September 2017 Editor-in-Chief Pick of the Month

The Association of Health Literacy with Preventable Emergency Department Visits: A Cross-Sectional Study

I don’t understand and I likely won’t let you know

I chose the article by Balakrishnan as the Pick of the Month. Health literacy’s effect has been studied with close to 12,000 PubMed citations and 202 listed when combined with emergency department. Poor health literacy is associated with a host of poor outcomes. Balakrishnan and colleagues are the first to show the relationship between literacy and ambulatory care sensitive conditions (ACSC) resulting in preventable emergency department (ED) visits. The association of poor health literacy and ACSC controlling for the usual confounders was noteworthy. Those with poor literacy were 2.3 times as likely to be admitted after presentation with a preventable condition.  Poor health literacy in their setting was high with one-third of patients failing the health literacy test they used. They found 9.5 percent of visits were for ACSC, about what others have shown.  They note that punitive measures such as increased copay have not worked in reducing ACSC. The question then is what can you do about it. While the mechanism remains in a black box, clinicians can still act.  The authors used a 66-word test (REALM) for medical literacy that is not suitable for use in the ED. However, there is a short version of REALM that asks the patient to read seven words. Patients or caregivers are given five seconds per word.  Maybe discharge instructions can be modified to the patient’s or caregiver’s literacy. This may work to reduce revisits if used in the ED, better yet if used in the outpatient setting to prevent the ACSC in the first place. It is worth investigating whether this is time well spent. 

The article also contains a (perhaps more subtle) message for those who conduct and publish research. The authors used the STROBE criteria. Carpenter and Meisel1recently published a commentary of the value of following the EQUATOR guidelines. This publication is an excellent example of the value of adhering to the appropriate guideline for the study type.

Best regards,
Lowell W. Gerson, PhD, Northeast Ohio Medical UniversityGuest Editor, Academic Emergency Medicine 


Narrative Summary

Zachary F. Meisel, MD, Associate Professor of Emergency Medicine at the Perelman School of Medicine at the University of Pennsylvania, places the EIC Pick into perspective in the emergency setting:

“Those papers won’t get her to the doctor. With my grandmom, you have to make it real for her.” The teenager was doing her best to close the gaps between what we were trying to say with the incidental finding notification form (stating that grandma had a suspicious nodule on her lung) and the reality that this was something that needed non-urgent follow up. Those forms, created by thoughtful quality improvement-focused nurses and doctors, filtered through various legal and hospital committees, were useless to our patient with low literacy.  What she needed was context to wrap her head around the nuanced scenario (she needed a test… but didn’t need it today… it was very important and could save her life… but the nodule was unlikely to be life threatening).  Carden and colleagues show us that low health literacy is a risk factor independent of other social determinants of health for visits and hospital admissions among patients with preventable conditions. Indeed, our patient had good insurance and good follow up, but as her granddaughter was trying to explain, it wasn’t enough. So we did our best to make it real (by telling the patient a story that made sense to her). We also sent the forms back to the hospital QI group to come up with more literacy sensitive approaches to these notifications.