Health Literacy and Patient Reported Outcomes in Orthopaedic Surgery Patients

47 Health Literacy and Patient Reported Outcomes in Orthopaedic Surgery Patients Udawatta et al. Journal of Health Disparities Research and Practice Volume 12, Issue 3, Fall 2019, pp. 47-58 © 2011 Center for Health Disparities Research School of Community Health Sciences University of Nevada, Las Vegas Health Literacy and Patient Reported Outcomes in Orthopaedic Surgery Patients Thiran Udawatta MD, Saint Louis University Lance E. Flesch, MD, MountainView Hospital GME Michael Eng, MD, Cedars-Sinai Orthopaedics Jane E. Oliphant, MSW, Washington University in St. Louis, Scott G. Kaar, MD, Saint Louis University Corresponding Author: Thiran Udawatta, ABSTRACT Background: Health literacy may be an important factor in patient health outcomes, however, prior research has primarily focused on primary care patients with research in orthopaedic specific populations lacking. Questions/purposes: The purpose of this study was to examine the relationship between health literacy and patient reported outcomes in an orthopaedic patient population. Patients and Methods: 183 patients >18 years of age who presented to our institution’s sports orthopaedic surgery clinic with shoulder or knee complaints were analyzed. The primary outcomes were physical function recorded using Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and Single Assessment Numerical Evaluation (SANE) scores. Health literacy was determined utilizing Health LiTT, a self-administered multimedia touchscreen test based on item response theory that provides a numerical score of 0100 with a score >50 suggestive of health literacy. In addition, demographic data including age, race, gender, highest level of education, injury location, and surgery status were collected. Results: Bivariate analysis revealed that low health literacy (Health LiTT score <50), GED education or less, and lack of employment status correlated with worse PROMIS scores. However, regression results suggested that lower physical function correlated with disability status (p=0.003), increasing age (p=0.004), having had surgery (p=0.045) and a level of education of GED or less (p=0.029). Being employed (p=0.001) and retired (p=0.044) were predictive of improved PROMIS scores. Health literacy scores were not significant in the regression analysis (p=0.849). Conclusions: Our data showed that PROMIS scores are less reliant on health literacy and more dependent on age, employment status, having surgery and low education level achieved. Adaptations to clinical practice may be necessary to better guide these select populations and Journal of Health Disparities Research and Practice Volume 12, Issue 3, Fall 2019 http://digitalscholarship.unlv.edu/jhdrp/ Follow on Facebook: Health.Disparities.Journal Follow on Twitter: @jhdrp 48 Health Literacy and Patient Reported Outcomes in Orthopaedic Surgery Patients Udawatta et al. improve patient-reported physical function. Furthermore, PROMIS measures can be administered successfully to patients regardless of health literacy. Level of Evidence: Level II Keywords: Health Literacy, orthopaedic surgery, PROMIS score, SANE score, Health LiTT, patient reported outcomes INTRODUCTION Health literacy is an important component of patient's health status. The Institute of Medicine defines health literacy as "the degree to which an individual can obtain, process, and understand the basic health information and services they need to make appropriate health decisions. It also depends upon the skills, preferences, and expectations of health information and care providers: our doctors; nurses; administrators; home health workers; the media; and many others" (White, 2008). This definition encompasses the multifaceted nature of health literacy. The practical implications of low health literacy among patients cannot be understated. A recent study by the National Assessment of Adult Health Literacy (NAAL) showed a significant portion of the US population (38%) have limited health literacy (Education, 2006; Kutner, Greenber, Jin, & Paulsen, 2006; McClellan, Wood, Fahmy, & Jones, 2014; White, 2008). A recent systematic review of health literacy by Berkman, Sheridan, Donahue, Halpern and Crotty (2011) and confirmed by further studies, demonstrated low health literacy is consistently associated with more hospitalizations, greater use of emergency care, lower receipt of mammography screening and influenza vaccine and poorer ability to demonstrate taking medications appropriately among others (Baker, Gazmararian, Green, Ren, & Peel, 2002; Baker, Williams, Parker, Gazmararian, & Nurss, 1999). Health literacy may play a major role in a patient’s response to a variety of treatments as well. Most of the established studies on health literacy have been performed on primary care populations using a variety of different modalities to measure health literacy. Inquiry into the subset of orthopaedic surgery patients is lacking with only a few published studies (Badarudeen & Sabharwal, 2010; Kadakia et al., 2013). Nonetheless, health literacy has important implications for orothpaedic populations. Treatment of orthopaedic injuries requires at times prolonged rehab courses with typical alterations in weight bearing status. Identifying patients who may have difficulty with understanding treatment protocols may influence their outcome. A study by Kadakia et al. (2013) highlighted the fact that less than 50 percent of patients knew what bone they fractured, let alone their weight bearing status. Thus research in this field of medicine stands to yield important findings that can help improve patient outcomes. Measuring health literacy evolved over the past few decades. The two most commonly used assessments for health literacy are the Rapid Estimate of Adult Literacy in Medicine (REALM), its shortened version, s-REALM, and the Test of Functional Health Literacy (TOFHLA) and its short form, the S-TOFHLA (Davis et al., 1991; Davis et al., 1993; Dumenci, Matsuyama, Kuhn, Perera, & Siminoff, 2013; Griffin et al., 2010; Parker, Baker, Williams, & Nurss, 1995). Despite being widely adopted, critical reviews of the above measurement tools and several others have highlighted limited construct validity, limited extrapolation to outcomes, and weakness in psychometric properties (Altin, Finke, Kautz-Freimuth, & Stock, 2014; Dumenci et al., 2013; Hahn, Choi, Griffith, Yost, & Baker, 2011; Jordan, Osborne, & Buchbinder, 2010). Hahn et. al. (2011) developed a relatively new measurement tool based on item response theory (IRT), Journal of Health Disparities Research and Practice Volume 12, Issue 3, Fall 2019 http://digitalscholarship.unlv.edu/jhdrp/ Follow on Facebook: Health.Disparities.Journal Follow on Twitter: @jhdrp 49 Health Literacy and Patient Reported Outcomes in Orthopaedic Surgery Patients Udawatta et al. modern psychometric principles and novel health information in response. This new measurement system, Health Literacy Asses (...truncated)