Brief review about health literacy, communicating with patients, and shared decision making

1. Communicating
with Patients:
Information that
Matters
Lisa F. Han, MPH
Partner, Insight Therapeutics
April 19, 2013

2. Objectives
 Define health literacy and describe those
at highest risk
 Recognize barriers for patients with low
literacy
 Discuss strategies for improving
communication with patients and family
caregivers
April 19, 2013

3. Health literacy
 the degree to which an individual has the
capacity to obtain, communicate,
process, and understand basic health
information and services to make
appropriate health decisions.
 Patient Protection and Affordable Care Act
of 2010, Title V
April 19, 2013

4. Poor health literacy
 Lack basic skills to execute
recommended preventive
care and treatment – 1/3 of
US population, only 12%
considered proficient
April 19, 2013
 Groups at higher risk of poor
literacy
 Elderly, poor, minorities
 English not first language
 Low education (poor surrogate
though)
Source: ihealthtran.com

5. April 19, 2013
Execute proper
inhaler use
techniques
Modify insulin dose
based on food
intake/fingersticks
Manage
administration of
multiple
medications
Recognize
hypoglycemia
symptoms
Proficient
Health Literacy

6. Take two tablets by mouth twice daily
States
correctly
Health literacy
level*
Demonstrated
correctly
71% Low
(6th grade or below)
35%
84% Marginal 63%
89% Adequate 80%
April 19, 2013
Davis T, Wolf MS, Bass PF et al. Ann Intern Med 2006
Almost half of patients misunderstood 1 or more of
prescription label instructions
* REALM Score

7. Poor literacy leads to…
April 19, 2013
Missed appointments
Medication errors and adverse events
Low use of preventive services
Preventable hospital visits and admissions
High cost – $106-$238 billion annually
Higher mortality

8. You can’t tell by
looking
whether someone has skills to adequately
understand health concepts and carry out
health care instructions.
April 19, 2013

9. Signals – indicators of possible
limited health literacy
 Incomplete forms
 Nonadherence with treatment
regimens
 Excuses
 Forgot my glasses
 Need to bring home to discuss with
family member
 Does not know medications names
or what they are for
 Many missed appointments
 Poor follow-through
 Referral appointments, labs, imaging
Many people
show no signals
April 19, 2013

10. Factors Related to
Understanding
 General ability to read and write
 Experience in the health care system
 Complexity of information presented
 Culture
 Method of communication
36% of American adults have basic or below basic
skills; about 60% of those age 65 and older have
basic or below basic skills
April 19, 2013
Weiss B. Health literacy and patient safety: Help patients understand. AMA Foundation 2007.

11. How can we improve?
 Simple, plain language (for all
patients)
 Slow down
 Visual images are helpful for
many patients
 Limit information quantity
 Repetition
 Teach-back
 Encourage questions
April 19, 2013
Weiss B. Health literacy and patient safety: Help patients understand. AMA Foundation 2007.

12. Shared Decision Making
is the goal
April 19, 2013

13. So what is Shared Decision
Making
April 19, 2013
 Must include
o Options (including
no treatment)
o Potential risks and
benefits
o Patient preferences
o Should be
balanced and
unbiased
“Collaborative process that
allows patients and their
providers to make health care
decisions together, taking into
account the best scientific
evidence available as well a
the patient’s values and
preferences”

14. Rationale for shared decision
making
 Many decisions have no 'best choice'—more
than one appropriate option
 Evidence uncertain
 Need to consider
 Benefits and harms
 Values & preferences
 Practical aspects
April 19, 2013

15. PCORI
1. “Given my personal characteristics, conditions
and preferences, what should I expect will
happen to me?”
2. “What are my options and what are the
potential benefits and harms of those
options?”
3. “What can I do to improve the outcomes that
are most important to me?”
4. “How can clinicians and the care delivery
systems they work in help me make the best
decisions about my health and healthcare?”
April 19, 2013

16. Decision Aids
April 19, 2013
http://shareddecisions.mayoclinic.org/files/20
11/08/Diabetes-Choice-Pamphlet.pdf
 Adjunct to prepare
patients for
decision making
 Provides
information on the
alternatives,
benefits, and risks
appropriate for
patients' clinical
condition
http://summaries.cochrane.org/CD001431/decision-aids-to-help-
people-who-are-facing-health-treatment-or-screening-decisions

17. Health Decisions
April 19, 2013
 Good decisions
 Informed
 Supported by best
evidence
 Compatible with
patients values
 Considers patient
preferences
 Weigh pros and
cons
 Practical
 Poor decisions
 Inadequate objective
data
 Too few options
considered
 Alternatives unclear
 Values and preferences
unexplored
 Roles unclear
 Poor communication
 May be impractical
Cornelia Ruland
http://people.dbmi.columbia.edu/~cmr7001/sdm/html/shared_decision_making.htm

18. Shared Decision
Making Month –
March 2013
-We missed it!
http://informedmedicaldecisio
ns.org/about-sdm-month/
April 19, 2013

19. Resources
 PCORI – Patient Centered Outcomes Research
Institute |www.pcori.org
 US Department of Veterans Affairs |
http://www.va.gov/geriatrics/guide/longtermcare/Shared_De
cision_Making.asp
 AHRQ | http://www.innovations.ahrq.gov/issue.aspx?id=85
 Dartmouth Hitchcock Center for Shared
Decision Making |http://patients.dartmouth-
hitchcock.org/shared_decision_making.html
 Informed Medical Decisions Foundation
|http://informedmedicaldecisions.org/
April 19, 2013