Is low health literacy associated with increased emergency department utilization and recidivism

Objectives The objective was to determine whether patients with low health literacy have higher emergency department (ED) utilization and higher ED recidivism than patients with adequate health literacy. Methods The study was conducted at an urban academic ED with more than 95,000 annual visits that is part of a 13-hospital health system, using electronic records that are captured in a central data repository. As part of a larger, cross-sectional, convenience sample study, health literacy testing was performed using the short test of functional health literacy in adults (S-TOFHLA) and standard test thresholds identifying those with inadequate, marginal, and adequate health literacy. The authors collected patients' demographic and clinical data, including items known to affect recidivism. This was a structured electronic record review directed at determining 1) the median number of total ED visits in this health system within a 2-year period and 2) the proportion of patients with each level of health literacy who had return visits within 3, 7, and 14 days of index visits. Descriptive data for demographics and ED returns are reported, stratified by health literacy level. The Mantel-Haenszel chi-square was used to test whether there is an association between health literacy and ED recidivism. A negative binomial multivariable model was performed to examine whether health literacy affects ED use, including variables significant at the 0.1 alpha level on bivariate analysis and retaining those significant at an alpha of 0.05 in the final model. Results Among 431 patients evaluated, 13.2% had inadequate, 10% had marginal, and 76.3% had adequate health literacy as identified by S-TOFHLA. Patients with inadequate health literacy had higher ED utilization compared to those with adequate health literacy (p = 0.03). Variables retained in the final model included S-TOFHLA score, number of medications, having a personal doctor, being a property owner, race, insurance, age, and simple comorbidity score. During the study period, 118 unique patients each made at least one return ED visit within a 14-day period. The proportion of patients with inadequate health literacy making at least one return visit was higher than that of patients with adequate health literacy at 14 days, but was not significantly higher within 3 or 7 days. Conclusions In this single-center study, higher utilization of the ED by patients with inadequate health literacy when compared to those with adequate health literacy was observed. Patients with inadequate health literacy made a higher number of return visits at 14 days but not at 3 or 7 days. Resumen Objetivos Determinar si los pacientes con una educacion sanitaria baja tienen un mayor uso y frecuentacion al servicio de urgencias (SU) que los pacientes con una educacion sanitaria adecuada. Metodologia Este estudio se llevo a cabo en un SU urbano y universitario con mas de 95.000 visitas al ano que forma parte de un sistema sanitario de 13 hospitales, mediante la revision de historias clinicas electronicas que son capturadas en un repositorio de datos central. Como parte de un gran estudio transversal de muestra de conveniencia, se realizaron pruebas de educacion sanitaria mediante el Short Test of Functional Health Literacy in Adults (S-TOFHLA) y los umbrales de la prueba estandar identificaron aquellos con educacion sanitaria inadecuada, marginal y adecuada. Los autores recogieron datos demograficos y clinicos de los pacientes, que incluian variables conocidas para el impacto de la refrecuentacion. Se realizo una revision de historia clinica electronica estructurada dirigida para determinar: 1) la mediana de numero de visitas totales al SU en este sistema sanitario en un periodo de 2 anos, y 2) la proporcion de pacientes en cada nivel de educacion sanitaria que revisitan a los 3, 7 y 14 dias de la visita indice. Se documentaron los datos descriptivos para la demografia y las revisitas al SU estratificados por el nivel de educacion sanitaria. Se uso el test de la ji cuadrado de Mantel-Haenszel para analizar si habia una asociacion entre la educacion sanitaria y la refrecuentacion al SU. Un modelo multivariable binomial negativo se utilizo para examinar si la educacion sanitaria impacta en el uso del SU, el cual incluia las variables significativas con nivel de alfa de 0,1 en el analisis univariable, y permanecieron aquellas con nivel de alfa de 0,05 en el modelo final. Resultados De los 431 pacientes evaluados, 13,2% tuvieron una educacion sanitaria inadecuada, 10% marginal y 76,3% adecuada segun el S-TOFHLA. Los pacientes con educacion sanitaria inadecuada tuvieron mayor uso del SU en comparacion con aquellos con educacion sanitaria adecuada (p = 0,03). Las variables que permanecieron en el modelo final incluyeron la puntuacion del S-TOFHLA, el numero de medicaciones, el tener un medico personal, el ser propietario, la raza, el seguro, la edad y la puntuacion de la comorbilidad simple. Durante el periodo del estudio, unicamente 118 pacientes hicieron al menos una revisita al SU en el periodo de 14 dias. La frecuencia de pacientes con educacion sanitaria inadecuada que hizo al menos una revisita fue mayor que en aquellos pacientes con educacion sanitaria adecuada a los 14 dias, pero no fue significativamente mayor entre los primeros 3 o 7 dias. Conclusiones En este estudio de un unico centro, se observo una mayor utilizacion del SU por los pacientes con educacion sanitaria inadecuada cuando se comparo con aquellos con educacion sanitaria adecuada. Los pacientes con educacion sanitaria inadecuada hicieron un mayor numero de revisitas a los 14 dias, pero no a los 3 ni a los 7 dias.