Abstract
Purpose:
Low health literacy is associated with increased resource utilization and poorer outcomes in medical and surgical patients with various diseases. This observational study was designed to determine: (1) the prevalence of low health literacy for surgical cancer patients at an NCI-designated comprehensive cancer center; and (2) associations between health literacy and clinical outcomes.
Methods:
Patients receiving surgery (n=218) for gastrointestinal (60%) or genitourinary (22%) cancers, or sarcomas (18%) were recruited during their post-surgical hospitalization. Patients self-reported health literacy (Brief Health Literacy Screen [BRIEF]). Clinical data (length of stay [LOS], post-acute care needs, and unplanned presentation for care within 30 days) were abstracted from the electronic medical record 90 days post-surgery. Multivariate linear and logistic regressions were used to examine the relationship between health literacy and clinical outcomes, adjusting for potential confounding variables.
Results:
Of 218 participants, 31 (14%) demonstrated low health literacy (BRIEF≤12). In regression analyses including 212 patients with complete data, low health literacy significantly predicted LOS (β=−2.04, 95% C.I.=[−3.19, −0.89], p=0.0006) and post-acute care needs (OR=0.23, 95% C.I.=[0.07, 0.82]). However, health literacy was not significantly associated with unplanned presentations for care in the 30 days post-surgery (OR=0.51, 95% C.I.=[0.20, 1.29]).
Conclusions:
This study demonstrates the prevalence of low health literacy in a surgical cancer population at a high-volume NCI-designated comprehensive cancer center, and its association with important clinical outcomes including length of hospital stay and post-acute care needs. Universal screening and patient navigation may be two approaches to mitigate the impact of low health literacy on post-surgical outcomes.
Keywords: Health disparities, Health literacy, Brief Health Literacy Screen, Surgical Oncology, Perioperative
1.0. Background
Health literacy consists of a set of complex and interconnected abilities that people need to function effectively in the health care environment.1-3 These skills impact multiple dimensions of communication and include print literacy, or the ability to read, understand, and act upon text and to locate and interpret health information in documents, and oral literacy, or the ability to speak and listen effectively about health information (e.g., communicating needs to health professionals, understanding professionals’ instructions). Only 12% of the US adult population is considered to have a “proficient” level of health literacy; the majority (53%) have “intermediate” health literacy.4 This finding has been referred to as the “health literacy epidemic”.5
Low health literacy is associated with difficulty communicating about health, including objectively poorer ability to understand and follow medical advice6 and to interpret written information in medical and surgical contexts.6-11 Low health literacy is also correlated with lower adherence to care recommendations and screening guidelines,6,12 and negatively influences clinical outcomes related to the management of chronic diseases including asthma,13 diabetes,14,15 congestive heart failure,10,16,17 and end-stage renal disease.18,19 Finally, given the importance of health literacy for self-management following discharge, low health literacy has also been shown to be associated with a higher incidence of unplanned readmissions post-hospitalization20 and an increased rate of acute care and emergency department (ED) visits in certain patient populations.21
Compared with evidence about the relationship between health literacy and outcomes for patients with chronic medical conditions, there is a relative dearth of research on the effects of low health literacy on post-operative outcomes. A recent systematic review of health literacy in surgery identified 51 studies addressing this topic, with only 6 that investigated the association of health literacy and surgical outcomes.22 In all studies, the prevalence of low health literacy was reported in more than one-third of patients, although this was determined in heterogeneous patient populations using various assessment tools between studies. Low health literacy is reported to impact whether patients undergo certain surgical procedures like breast reconstruction after mastectomy,23 or whether they are listed for kidney transplantation.7,24 Additionally, low health literacy was predictive of developing minor postoperative complications in patients undergoing a radical cystectomy.8 Finally, lower health literacy is independently associated with increased length of hospital stay in patients who are undergoing major abdominal surgery.9
To our knowledge, there are no published studies focusing on the role of health literacy in complex general surgical oncology. Surgical interventions for cancers such as gastrointestinal malignancies, genitourinary malignancies, and sarcomas require hospitalization and extended periods of recovery. The physical toll of these surgeries is substantial and often requires adjustments to a patient’s dietary habits, functional mobility, or digestive processes, among other changes. Within the complex setting of these surgical procedures and the postoperative course, the impact of health literacy is poorly understood.
To fill this gap, the present study reports on health literacy among a sample of patients presenting for complex cancer surgery at an NCI-designated Comprehensive Cancer Center (CCC). Study aims were twofold: (1) define the prevalence of low health literacy for surgical cancer patients at an NCI-designated CCC; and (2) examine the associations of health literacy with clinical outcomes. We hypothesized that: (1) using the Brief Health Literacy Screening tool (BRIEF) with a cut point of 12, ~30% of surgical oncology patients will demonstrate low health literacy, defined as scores ≤12 on the 4-Question BRIEF; and (2) compared to patients with marginal/adequate health literacy, patients with low health literacy would have longer length of hospital stay, more post-acute care needs, and more unplanned presentations for care in the 30 days post-surgery.
2.0. Methods
2.1. Procedures and Participants
An observational, longitudinal, single-group design was used. All procedures were approved by the University of South Florida Institutional Review Board (Protocol #00038579). As the BRIEF has not previously been utilized in surgical literature, the data points necessary to conduct a formal power analysis were not available. Thus, the target sample size for this study (200 cases with complete data) was based on prior studies of health literacy in surgical populations.22 To achieve this goal, a convenience sample of patients presenting for care at a NCI-designated CCC was used. Recruitment took place from March 2019 through September 2019.
Eligible participants were: (1) age ≥18; (2) presenting for surgical treatment of primary gastrointestinal (GI) cancer, genitourinary cancer, or sarcoma; (3) admitted to the hospital for ≥1 night; and (4) English-speaking. Study staff reviewed lists of recent admissions and patient electronic medical records (EMR) to identify patients meeting eligibility criteria. Eligible participants were approached by the study team during their post-surgical inpatient stay and, if interested, provided written informed consent. After obtaining consent, a study team member assisted participants in completing a self-report survey. Following survey completion, participants received a $20 gift card in appreciation of their time and effort. Clinical data was abstracted from the EMR 90 days post-surgery; thus, clinical data abstraction took place between June 2019 and December 2019.
2.2. Measures
The primary predictor of interest was health literacy. The primary outcomes of interest included length of hospital stay, post-acute care needs, and unplanned presentations for care in the 30 days post-surgery. Sociodemographic and clinical characteristics were examined as covariates.
2.2.1. Demographic characteristics.
Participants reported their age, sex, race/ethnicity, education, and insurance status.
2.2.2. Clinical characteristics.
Medical comorbidities (Charlson Deyo score25), functional status (Eastern Cooperative Oncology Group (ECOG) status26), and surgical complications (Clavien-Dindo grade) were abstracted from the EMR.
2.2.3. Health Literacy.
The 4-item Brief Health Literacy Screen (BRIEF)27 assessed ability to read and discuss health-related information. This screening tool was built upon the 3-question BHLS (Brief Health Literacy Screen),28-33 with the addition of one question to assess oral literacy in a quick, and validated measure.27,34 Responses are scored on a 5-point Likert scale (1=never to 5=always). Scores range from 4 to 20, and a cut point of 12 is used to determine low versus adequate health literacy.
2.2.4. Clinical Outcomes.
Data abstracted from the EMR 90 days post-surgery included: (1) length of hospital stay (days); (2) post-acute care needs, including home-based physical therapy or occupational therapy, home nursing, or discharge to a skilled nursing or rehabilitation facility (yes/no); and (3) unplanned presentations for care in the 30 days post-surgery, including emergency department (ED) visits and/or hospital readmissions (yes/no).
2.3. Statistical Methods
Descriptive statistics were used to examine the distribution of health literacy in this sample. Continuous variables are presented with mean (±SD) and categorical variables are presented with frequency (%). Chi-square test of association or Fisher’s exact test in case of cell value <5 was used for comparison between categorical variables. For comparing means, ANOVA model was used.
In the regression analyses, we combined the populations with marginal and adequate health literacy (BRIEF>12) to highlight the impact of low health literacy (BRIEF≤12) on clinical outcomes, as has been previously done.19,35 Multivariate linear regression analysis was used to examine the relationship between health literacy (low versus marginal/adequate) and hospital length of stay in days (continuous). Multivariate logistic regression analysis was used to predict the odds for re-presentation to ED/rehospitalization (yes versus no) and post-acute care needs (yes versus no) by health literacy (low versus marginal/adequate). Initial models included sociodemographic and clinical covariates (age, sex, race/ethnicity, education, insurance, Charlson-Deyo scores, and Clavien-Dindo grade III or IV complications). To ensure parsimony of the final models, only those variables that were significant predictors (p<0.05) in the multivariate models were retained for the final model. All tests were two-tailed, and p-value <0.05 was considered statistically significant. All analyses were conducted using the statistical program SAS 9.4 (Cary, NC).
3.0. Results
3.1. Preliminary and Descriptive Analyses
We approached 255 patients and 225 (88%) consented to participate (see Figure 1). Seven patients (3%) were deemed ineligible after consent due to having a secondary surgery related to their cancer (i.e. ileostomy takedown); thus, 218 patients were included in descriptive analyses. For regression analyses examining the relationship between health literacy and resource utilization, we excluded four outliers (Clavien-Dindo grade 5, n = 1; LOS>25 days, n = 3). As two patients had incomplete sociodemographic data, the final analytic sample included 212 patients with complete data. For a complete description of the sample, see Table 1. Health literacy groups significantly differed on education, such that a greater proportion of patients with low health literacy had less than a high school diploma (low health literacy = 12.9%; marginal = 6.1%; adequate = 2.5%). Groups also significantly differed on Charlson-Deyo score, such that a greater proportion of patients with low health literacy had ≥1 comorbid condition (low health literacy = 61.3%; marginal = 51.1%; adequate = 31.4%).
Figure 1.
Study Flow.
Table 1:
Sociodemographic, clinical, and surgical characteristics by health literacy score categories (N=218).
| BRIEF Score | p value | |||
|---|---|---|---|---|
| Low (6-12) |
Marginal (13-16) |
Adequate (17-20) |
||
| n=31 | n=66 | n=121 | ||
| Sociodemographic Characteristics | ||||
| Age, mean (SD) | 69.8 (10.0) | 66.4 (11.1) | 64.5 (13.5) | 0.09 |
| Sex, n (%) | 0.32 | |||
| Male | 22 (71.0) | 37 (56.1) | 69 (57.0) | |
| Female | 9 (29.0) | 29 (43.9) | 52 (43.0) | |
| Race/Ethnicity, n (%) | *0.96 | |||
| Non-Hispanic White | 27 (87.1) | 58 (87.9) | 104 (86.7) | |
| Other | 4 (12.9) | 8 (12.1) | 17 (14.1) | |
| Education, n (%) | *0.04 | |||
| <High school diploma | 4 (12.9) | 4 (6.1) | 3 (2.5) | |
| ≥High school diploma | 27 (87.1) | 62 (93.9) | 118 (97.5) | |
| Insurance, n (%) | 3 (9.7) | 6 (9.1) | 5 (4.2) | 0.25 |
| Medicaid/Uninsured | 3 (9.7) | 6 (9.1) | 5 (4.2) | |
| Private/Medicare/Military | 28 (90.3) | 60 (90.9) | 114 (95.8) | |
| Clinical Variables | ||||
| Charlson Deyo Score, n (%) | <0.01 | |||
| 0 | 12 (38.7) | 32 (48.5) | 83 (68.6) | |
| ≥1 | 19 (61.3) | 34 (51.5) | 38 (31.4) | |
| ECOG Status, n (%) | *0.93 | |||
| 0-1 | 29 (93.6) | 61 (92.4) | 114 (94.2) | |
| 2-3 | 2 (6.5) | 5 (7.6) | 7 (5.8) | |
| Surgery Type, n (%) | *0.56 | |||
| Gastrointestinal | 18 (58.1) | 36 (54.6) | 75 (62.0) | |
| Genitourinary | 9 (29.0) | 14 (21.2) | 26 (21.5) | |
| Sarcoma | 4 (12.9) | 16 (24.2) | 20 (16.5) | |
| Clavien-Dindo GRADE III or IV, n (%) | *0.12 | |||
| Yes | 1 (3.3) | 6 (9.1) | 3 (2.5) | |
| No | 29 (96.7) | 60 (90.9) | 118 (97.5) | |
| Hospital LOS, mean (SD) | 8.71 (4.1) | 7.50 (5.6) | 6.63 (4.9) | 0.10 |
| Re-presentation to ED/Hospital, n (%) | 0.17 | |||
| Yes | 10 (32.3) | 12 (18.2) | 21 (17.4) | |
| No | 21 (67.7) | 54 (81.8) | 100 (82.6) | |
| Post-Acute Care Needs, n (%) | *0.02 | |||
| Yes | 28 (90.3) | 42 (63.6) | 85 (70.3) | |
| Home health visit | 26 (83.9) | 39 (59.1) | 81 (66.9) | |
| Skilled Nursing Facility/Rehab | 2 (6.5) | 3 (4.6) | 4 (3.3) | |
| No | 3 (9.7) | 24 (36.4) | 36 (29.8) | |
p-values from ANOVA, Chi-square test of association and *Fisher's exact test; p <0.05 considered statistically significant.
3.2. Prevalence of Low Health Literacy
The mean BRIEF score for the sample was 16.49 (SD ±3.18). Of 218 participants, 31 (31/218=14%) demonstrated low health literacy according to scores on the BRIEF. Marginal health literacy was identified in 66 patients (66/218=30%), and adequate health literacy in 121 patients (121/218=56%).
3.3. Associations with Post-Surgical Outcomes
All linear and logistic regression analyses included health literacy, age, sex, race/ethnicity, education, insurance, Charlson-Deyo scores, and Clavien-Dindo grade III or IV complications as predictors. The results of the multivariate linear regression predicting average length of stay are presented in Table 2. In the initial model, only health literacy (p=0.002), education (p=0.01), and Clavien-Dindo grade III or IV complications (p<0.0001) significantly predicted average length of stay. Thus, these three variables were retained in the final model for length of stay. In the final model, on average, patients with marginal and adequate health literacy had significantly shorter length of hospital stay than patients with low health literacy (β = −2.04, 95% C.I. = [−3.19, −0.89], p=0.0006). In other words, on average, length of stay was 2.04 days lower for those with marginal/adequate health literacy compared to those with low health literacy, after adjusting for education and Clavien-Dindo grade III or IV complications.
Table 2:
Linear regression analysis for factors predicting hospital length of stay in days (n=212)
| Model 1: All Covariates (R2 = 0.1951) | |||
|---|---|---|---|
| Variable | Estimate (β) | 95% CI | p value |
| Intercept | 6.140 | (3.445 – 8.836) | <.0001 |
| BRIEF Score: Marginal-Adequate (13-20) v. Low (6-12) | −1.612 | (−3.000 – −0.656) | 0.002 |
| Age (years) | 0.030 | (−0.004 – 0.064) | 0.080 |
| Sex: Female v. Male | −0.551 | (−1.378 – 0.274) | 0.189 |
| Race/Ethnicity: Other v. Non-Hispanic White | 0.638 | (−0.624 – 1.900) | 0.320 |
| Education: <High School v. ≥High School | 2.315 | (0.480 – 4.150) | 0.014 |
| Insurance: Medicaid/Uninsured v. Private/Medicare | −0.893 | (−2.568 – 0.782) | 0.294 |
| Charlson Deyo Score: ≥1 v. 0 | 0.112 | (−0.717 – 0.941) | 0.790 |
| Clavien-Dindo grade III or IV: yes v. no | 5.092 | (3.016 – 7.167) | <.0001 |
| Model 2: Parsimonious Model (R2 = 0.1667) | |||
| Variable | Estimate (β) | 95% CI | p value |
| Intercept | 8.170 | (7.086 – 9.254) | <.0001 |
| BRIEF Score: Marginal-Adequate (13-20) v. Low (6-12) | −2.040 | (−3.191 – −0.890) | 0.0006 |
| Education: <High School v. ≥High School | 1.947 | (0.137 – 3.756) | 0.0351 |
| Clavien-Dindo grade III or IV: yes v. no | 5.115 | (3.033 – 7.198) | <.0001 |
The results of the multivariate logistic regression predicting the odds for re-presentation to ED/rehospitalization are presented in Table 3. In the initial model, none of the specified predictors were significantly associated with re-presentation to ED/rehospitalization.
Table 3:
Logistic regression analysis for factors predicting re-presentation to ED/rehospitalization 30 days post-surgery (n=212).
| Model 1: All Covariates (Area Under Curve [AUC] = 0.646) | ||
|---|---|---|
| Variable | OR | 95% CI |
| BRIEF Score: Marginal-Adequate (13-20) v. Low (6-12) | 0.508 | (0.200 – 1.291) |
| Age (years) | 1.006 | (0.976 – 1.038) |
| Sex: Female v. Male | 2.000 | (0.971 – 4.118) |
| Race/Ethnicity: Other v. Non-Hispanic White | 0.909 | (0.297 – 2.781) |
| Education: <High School v. ≥High School | 0.659 | (0.121 – 3.587) |
| Insurance: Medicaid/Uninsured v. Private/Medicare | 3.033 | (0.873 – 10.542) |
| Charlson Deyo Score: ≥1 v. 0 | 1.527 | (0.740 – 3.150) |
| Clavien-Dindo grade III or IV: yes v. no | 2.768 | (0.324 – 23.653) |
The results of the multivariate logistic regression predicting the odds for post-acute care needs are presented in Table 4. In the initial model, only health literacy (OR=0.25, 95% C.I. = [0.07, 0.91]), age (OR=1.05, 95% C.I. = [1.02, 1.08]), and sex (OR=2.1, 95% C.I. = [1.06, 4.2]) significantly predicted the odds for post-acute care needs. Thus, these three variables were retained in the final model for the odds for post-acute care needs. In the final model, patients with marginal and adequate health literacy were 77% less likely to need post-acute care than patients with low health literacy (OR=0.23, 95% C.I. = [0.07, 0.82]), after adjusting for age and sex.
Table 4:
Logistic regression analysis for factors predicting Post-Acute Care Needs (n=212)
| Model 1: All Covariates (Area Under Curve [AUC] = 0.713) | ||
|---|---|---|
| Variable | OR | 95% CI |
| BRIEF Score: Marginal-Adequate (13-20) v. Low (6-12) | 0.254 | (0.071 – 0.908) |
| Age (years) | 1.052 | (1.023 – 1.082) |
| Sex: Female v. Male | 2.101 | (1.058 – 4.175) |
| Race/Ethnicity: Other v. Non-Hispanic White | 0.716 | (0.272 – 1.884) |
| Education: <High School v. ≥High School | 2.879 | (0.499 – 16.605) |
| Insurance: Medicaid/Uninsured v. Private/Medicare | 1.223 | (0.279 – 5.363) |
| Charlson Deyo Score: ≥1 v. 0 | 0.937 | (0.486 – 1.807) |
| Clavien-Dindo grade III or IV: yes v. no | 2.768 | (0.324 – 23.653) |
| Model 2: Parsimonious Model (Area Under Curve [AUC] = 0.689) | ||
| Variable | OR | 95% CI |
| BRIEF Score: Marginal-Adequate (13-20) v. Low (6-12) | 0.232 | (0.065 – 0.821) |
| Age (years) | 1.049 | (1.022 – 1.077) |
| Sex: Female v. Male | 1.970 | (1.017 – 3.816) |
4.0. Discussion
Low health literacy is associated with increased resource utilization6,12,20,21 and poorer clinical outcomes6,10,11 in medical and surgical patients with various diseases. Despite the demonstrated importance of health literacy in the perioperative period,35,36 the role of health literacy in complex surgical oncology has not previously been delineated. As surgery for cancer is especially complex in terms of shared decision-making, perioperative instructions, and the postoperative course, there is an urgent need to understand the role of health literacy in outcomes following cancer surgeries. The present study fills this gap. These data demonstrate that only a small proportion (14%) of patients presenting for complex cancer surgery at a high-volume NCI-CCC had low health literacy. Nonetheless, lower health literacy was related to increased resource utilization in the form of length of hospital stay and post-acute care needs. Taken together, these data have clinical implications for the identification and management of patients with low health literacy.
Our first hypothesis, that ~30% of participants would demonstrate low health literacy, was not supported. The incidence of low health literacy in this cohort (14%) is lower than the previously reported average rate in other surgical cohorts (~33%).22 As 12% of the patients approached refused participation, it is possible that these patients may have disproportionately represented the low health literacy group thereby skewing our data. Alternatively, this lower rate of low health literacy may reflect differences in the types of patients that present to regional Comprehensive Cancer Centers; across most cancer diagnoses, patients are more likely to be treated at NCI-CCCs if they are non-Hispanic White, privately insured, and have high socioeconomic status.37 These characteristics have also been associated with higher health literacy.6,38-40 Seeking treatment at a stand-alone NCI-CCC often requires a high level of patient engagement to obtain a referral or navigate care between medical systems. Thus, higher levels of health literacy may be necessary in order to establish care at these institutions.
Although small numbers of patients in this sample demonstrated low health literacy, BRIEF scores were still related to greater length of hospital stay and post-acute care needs when accounting for the sociodemographic and clinical variables that were significantly related to our outcomes of interest. Even at an NCI-CCC, which has incorporated peri-operative interventions that reduce length of stay post-surgery,41 we still observed differences in clinical outcomes by level of health literacy. Thus, our second hypothesis was partially supported. We did not observe any relationship between BRIEF scores and unplanned presentation for care within 30 days post-surgery. This contradicts the findings in certain medical conditions in which low health literacy is related to higher incidence of unplanned readmissions post-hospitalization20 and an increased rate of acute care and ED visits21 in the 30 days post-surgery. There are several potential explanations for our null findings. First, our results could be confounded in part by the source of data on unplanned presentation for care. This data was abstracted from the institutional electronic medical record, which may not capture readmissions and ED visits at outside facilities. Thus, the data presented here may underestimate unplanned re-presentations for care in the 30 days following surgery. Additionally, our patient population included complex surgeries for multiple types of cancers (gastrointestinal, genitourinary, and sarcoma) for whom different degrees of morbidity and post-acute care needs would be expected depending on the surgery performed. Although different trends existed for resource utilization by cancer types, the low number of patients in these independent groups precluded subgroup analyses. As such, this heterogeneity may limit the sensitivity of our analysis.
The data presented here have important system-level implications. Specifically, screening for low health literacy in the post-surgical setting was feasible; we did not observe patient unwillingness to participate due to stress, post-operative pain, or medication-related impairment. Other studies that have reviewed health literacy post-operatively have done so in the outpatient clinic setting.7,23,42 Therefore, the feasibility of health literacy screening during this post-operative admission is a novel contribution to the literature.
Although universal health literacy screening has been criticized for its potential to result in negative profiling of patients through perceived or actual stigmatization,43-48 the present study suggests that screening for health literacy may allow for a targeted intervention approach to reduce the clinical impact of low health literacy. This aligns with recent recommendations for the use of universal health literacy screening in addition to universal precautions (i.e. plain language and teach back communications for all patients, etc.) as best practices for managing patients with low health literacy.49 With multiple studies demonstrating increased resource utilization by patients with low health literacy (i.e., length of stay), a proactive re-alignment of resources (i.e., high-touch interaction with the clinical team, patient navigation, social work, home care assistance, etc.) earlier in the perioperative period could help these patients adhere to standard treatment courses and mitigate the impact of low health literacy on clinical outcomes.
Once patients with low health literacy are identified, evidence-based interventions could be used to improve the post-operative outcomes and resource requirements of this population.50 For example, intensive self-management interventions (e.g., tailored educational materials about disease management and scheduled telephone follow-up) have been shown to reduce emergency department visits and hospitalizations.51,52 However, to our knowledge, these interventions have not been tested in the surgical oncology context. Future studies are needed to assess whether the positive intervention results observed in other populations would translate to this setting. In addition, there has been a recent push for the integration of nurse navigators in the post-surgical setting.53,54 Emerging data demonstrate that nurse navigation interventions can reduce hospital length of stay and post-surgical readmissions.55 Future research should examine the potential of navigation interventions specifically for surgical patients with low health literacy.
Strengths of our study include the direct clinical applicability and the novel application of health literacy screening in the post-surgical setting. Furthermore, this study is among the first to examine health literacy in the complex surgical oncology setting. To our knowledge, this is the first evaluation to focus on health literacy in surgical patients at a high volume, free-standing, NCI-designated Comprehensive Cancer Center. We also used an established measure to assess health literacy; the BRIEF Health Literacy Screen.27 Limitations must also be acknowledged: (a) data from a single institution may not be generalizable across all surgical practice settings; (b) limited ability to examine the potential confounding role of sociodemographic characteristics due to the homogenous sample (i.e., 87% non-Hispanic White, 95% ≥ high school diploma, 93% insured); (c) homogenous sample reduces generalizability of results to diverse patient populations; (d) EMR data exclusive to our institution may underrepresent ED visits and readmissions if they occurred at outside facilities; (e) convenience sample of patients presenting for surgery may be subject to selection bias; (f) self-reported health literacy may be subject to demand characteristics and social desirability; and (g) there may be additional predictors of resource utilization (e.g., psychological symptoms, social support, quality of/satisfaction with care, etc.) that were not assessed in this study.
Conclusions
Low health literacy adversely affects clinical outcomes and resource utilization in medical and surgical patients. This pilot study demonstrates the prevalence of low health literacy in a surgical cancer population at a high-volume NCI-designated Comprehensive Cancer Center, and its association with important clinical outcomes including length of hospital stay and post-acute care needs. Health literacy is a patient-level determinant of health that should be considered among other biological, psychological, social, and health system determinants of health when evaluating a patient’s ability to navigate their complex medical care.
Footnotes
Conflict of Interest: The authors declare that they have no conflict of interest.
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