Spreadsheet: 139498d1328276114-excel-2007-copy-data-from-cells-in-one-workbook-to-another-based-on-the-cell-headings-jama-eletters-data
Sheet: jama.2011.1203v1

 | Response ID | Status | Title, Author | Responder | [NAME] | Response
 | jama_el;858 | P | Frail persons, limited health literacy and the clinician role [NAME], et [NAME], August 22, 2011 | [NAME],  MD  Dept Internal Medicine & Geriatrics, ([NAME], [NAME]); GRG,  [NAME], MD | [EMAIL] | To the editor: the clinical crossroad by Ship (1) on health literacy in patients care, and the related commentary by Martin and Parker on its role in the future of insurances (2) deserve remarks regarding the responsibility of clinicians in improving the degree to which individuals manage information important for their health. Association between health literacy and socio-economical status is too much obvious in real world. Clinician who is at the same time healer, advocate, and educator may exert a peculiar function in screening and reducing the negative influence of those factors. The following conditions should characterise clinicianâ€™s behaviour toward citizens at risk of negative health outcomes due to reduced literacy: a) physicians should be deeply convinced of the role of health literacy for the well being of their patients having in mind the hierarchy of needs and controlling the improvement of the level of knowledge. This attitude will take time not reimbursed by insurances nor by public authorities; only a deep convincement will allow to pursue; b) physicians should measure the level of literacy of patients and their caregivers. In peculiar conditions (e.g. frail elderly) both family caregivers or paid informal ones play a critical role in guiding correct life styles and health care decisions; c) while trying to increase with time the patientâ€™s empowerment, clinician must adopt a language adequate to the literacy of patients and also a flexible paternalistic approach to obtain results in the short range; d) in our country (Italy) all citizens are enrolled in the national health system offering free total coverage; under the pressure of economical crisis, various planners indicate the need to give citizens a more direct responsibility for their well being, thus making the health literacy issue among the most discussed to reduces expenses.   References 1) Ship A. A 76-Year-Old Man With Multiple Medical Problems and Limited Health Literacy. [NAME], August 10, 2011, Vol 306, No. 6.   2) [NAME], Parker RM. Insurance Expansion and Health Literacy. Published Online: August 9, 2011.   Conflict of Interest: None declared
 | jama_el;850 | NR | Addressing Mr. J's Limited Health Literacy Nancy R Kressin, August 18, 2011 | [NAME] R Kressin,  PhD  Boston VA Healthcare System; Boston University School of Medicine | [EMAIL] | Low health literacy is common 1 , affects patients' understandings of their health, adherence to therapy, and outcomes 2,3. Clinicians tend to overestimate patients' literacy 4; moreso for African American patients 3.   Mr. [NAME], an older African American man originally from the rural South, has a longstanding relationship with his white doctor, who recognizes his patients' low literacy. Thus, literacy screening is not needed here; caregivers should go beyond screening, to better understand this patient and target his specific literacy gaps.   Mr. [NAME] says his eyesight is his 'only' problem, suggesting that neither diabetes, heart disease, nor sleep apnea is his priority; he indicates that the prescribed medicines don't make him FEEL any better, and that doctors don't always explain their purpose very well (perhaps limiting his motivation to take them). A key part of his literacy gap may be around the goals for the risk factor reduction medications he is taking and the need to clarify that such medications don't necessarily make one feel better, but reduce risk for future health problems. It seems worth assessing whether Mr. [NAME] has any sense of that or cares about it. He may feel that he has lived to 76 years (nearly 6 years more than the average African American man 5) and is now most concerned about his quality of life, for which vision is central. Identifying his priorities is a starting point to determine the emphasis of therapy and the most important point(s) around which to increase his literacy.   Caregivers need more information about several aspects of Mr. [NAME]'s self-management. What is his adherence to prescribed therapies; what does HE say about why he does or does not adhere, or what might help him to do so? Does he agree that the conditions for which they are prescribed are important, or that he should be taking such medications? The biggest breakthroughs have been around identifying strategies to help Mr. J with adherence (blister packs, Lantus pen), but these necessitated an understanding of the barriers to his self-management. Developing more of this understanding is critical.   Strategies such as asking patients to repeat back their understanding or view of a condition, diagnosis or recommended therapy can help identify literacy gaps or misunderstandings. Approaches such as 'building a history' 6 can help elicit patients' understandings of their health and priorities, which can in turn help clinicians better target additional information or strategies to address barriers to self-care. Regular monitoring - of blood pressure, blood sugar, and adherence - could help identify additional literacy gaps and emergent problems.   1.Institute of Medicine. Health literacy: a prescription to end confusion. Washington, DC: National Academies Press; 2004. 2. [NAME], [NAME], Griffith CH, Barnett DR. Residents' ability to identify patients with poor literacy skills. Acad med 2002; 77: 1039-41. 3. Lindau ST, Tomori C, Lyons T, [NAME], [NAME], [NAME] The association of health literacy with cervical cancer prevention knowledge and health behaviors in a multiethnic cohort of women. Am J Obstet Gynecol 2002; 186: 938-43. 4. [NAME], PA, Haidet, P (2007) Physician overestimation of patient literacy: A potential source of health care disparities. Patient Education and Counseling 66; 119-122. 5. Life expectancy: http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf 6. Haidet, P, Paterniti, DA. (2003). 'Building' a History Rather than 'Taking' One: A Perspective on information sharing during the medical interview. [NAME] 163:1134-1140.   Conflict of Interest: None declared
 | jama_el;847 | NR | crossroads G Thomas A Morris, August 17, 2011 | G Thomas A [NAME],  MD  Retired Internist | [EMAIL] | Mr J's focus is on his perception of how he feels and how pills are supposed to help him feel better. His physician of eight years highlights the issues of compliance and multiple substantial medical diagnoses. If Mr J appears to be at a crossroads now it is probably due to the complicating problems that incipient renal and cardiac failure are imposing. His inpatient record should provide useful baselines for designing an out patient regimen which would ideally have once daily dosing for ease of compliance and monotoring.( One wonders that the inpatient MDs saw no utility in contacting the long time attending in any manner!) The useful thing in this situation is the built up relationship between Mr J and his Medical Caregivers. Patients of all levels of sophistication intuit concern for wellbeing as a primary basis for ongoing effective relationships. It is likely that Mr J is well liked and held in reguard and will continue to receive good care.   Conflict of Interest: None declared
 | [NAME] | NR | crossroads G Thomas A Morris, August 17, 2011 | G Thomas A [NAME],  MD  Retired InternistG Thomas A Morris, | [EMAIL] | Mr J's focus is on his perception of how he feels and how pills are supposed to help him feel better. His physician of eight years highlights the issues of compliance and multiple substantial medical diagnoses. If Mr J appears to be at a crossroads now it is probably due to the complicating problems that incipient renal and cardiac failure are imposing. His inpatient record should provide useful baselines for designing an out patient regimen which would ideally have once daily dosing for ease of compliance and monotoring.( One wonders that the inpatient MDs saw no utility in contacting the long time attending in any manner!) The useful thing in this situation is the built up relationship between Mr J and his Medical Caregivers. Patients of all levels of sophistication intuit concern for wellbeing as a primary basis for ongoing effective relationships. It is likely that Mr J is well liked and held in reguard and will continue to receive good care.   Conflict of Interest: None declared
 | jama_el;844 | NR | Review the Treatment [NAME], August 16, 2011 | [NAME],  Phd.in progress  Federal University of Uberlândia | [EMAIL] | I recommend intelligibly explain the health problems of the patient, teaching the proper way to use the medication and check with a color that sets the schedule. Guiding and encouraging about the benefits of a diet and exercise for your clinical condition, language learning, positive mental state and sex.   Prevention of Overweight/Obesity as a Strategy to Optimize Cardiovascular Health. Circulation.2011; 124: 840-850   Dose Response Between Physical Activity and Risk of Coronary Heart Disease / Clinical Perspective : A Meta-Analysis. Circulation.2011;124:789 -795   Association of Episodic Physical and Sexual Activity With Triggering of Acute Cardiac EventsSystematic Review and Meta- analysis.JAMA.2011;305(12):1225-1233   Physical Activity Advice Only or Structured Exercise Training and Association With HbA1c Levels in Type 2 Diabetes: A Systematic Review and Meta-analysis.[NAME]. 2011;305(17):1790-1799.   Conflict of Interest: None declared
 | jama_el;840 | NR | Teach back, involve, and individualize [NAME], August 10, 2011 | [NAME],  MS RN  Phoenix Children's Hospital | [EMAIL] | Mr. [NAME]'s problem: "I don't think, despite numerous discussions, he understands what heart disease is, or understands dialysis, or the many consequences that are associated with chronically elevated blood sugars." Is there a learning barrier, or does Mr. [NAME] need to be involved in the process, so teaching can better be individualized to his needs? The success of prepackaged medications in blister packs is an example of successful individualization.   The most direct way to determine if health literacy is an issue is to have the patient teach back your instructions in his or her own words. It does not take long, and will immediately bring to light misunderstandings that can be corrected on the spot. [NAME] said, "If you can't explain it simply, you don't understand it well enough."   Then ask the patient the chance that he or she could and would follow through on your prescriptive advice. That would have revealed the challenge of a perceived $98 prescription much earlier in the process.   Yes, this takes time, but overall less time and fewer resources if you address it up front. Remember, the term Doctor comes from docere, meaning to teach.   References:   Agency for Healthcare Research and Quality. (2011). Health Literacy Interventions and Outcomes: An Updated Systematic Review: Executive Summary No. 199. Retrieved from http://www.ahrq.gov/clinic/epcsums/litupsum.pdf   [NAME], D. A., Callahan, [NAME], V., [NAME], K., Hink, A., & Rudd, R. (2010). Health Literacy Universal Precautions Toolkit. Available from http://www.ahrq.gov/qual/literacy/healthliteracytoolkit.pdf   Joint Commission. (2007). "What Did the Doctor Say?:" Improving Health Literacy to Protect Patient Safety Retrieved 3/14, 2009, from http://www.jointcommission.org/NR/rdonlyres/F53D5057-5349-4391-9DB9- E7F086873D46/0/health_literacy_exec_summary.pdf   Schuz, [NAME], [NAME], C., Wurm, S., Warner, [NAME] [NAME], [NAME], R., et [NAME]. (2011). Medication beliefs predict medication adherence in older adults with multiple illnesses. J [NAME], 70(2), 179-187.   [NAME], [NAME], [NAME], K., Bailey, S. C., Hedlund, L. A., [NAME], [NAME], et [NAME]. (2011). Helping patients simplify and safely use complex prescription regimens. Archives of Internal Medicine, 171(4), 300- 305.   Conflict of Interest: None declared