, staff administered the Questionnaire for Identifying Children with Chronic Conditions – Revised (QuICCC-R) to confirm the teen’s YSCHCN status (28). Eligible caregivers and teens were then invited to schedule a study visit. At the study visit, caregivers and teens provided consent and assent and completed self-administered assessments of demographics, health-related quality of life, medical home status, HL, and health care transition planning and readiness. Survey data were collected using REDCap (Vanderbilt University, Nashville, TN), a secure, web-based application designed to support data capture for research studies (29). Of the 1,385 potentially eligible teens who could be reached, 535 completed a study visit (response rate=39%; Appendix A). Medicaid claims, through PFK, were obtained for the six months before the month of the study visit, the month of the visit, and six months after the study visit to examine four health care utilization measures. Some participants were excluded from the present study due to incomplete PFK data for the following reasons: 1) the participant had fewer than six total months of Medicaid enrollment during that time period (n=14), 2) the participant was not enrolled in Medicaid (n=54), or 3) the claims could not be pulled due to a change in PFK claims data vendors (n=50) that affected claims after July 2017 (Appendix A). The final sample included 417 dyads. This study was approved by the Institutional Review Board at Nationwide Children’s Hospital.
2.2. Measures
Transition readiness.
Transition readiness was assessed by teen responses to the Transition Readiness Assessment Questionnaire (TRAQ). The TRAQ is a 20-item instrument that asks participants if they endorse levels of responsibility for particular health behaviors and health management skills (30). Items are grouped to measure five domains of transition readiness: Managing Medications, Appointment Keeping, Tracking Health Issues, Talking with Providers, and Managing Daily Activities (30). The overall score and domain scores are determined by taking the mean of the items. Answer choices were scored from one to five and response options ranged from “No, I do not know how” to “Yes, I always do this when I need to” (30). To compute an overall TRAQ20 score, all items were averaged with higher values indicating greater readiness. Items were also averaged within each domain.
Health care utilization.
Medicaid inpatient and outpatient claims data provided information on health care use during the six months before the study visit, month of the visit, and six months after the study visit. Health care utilization was centered around our survey measures because it was expected that without a direct intervention, readiness and literacy would not vary greatly within a 13-month window. Health care utilization outcomes included whether a participant had a well-check, any ED visits, any ambulatory sensitive condition (ASC) ED visits, and any inpatient stays. ED visits were classified to be ASC if the patient had a primary diagnosis of asthma, skin-soft tissue infections, otitis media, urinary tract infection, diabetes or upper respiratory infection on that ED claim. ASC conditions can be prevented or reduced with adequate primary care services (31).
Health literacy.
HL was assessed using teen self-reported health literacy (32). Teens were asked three questions regarding if they have problems understanding written medical information (“never”, “occasionally”, “sometimes”, “usually”, “always”), their confidence in independently completing forms (“extremely”, “quite a bit”, “somewhat”, “a little bit”, “not at all”), and if they have someone help them read medical forms (“never”, “occasionally”, “sometimes”, “usually”, “always”). The three-question screener has been validated against the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM) and shown to be valid (33). HL was scored as adequate (vs. less than adequate) if the respondent reported never to sometimes having problems understanding medical information or having someone help read material and being somewhat to extremely confident completing forms.
Medical home.
Medical home status (“yes” or “no”) was determined based on caregiver responses to the 2005/2006 NS-CSHCN medical home questions (34). The NS-CSHCN assesses whether five sub-components of the medical home are present: 1) access to a personal doctor, 2) family-centered care (FCC), 3) getting referrals when needed, 4) having a usual source of sick and well care, and 5) receiving effective care coordination. All sub-components had to be satisfied for care to be considered consistent with a medical home.
Limitation level. Teen’s functional limitation level was categorized based on caregiver responses to two questions from the NS-CSHCN. Consistent with previous research (35–37), teens were assigned to the three limitation categories based on caregiver responses as follows: 1) "severe limitation” if the youth’s health “usually/always” affected their ability to do things and their ability was affected “a great deal;” 2) “some limitation” if the youth’s health "sometimes” affected his/her ability to do things and their ability was affected “some” or “very little;” and 3) “no limitation” for all other responses. The “severe” and “some” limitation categories were combined for this analysis.
The teen’s total months of Medicaid eligibility was determined by the number of months the participant was enrolled in the PFK ACO during the 13-month period (range = 6–13 months).
Demographics.
Demographic variables included teen age, teen race (White and non-White), teen gender (male and female), caregiver education (high school diploma/GED or less and some college or more), and place of residence (Central Ohio or Appalachia Ohio).
2.3. Analysis
Chi-square tests and t-tests were used to examine HL differences in transition readiness, race, medical home status, limitation level, and demographic variables. Multivariate linear regression models were utilized to examine the association between HL and the overall composite TRAQ20 score adjusting for covariates. Multivariate logistic regressions were used to examine the association between HL and having had a well-check, any hospitalization, any ED visit or any ASC ED visit, adjusting for covariates. In all analyses, medical home status, gender, race, age (centered at 15), limitation level, and caregiver education level were used as covariates because previous studies have found them to be significantly related to transition readiness outcomes and health care utilization (38). In addition, place of residence (i.e. Central Ohio or Appalachia) was included in regression models because of the oversampling of Appalachian families. Months of Medicaid eligibility was controlled for in the health care utilization models.
To test the mediation effect of transition readiness on the relationship of HL and health care utilization outcomes the Process program developed by Hayes was used (39). This method evaluated the direct relationship of HL on health care utilization as well as the indirect relationship of transition readiness. Analyses were conducted using SPSS version 26.
3. RESULTS
3.1. Sample description and descriptive analyses
The sample included 417 teens aged 12 to 18. The majority of the teen sample had adequate HL (67.1%), were White (54.9%), female (53.0%), resided in urban or suburban Central Ohio (86.3%), and experienced some or severe functional limitations (71.7%) (Table 1). The average age of the teen sample was 17.0 (SD = 0.9). Compared to those with adequate HL, those without adequate HL were more likely to be from Appalachia and had a slightly higher number of average months enrolled in PFK.
Table 1.
Sample Characteristics by Teen Health Literacy
| Teen Health Literacy | ||||
|---|---|---|---|---|
| Overall n=417 | Not Adequate n=137 (32.9%) | Adequate n=280 (67.1%) | ||
| Characteristic | n (%) | n (%) | n (%) | p-valuea |
|
| ||||
| Teen average age (Mean, SD, range 12–18) | 17.0 (0.9) | 17.0 (0.8) | 17.0 (0.9) | 0.513 |
| Teen gender | ||||
| Male | 196 (47.0) | 63 (46.0) | 133 (47.5) | 0.771 |
| Female | 221 (53.0) | 74 (54.0) | 147 (52.5) | |
| Race | ||||
| White | 229 (54.9) | 78 (56.9) | 151 (53.9) | 0.562 |
| Non-White | 188 (45.1) | 59 (43.1) | 129 (46.1) | |
| Place of residence | ||||
| Appalachia Ohio | 57 (13.7) | 26 (19.0) | 31 (11.1) | 0.027 |
| Central Ohio | 360 (86.3) | 111 (81.0) | 249 (88.9) | |
| Teen limitation level | ||||
| None | 118 (28.3) | 31 (22.6) | 87 (31.1) | 0.072 |
| Some or severe | 299 (71.7) | 106 (77.4) | 193 (68.9) | |
| Teen medical home | ||||
| No | 302 (72.4) | 100 (73.0) | 202 (72.1) | 0.855 |
| Yes | 115 (27.6) | 37 (27.0) | 78 (27.9) | |
| Months enrolled in PFK (Mean, SD, range 6–13) | 11.8 (2.2) | 12.1 (1.7) | 11.6 (2.4) | 0.031 |
| Caregiver education | ||||
| High school diploma or less | 178 (42.7) | 62 (45.3) | 116 (41.4) | 0.458 |
| Some college or more | 239 (57.3) | 75 (54.7) | 164 (58.6) | |
Results are from chi-squared, Fisher’s exact test or t-tests between health literacy and each characteristic
For transition readiness, the average overall TRAQ20 score was 3.4 (max=5; SD=0.7) (Table 2). Overall, those with adequate HL had a significantly higher mean TRAQ20 score compared to teens without adequate HL, 3.6 (SD=0.7) relative to 3.2 (SD=0.7) (p=<0.001). In addition, teens with adequate HL had higher individual domain scores as well (Table 2). For health care use, a higher proportion of teens without adequate HL had an ED visit (55.5% vs 42.9%, p=0.02) and any ASC ED visit (9.5% vs 4.3%, p=0.04). However, there were no significant differences in the proportions with a well-check or inpatient stay (Table 2).
Table 2.
Transition Readiness and Health Utilization by Health Literacy
| Teen Health Literacy | ||||
|---|---|---|---|---|
| Overall n=417 n (%) or M (SD) | Not Adequate n=137 n (%) or M (SD) | Adequate n=280 n (%) or M (SD) | p-valuea | |
|
| ||||
| Transition Readiness Assessment Questionnaire (TRAQ) | ||||
| Average TRAQ overall score (range 1–5) | 3.4 (0.7) | 3.2 (0.7) | 3.6 (0.7) | <0.0001 |
| Average TRAQ Medication Management score (range 1–5) | 3.8 (1.0) | 3.5 (1.0) | 3.9 (1.0) | 0.0019 |
| Average TRAQ Appointment Keeping (range 1–5) | 3.0 (1.0) | 2.8 (1.0) | 3.1 (1.0) | 0.0014 |
| Average TRAQ Tracking Health Issues (range 1–5) | 2.7 (1.0) | 2.4 (0.9) | 2.8 (1.0) | 0.0005 |
| Average TRAQ Talking with Providers (range 1–5) | 4.6 (0.8) | 4.3 (0.9) | 4.7 (0.6) | <0.0001 |
| Average TRAQ Managing Daily Activities (range 1–5) | 4.3 (0.8) | 4.1 (0.9) | 4.4 (0.7) | <0.0001 |
| Health Care Utilization | ||||
| Proportion with any Well-Check | 190 (45.6) | 60 (43.8) | 130 (46.4) | 0.612 |
| Proportion with any EDb Visit | 196 (47.0) | |||
3.2. Regression analyses
Results from the multivariable regression models measuring the association with the overall TRAQ20 are presented in Table 3. The positive relationship between adequate HL and overall TRAQ20 score remained significant after adjusting for demographic characteristics, limitation level and medical home status.
Table 3.
Multivariable Regression Models of Characteristics Associated with TRAQ scores
| Overall TRAQ Score |
|||
|---|---|---|---|
| B | SE B | p-value | |
|
| |||
| Teen health literacy (ref= inadequate) | 0.34 | 0.07 | <0.0001 |
| Teen age (centered at 15) | 0.17 | 0.04 | <0.0001 |
| Teen gender (ref= Male) | 0.33 | 0.07 | <0.0001 |
| Teen race (ref= non-White) | −0.05 | 0.07 | 0.481 |
| Place of residence (ref = Appalachian Ohio) | −0.04 | 0.11 | 0.701 |
| Teen limitation level (ref= none) | −0.05 | 0.11 | 0.541 |
| Teen medical home (ref= no) | −0.03 | 0.08 | 0.697 |
| Caregiver education (ref= high school diploma/GED or less) | −0.07 | 0.07 | 0.309 |
Table 4 shows the results of the multivariable logistic regression models focused on health care utilization. After adjusting for covariates, adequate HL remained significantly associated with lower odds for an ASC ED visit. The relationship with any ED use neared significance as well (p= 0.054). The relationship of HL with well child visits and inpatient stays was not significant after adjustment.
Table 4.
Multivariable Logistic Regression Models of Characteristics Associated with Health Care Utilization
| Any Well-Check | Any Hospitalization | Any ED Visit | Any ASC ED Visit | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
||||||||||||
| OR | (95% CI) | p-value | OR | (95% CI) | p-value | OR | (95% CI) | p-value | OR | (95% CI) | p-value | |
|
|
||||||||||||
| Teen health literacy (ref = inadequate) | 1.19 | (0.77–1.83) | 0.436 | 0.52 | (0.22–1.20) | 0.122 | 0.66 | (0.43–1.01) | 0.054 | 0.42 | (0.18–0.96) | 0.040 |
| Teen age (centered at 15) | 0.87 | (0.67–1.11) | 0.260 | 0.94 | (0.57–1.56) | 0.813 | 1.02 | (0.79–1.31) | 0.903 | 1.20 | (0.70–2.07) | 0.505 |
| Teen gender (ref=Male) | 1.47 | (0.98–2.22) | 0.064 | 3.29 | (1.30–8.33) | 0.012 | 1.58 | (1.05–2.37) | 0.028 | 3.63 | (1.31–10.11) | 0.014 |
| Teen race (ref= non-White) | 1.20 | (0.78–1.85) | 0.416 | 4.84 | (1.71–13.75) | 0.003 | 1.13 | (0.73–1.74) | 0.577 | 1.01 | (0.43–2.40) | 0.982 |
| Place of residence (ref = Appalachian Ohio) | 1.10 | (0.59–2.04) | 0.769 | 2.97 | (0.80–11.06) | 0.104 | 1.15 | (0.62–2.14) | 0.651 | 5.44 | (0.67–44.16) | 0.113 |
| Teen limitation level (ref = none) | 0.62 | (0.40–0.98) | 0.042 | 2.01 | (0.64–6.28) | 0.232 | 1.55 | (0.98–2.45) | 0.059 | 1.22 | (0.46–3.24) | 0.697 |
| Months of Eligibility | 1.23 | (1.10–1.38) | 0.000 | 1.48 | (0.95–2.30) | 0.085 | 1.16 | (1.04–1.29) | 0.009 | 1.12 | (0.87–1.44) | 0.385 |
| Teen medical home (ref = no) | 1.36 | (0.86–2.15) | 0.190 | 0.77 | (0.29–2.06) | 0.600 | 0.69 | (0.43–1.09) | 0.109 | 1.45 | (0.59–3.60) | 0.420 |
| Caregiver education (ref = high school diploma/GED or less) | 1.19 | (0.79–1.78) | 0.415 | 0.85 | (0.37–1.97) | 0.701 | 0.77 | (0.52–1.16) | 0.211 | 0.76 | (0.33–1.75) | 0.514 |
3.3. Mediation analyses
Figure 1a and 1b show the results from the fully adjusted mediation models evaluating transition readiness as a mediator of the association of HL on health care utilization measures. Analyses were conducted for ED use and ASC ED use since there was a direct association between these measures and HL. For ED visits, transition readiness significantly mediated the association with HL but not in the way hypothesized. Those with adequate HL had 1.12 times the odds of having an ED visit as a result of the effect HL on ED visits through TRAQ20 score. This is the opposite effect seen in the direct effect of adequate HL on the odds of having an ED visit (OR: 0.59, p-value: 0.018). The direct association of the TRAQ20 score on ED utilization showed that a one-point increase in the mean TRAQ20 score translated to 1.4 times the odds of having an ED visit (Figure 1a). Similar, but non-significant effects are seen in the relationship of HL and TRAQ20 on having an ASC ED visit.
Figure 1 a-b: Process Mediation Models: Health Literacy, TRAQ20 and Healthcare Utilization.
4. DISCUSSION AND CONCLUSION
4.1. Discussion
To our knowledge, this is the first study to explore how HL and transition readiness factors are associated with some measures of health care utilization among YSHCN. We found that youth HL was inversely associated with overall ED visits and ASC ED visits in our regression models. Not surprisingly, the relationship among these variables and health care use are complex. After controlling for potential confounders, HL was significantly associated with lower rates of ASC ED visits and marginally associated with overall ED use. Our hypothesis that the relationship between HL and health care utilization was mediated by transition readiness was supported in relation to emergency department use. However, the direction of the association was the opposite of what was expected, with the indirect effect of adequate health literacy through higher transition readiness having an association with significantly higher odds of ED use.
These findings offer new insights into the role of adolescent HL in transition age youths. Previous research on an adult cohort found that participants with below adequate health literacy had increased ED utilization and higher health care costs when compared to those with adequate health literacy (40). Adolescent HL is not simply a proxy for, or a correlate of, other social drivers of health. Teen HL’s association with transition readiness and utilization outcomes was significant even in a Medicaid population with uniform health care coverage after controlling for demographic, functional limitation, and medical home. As such, HL in teens is deserving of direct attention. This attention can occur in both delivery of health care (universal precautions, literacy tailoring) and patient engagement (health education, capacity building) (41–42).
This study found a modest but statistically significan correlation between health literacy and transition readiness. Previous research has been inconsistent in this regard, with one study finding similar small but statistically significant relationships (20).Other studies have found a positive association between health literacy and transition readiness, but these did not reach statistical significance (18,22). These previous studies had smaller study populations and may not have been powered to detect the relationship. This study adds to the growing understanding of health literacy and transition readiness in adolescents by showing that each have an independent role to play in the development of an adolescent’s knowledge and skills related to health care as they move toward independent management of their health care needs.
The findings of our mediation model did not conform to our hypothesis that HL affects improved health care utilization through a transition readiness pathway. Adequate HL was directly associated with reduced odds of ED use, but also indirectly associated with increased the odds of ED use through increases in transition readiness. A non-significant relationship would not have been a complete surprise given that the association between transition readiness and health care utilization has been mixed in previous studies (23, 25–27). The significant relationship in the opposite of the expected direction is more challenging. While it is possible that this is a spurious finding, it is also possible that this finding, which is only present for ED use, is driven by the nature of emergent health care. In cases of true emergent need, we would not expect the youth’s HL or transition readiness to be the primary driver of use. Parents, in most cases, become the primary decision makers during times of acute need or life-threatening situations. In cases were the need is less certain, teens who perceive a need for care and have higher transition readiness may more effectively advocate with parents or guardians to seek care or even seek care themselves, thus more directly linking transition readiness to increased utilization. While we tried to control for confounding due to disease severity by including degree of teen limitation in our statistical analyses, residual confounding due to disease severity and emergent need or other unobserved confounders may still be contributing to the identified relationship.
The positive association between transition readiness and ED use we observed is consistent with that observed by Phillips et al., which found that greater transition readiness was associated with more use of the emergency department, more hospitalizations, and longer length of stay in the hospital (27). Interestingly, participants in the present study and in the Phillips et al. paper were insured through Medicaid. Our findings suggest that HL’s positive direct effect on reduced ED use operate through other pathways which may include communication quality or adherence.
The hypothesis that HL-enabled transition readiness would improve utilization for YSHCN was grounded in the recognition that optimal outcomes for YSHCN require a higher level of adherence to medication regimens, more interaction with providers and overall better understanding of disease. For example, previous studies in youth with diabetes have shown that during the transition of care there is a decrease in having a sufficient number of health care visits, increase in poor glycemic control and worse health outcomes (43). Transition readiness has been associated with higher levels of medication independence in patients with asthma, but that relationship does not translate to differences in outcomes (23). This seeming disconnection may reflect the need for better tools for measuring the construct of transition readiness (44, 45).
As with all studies, several limitations should be noted. First, the study population was limited to Medicaid enrolled youth in central and southeastern Ohio. As such, results may not be generalizable across payers orgeographic regions. Our response rate of 39% was impacted in part by the challenges in reaching the highly transient Medicaid population. Those who were reachable and agreed to participate may have differed from those who were unreachable or who did not agree to participate on measured and unmeasured variables. Specifically, the fact that our sample had higher than estimated levels of post high school education may suggest that those with more education were more likely to be reachable due to more stable housing circumstances, for example, or were more willing to participate in a research study that included measurement of their reading skills. Because we have limited demographic data on those we could not reach or who declined participation we cannot compare their race or education levels to that of study participants. However, it is reasonable to assume that participation bias truncated the lower end of the educational and likely HL distribution. This truncation would be likely to bias results toward the null suggesting that relationships may be stronger than those reported.
4.2. Conclusion
Overall, this study demonstrates that there are significant opportunities for improvement in HL and transition readiness in Medicaid enrolled YSHCN. These findings demonstrate that adequate HL has a significant positive direct association with lower ED use. Adequate HL is also positively associated with transition readiness. Findings of the mediation model were unanticipated and more difficult to interpret. Future research should evaluate whether programs designed to improve HL can drive reductions in ED use and further elucidate the mechanisms through which such a reduction in use may occur.
Supplementary Material
Acknowledgements:
All phases of this study were supported by an NIH grant, 5R01MD00716005. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. All individuals that contributed significantly to this manuscript have been listed.
Abbreviations:
- YSHCN
Youth with special healthcare needs
- HL
Health literacy
- ACO
Accountable care organization
- PFK
Partners for Kids
- NS-CSHCN
National Study of Children with Special Healthcare Needs
- QuICCC-R
Questionnaire for Identifying Children with Chronic Conditions- Revised
- TRAQ
Transition Readiness Assessment Questionnaire
- ASC
ambulatory sensitive condition
- FCC
Family-Centered Care
Appendix A:
Study recruitment and enrollment flow diagram
Footnotes
Implications and Contribution
Incorporating HL into transition readiness interventions for YSHCN may be a helpful next step for independently improving both utilization and transition readiness among this population.
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Conflict of Interest: The authors have no conflicts of interest relevant to this article to disclose.
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