Universal Health Literacy Precautions Are Associated With a Significant Increase in Medication Adherence in Vulnerable Rheumatology Patients.

OBJECTIVE: Our objective was to determine the impact of the Health Literacy Universal Precautions Toolkit, adapted for rheumatology, on medication adherence, patient satisfaction, and feasibility in all patients; its effect on the clinical disease activity index (CDAI) was studied in a rheumatoid arthritis (RA) subpopulation. METHODS: Data collected during a 6-month prospective quality assurance intervention was compared with data from a prior 6-month period. Interventions included 1) encouraging questions, 2) teach-back communication, and 3) brown-bag medication review. Analysis was performed using linear regression or generalized estimating equation (GEE) regression. RESULTS: During the intervention period, 46 physicians completed 1737 patient visits. Questions were encouraged, and teach-back communication was performed in more than 90% of visits. Brown-bag medication reviews were performed in 47% of visits overall and 69% of visits in a subgroup that received additional reminder calls. Visit duration and patient satisfaction were not significantly increased. Adherence for rheumatology-related medications that were prescribed both before and during the intervention increased by 22% (P ≤ 0.001; by GEE). Teach-back communication predicted a statistically significant improvement in medication adherence in this subpopulation (by linear regression). The mean CDAI did not improve; however, African American race and Hispanic ethnicity were associated with a decreased CDAI (by GEE). CONCLUSION: Implementation of the Health Literacy Universal Precautions Toolkit, adapted for rheumatology, improved medication adherence in our safety-net clinic, with particularly strong effects seen with teach-back communication. In certain populations, use of the toolkit may also improve RA disease activity. This is the first study to document improved medication adherence with this intervention in a real-world setting.

Cross-sectional correlation of single-item health literacy screening questions with established measures of health literacy in patients with rheumatoid arthritis.

Research suggests that health literacy (HL) is associated with rheumatoid arthritis (RA) patients' functional status. Single-item health literacy screening (SILS) questionnaires may establish patients' HL; however, the wording of SILS may be misinterpreted by RA patients as a query regarding physical limitations. Despite this threat to validity, multiple publications have employed the SILSs as a measure of health literacy. We assessed the construct validity of two SILS's versions by correlating scores with standardized HL measures. English-speaking adult RA patients at a hospital serving low-income patients were enrolled in a cross-sectional study. Subjects completed two SILS versions, as well as two longer HL measurement tools [short test of functional health literacy in adults (s-TOFHLA) and the rapid estimate of adult literacy in medicine (REALM)]. Spearman correlation was used to compare these tools. The study enrolled 110 subjects. There was a good correlation between the two SILS versions (r = 0.705). The correlation of SILS2 and REALM or s-TOFHLA was less robust. The distribution of scores within each SILS2 category demonstrated substantial variation. The SILS2 has construct validity in the assessment of HL in patients with RA, though its correlation with traditional methods of assessing HL is weak.

Validation of disease activity and functional status questionnaires in spondyloarthritis.

OBJECTIVES: Patients naïve to the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and to the Ankylosing Spondylitis Disease Activity Score (ASDAS) have voiced confusion in our clinics over the use of the term "AS" in these instruments. It is unknown whether these tools may be applied to other related forms of spondyloarthritis (SpA). The Bath Ankylosing Spondylitis Functional Index (BASFI) questionnaire also requires more definitive validation. We 1) validated the BASFI against a standard definition of disability; and 2) validated slightly modified versions of the BASDAI and ASDAS questionnaires that replace references to "AS" with the term "inflammatory arthritis" for use in non-AS SpA. METHODS: Adult patients with SpA enrolled in the Veterans Affairs Program to Understand the Longterm outcomes in Spondylo-ARthritis (PULSAR) completed the BASFI, BASDAI, ASDAS and altered versions of the BASDAI (PULSAR-modified Bath Disease Activity Index [PuBaDAI]) and ASDAS (PULSAR-modified Ankylosing Spondylitis Disease Activity Score [PuASDAS]). Spearman correlations and logistic regression were used to analyse the scores. RESULTS: The correlation between BASDAI and PuBaDAI and between ASDAS and PuASDAS scores was high (Spearman's rho=0.92, p<0.001 and Spearman's rho=0.85, p<0.001, respectively). The test-retest correlation of BASFI was also high (Spearman's rho=0.92, p<0.001). The BASFI (OR 1.67, 95% C.I. 1.12-2.47), ASDAS (OR 1.34, 95% C.I. 1.02-1.76) and PuASDAS (OR 1.62, 95% C.I. 1.07-2.49) predicted federally-determined disability. CONCLUSIONS: Preliminary data suggest that BASDAI and ASDAS scores correlate well with modified forms of these questionnaires and that the ASDAS, PuASDAS and BASFI are associated with disability.

Health literacy predicts discrepancies between traditional written patient assessments and verbally administered assessments in rheumatoid arthritis.

OBJECTIVE: Patient assessments of disease activity (PtGA) and general health (GH) measured by visual analog scale (VAS) are widely used in rheumatoid arthritis (RA) clinical practice and research. These require comprehension of the question's wording and translation of disease activity onto a written VAS, which is problematic for patients with limited health literacy (HL) or difficulty completing forms. This study's objective was to validate verbally administered versions of patient assessments and identify factors that might explain discrepancies between verbal and written measures. METHODS: We enrolled patients with RA at the Denver Health rheumatology clinic (n = 300). Subjects were randomized to complete the traditional written PtGA and GH and one of the verbal assessments. Subjects provided a verbal numeric response after reading the question, having the question read to them in person, or hearing the question over the phone. Spearman and Lin correlations comparing written and verbal assessments were determined. Multivariate logistic regression was performed to explain any discrepancies. RESULTS: The instruments administered verbally in-person showed good, but not excellent, correlation with traditional written VAS forms (Spearman coefficients 0.59 to 0.70; p < 0.001 for all correlations). Twenty-three percent of subjects were unable to complete 1 of the written VAS assessments without assistance. HL predicted missing written data and discrepancies between verbal and written assessments (p < 0.05 for all correlations). CONCLUSION: Providers should use verbal versions of PtGA and GH with caution while caring for patients unable to complete traditional written version. Limited HL is widely prevalent and a barrier to obtaining patient-oriented data.

Strong association of health literacy with functional status among rheumatoid arthritis patients: a cross-sectional study.

OBJECTIVE: Studies linking health literacy to outcomes in rheumatoid arthritis (RA) have been underpowered and have not adequately accounted for confounders. We examined the association of health literacy with functional status in 6,052 subjects participating in a prospective observational study, controlling for numerous important covariates. METHODS: Using linear regression, we analyzed the cross-sectional association of health literacy, as measured by 2 validated single-item literacy screening questions (SILS1 and SILS2), and functional status, assessed by the Health Assessment Questionnaire (HAQ) disability index. Subjects reported demographics, comorbidities, social support, educational attainment, visual problems, and memory problems, as well as use of prednisone, disease-modifying antirheumatic drugs, and biologic agents. Each SILS measure was forced into the final model. RESULTS: Low health literacy was present in 7.0% and 4.3% of subjects (per SILS1 and SILS2, respectively). When controlling for all covariates, low health literacy was associated with a 0.376-point greater HAQ score, compared to subjects with adequate health literacy (95% confidence interval 0.306, 0.447; P < 0.001). This relationship persisted, even after modeling educational attainment. Results were similar for the 2 SILS instruments. Low health literacy was also associated with poorer self-reported adherence to RA medications. Visual and memory problems were associated with worse functional status. CONCLUSION: Health literacy was more strongly associated with functional status than prednisone use, smoking history, and biologic agent use, and independent of educational attainment. Health literacy may play an important role in understanding functional status in RA patients. Single-item questions amenable to use in the clinical setting may identify subjects with low health literacy, who are at risk for poor RA outcomes.

Limited health literacy is a common finding in a public health hospital's rheumatology clinic and is predictive of disease severity.

BACKGROUND: Health literacy (HL) is associated with outcomes in many conditions, but little is known about its impact on arthritic diseases. OBJECTIVES: We sought to determine whether HL is related to disease activity and severity in patients with rheumatoid arthritis (RA). METHODS: English-speaking adult RA patients were recruited for this cross-sectional study. Background information was ascertained by medical record review; Disease Activity Score 28 (DAS-28) scores were determined by providers; subjects completed the Multidimensional Health Assessment Questionnaire (MDHAQ), demographic questionnaires, and validated HL instruments, including the Short Test of Functional Health Literacy in Adults, Rapid Estimate of Adult Literacy in Medicine, and the single-item literacy screener. We used linear regression to assess whether HL was associated with MDHAQ and DAS-28 scores. RESULTS: One hundred ten subjects participated in the study. Limited HL was a common finding, especially among ethnic minorities. The single-item literacy screener results were predictive of lower MDHAQ scores by univariate regression analysis. Similar trends were observed for the Short Test of Functional Health Literacy in Adults and Rapid Estimate of Adult Literacy in Medicine. The relationship between the single-item literacy screener and MDHAQ remained statistically significant in multivariate analysis that controlled for the impact of demographic features and RA disease characteristics. Health literacy scores were not associated with DAS-28 scores. CONCLUSIONS: Health literacy was independently associated with functional impairment in English-speaking RA patients at an urban safety-net clinic. This new finding suggests that RA functional status might be improved by strategies that target limited HL's causal pathways.