Design and Impact of a Novel Rural Hospital Alliance.

Without rural hospitals, many patients may not have access to essential services, or even any health care. Rural hospitals provide a community hub for local access to primary care and emergency services, as well as a bridge to specialized care outside the community. The goal of this review was to demonstrate how the University of Arkansas for Medical Sciences supports and empowers rural hospitals through an alliance that provides cost savings through clinical networks, collaborative purchasing, and leveraged services; workforce recruitment and education; telemedicine and distance learning; community outreach; and access to best practices, resources, and tools for hospital transformation. Born out of grassroots efforts in the rural US South, this model alliance, the Arkansas Rural Health Partnership, with the University of Arkansas for Medical Sciences supporting as an academic medical center participant, offers resources and programs intended to help rural hospitals and healthcare providers survive and even thrive in the challenging landscape that is forcing many other rural hospitals to close. The Arkansas Rural Health Partnership model is relevant for rural states that are seeking to develop or reenvision rural hospital alliances with academic medical centers to the benefit of the hospitals and the health of their communities and state.

Revising Recruitment for Focus Groups to Meet Shifting Needs During COVID-19.

BACKGROUND: The COVID-19 pandemic forced researchers to modify recruitment strategies to meet accrual goals for qualitative studies. Traditional methods of in-person recruiting and using paper marketing material were eliminated almost overnight at the onset of the pandemic. Researchers quickly adapted their recruitment strategies, but researchers had to shift local, in-person recruitment efforts to solely using online platforms. The shifting recruitment strategies were accompanied with unexpected challenges, but we were able to meet our accrual goal for focus groups. OBJECTIVES: The objective of this brief report is to explore new recruitment strategies that developed during the COVID-19 pandemic and offer suggestions for future online-based qualitative studies. RESULTS: Prior to COVID-19, we designed four main strategies (research registry, marketing material, social media, and provider endorsement) to recruit potential participants for focus groups as part of a qualitative, descriptive study involving young women breast cancer survivors. After the onset of COVID-19, we successfully adapted each of our initial four strategies to recruit potential participants in an incremental process. Using these adapted strategies, a total of 62 young women completed the first part of the data collection process prior to participating in a focus group. Thirty-three women participated in the focus groups, and the remaining 29 participants were lost to follow-up. The vast majority of participants were recruited through marketing material and social media after making strategic changes to recruitment. DISCUSSION: The most effective method of recruitment was the strategic use of marketing material and social media, and we offer suggestions for researchers considering online recruitment methods. We recommend that researchers use various social media platforms and specific hashtags and target their sample population at the onset of the study. The data collection changes initiated by the effects of COVID-19 may remain, and researchers can consider implementing permanent recruitment strategies to best meet the needs of this new landscape of conducing online focus groups.

What's in Between the Lines: Assessing the Readability, Understandability, and Actionability in Breast Cancer Survivorship Print Materials.

Educational print materials for young women breast cancer survivors (YBCS) are supplemental tools used in patient teaching. However, the readability of the text coupled with how well YBCS understand or act upon the material are rarely explored. The purpose of this study was to assess the readability, understandability, and actionability of commonly distributed breast cancer survivorship print materials. We used an environmental scan approach to obtain a sample of breast cancer survivorship print materials available in outpatient oncology clinics in the central region of a largely rural Southern state. The readability analyses were completed using the Flesch-Kincaid (F-K), Fry Graph Readability Formula (Fry), and Simple Measure of Gobbledygook (SMOG). Understandability and actionability were analyzed using Patient Education Materials Assessment Tool for Printable Materials (PEMAT-P). The environmental scan resulted in a final sample of 14 materials. The mean readability of the majority of survivorship materials was "difficult," but the majority scored above the recommended 70% in both understandability and actionability. The importance of understandability and actionability may outweigh readability results in cancer education survivorship material. While reading grade level cannot be dismissed all together, we surmise that patient behavior may hinge more on other factors such as understandability and actionability. Personalized teaching accompanying print material may help YBCS comprehend key messages and promote acting upon specific tasks.

Assessing the Feasibility of an Online Module for Promoting Cancer Prevention Measures.

OBJECTIVES: The aims of this pilot study were (1) to develop a cancer prevention module consisting of an animated video and a short questionnaire, (2) to assess new knowledge gained by the participants, and (3) to solicit feedback for improving the cancer prevention module. METHODS: Volunteers who previously agreed to be contacted regarding research studies were approached via email. After completing the cancer prevention module, a list of cancer prevention recommendations was provided. Newly gained knowledge was assessed, and feedback was solicited. RESULTS: Overall, 290 of 3165 individuals contacted completed the online module (9.2%), and 38.6% of the participants indicated that they learned something new about cancer prevention measures. A similar proportion, 41.4%, mentioned that they learned about measures that were recommended and due. Paradoxically, response rate was the lowest in the ≥50 year old age group although this group reported the highest rate of learning about new cancer prevention measures. Feedback was favorable in that 70.7% mentioned that the recommendations were helpful to them personally, 69.3% felt motivated to take action to reduce their risk of cancers, and 67% would recommend the online module to their friends and family. CONCLUSION: We developed an online cancer prevention module which seems to be suitable for promoting cancer prevention measures as feedback was favorable, and new knowledge was gained. Future efforts will focus on using the module to promote cancer prevention measures to the general public particularly for the ≥50 year age group.

Exploring Knowledge, Beliefs, and Attitudes about Teen Pregnancy among Latino Parents in Arkansas.

OBJECTIVES: Arkansas has the highest incidence of teen pregnancy in 15- to 19-year-olds in the United States, and Latinas remain one of the cultural groups that are most at risk of becoming adolescent mothers. Teen mothers and their children are more likely to face poor socioeconomic conditions and negative health sequelae that perpetuate the cycle of poverty. Tailored interventions meant for families, communities, and/or churches should address both abstinence and other types of contraception to educate young people how to stay healthy, prevent unwanted pregnancy, and empower them to make informed decisions. To develop effective educational interventions, it is essential to understand the current knowledge, beliefs, and attitudes toward teen pregnancy among Latino parents in Arkansas. METHODS: Adult Latino parents were surveyed at two clinical sites, one church and one school in Little Rock between January 16, 2019 and February 23, 2019. The survey instrument was conducted in Spanish and included questions on demographics, knowledge, attitudes, and beliefs about teenage pregnancy. Response frequencies, percentages and descriptive statistics were calculated for the dataset. RESULTS: A total of 181 individuals completed the survey. Participants almost unanimously agreed with the statement that it is important to talk about sex with their children for their sexual health development. Nearly all respondents, 96.1%, believe that it is important to prevent teenage pregnancy. Most respondents agreed that they speak with their sons and daughters differently on the topic of sexual health. In our sample, only 17.8% of parents believed that abstinence-only education should be the primary focus of reproductive health education. "My family values" was most frequently cited as the predominant factor in shaping participants' beliefs about teen pregnancy, followed by a desire for their child to attend college or be economically stable before having a child. CONCLUSIONS: Our findings indicate that based on attitudes toward sexual health, interventions should be tailored to certain groups based on children's sex and age and to parents who had children as teens themselves. Educational materials should emphasize the strengths of Latino culture, such as family values and desire for children to attain a college degree and economic stability before bearing children.

Accuracy of the Spinal Pain Diagram Is Influenced by Patient Health Literacy in Completion of the Scoliosis Research Society30 Questionnaire.

The Scoliosis Research Society Questionnaire (SRS30) was designed to measure healthrelated quality of life in scoliosis patients. Patients with low health literacy may need specific guidance when providing feedback on the SRS30 so that reliable and valid results are collected for clinical decision making. The purpose of this research study was to investigate the health literacy demands of the Scoliosis Research Society Questionnaire (SRS30) and to determine if health literacy best practices mitigate errors for patients with low health literacy. Readability assessment, focus groups and structured interviews were used. Results indicated that patients with low health literacy perceived health literacy best practices as helpful in completing the SRS30 drawing. Additionally, patients with inadequate health literacy had a higher proportion of errors in pain location on the drawing (p = 0.0325) compared to patients with adequate health literacy. (Journal of Surgical Orthopaedic Advances 29(1):3942, 2020).

Health Literacy Evaluation of Opioid Patient Education Materials for Orthopaedic Surgery.

Increased opioid use in the United States has resulted in greater incidence of misuse. Orthopaedic patients are more likely to be prescribed opioids for pain. Low health literacy is related to opioid misuse; therefore, orthopaedic patient education tools on use of opioids must be easy to read, understand, and use for patients of all skill levels to be effective. This project aimed to review a broad array of opioid patient education tools and evaluate them from a health literacy perspective. Content evaluation revealed that not all tools expressed the same essential messaging. The mean readability score of the tools assessed was 9.5 grade; higher than the national and recommended 8th-grade reading level. Therefore, many opioid patient education tools may be difficult for patients to read and understand. Improvements in readability and other health literacy best practices are recommended to improve reading, comprehension, and use of opioid patient education tools. (Journal of Surgical Orthopaedic Advances 28(3):232-236, 2019).

Patient Health Literacy and Diabetic Foot Amputations.

Patient health literacy is associated with self-care and management of chronic diseases, including diabetes. Interventions that address health literacy and aim to improve clinical outcomes have been focused mostly in primary care. The purpose of this study was to explore the association between patient health literacy and diabetic foot amputations in a retrospective cohort analysis in a large orthopaedic practice at an academic medical center. Using data extraction from clinical records, orthopaedic patients who had a diabetic foot amputation or re-amputation in the last 2 years were compared with the general orthopaedic patient population, with patient health literacy screening results as the dependent variable. Results revealed a statistically significant difference in health literacy between the foot amputee group (N = 177) and the general orthopaedic patient group (N = 14,683) (p < .0001). Patients in the foot amputee group were 8.07 times more likely to have inadequate health literacy than patients in the general orthopaedic patient group. Because diabetic amputations are frequently associated with poorly controlled diabetes, these results provide a strong rationale to develop health literacy-based interventions that address diabetes self-management and foot exams in orthopaedic practices to improve clinical outcomes, including amputation prevention.

Health Literacy Among a Formerly Incarcerated Population Using Data from the Transitions Clinic Network.

Health literacy is increasingly understood to be a mediator of chronic disease self-management and health care utilization. However, there has been very little research examining health literacy among incarcerated persons. This study aimed to describe the health literacy and relevant patient characteristics in a recently incarcerated primary care patient population in 12 communities in 6 states and Puerto Rico. Baseline data were collected from 751 individuals through the national Transitions Clinic Network (TCN), a model which utilizes a community health worker (CHW) with a previous history of incarceration to engage previously incarcerated people with chronic medical diseases in medical care upon release. Participants in this study completed study measures during or shortly after their first medical visit in the TCN. Data included demographics, health-related survey responses, and a measure of health literacy, The Newest Vital Sign (NVS). Bivariate and linear regression models were fit to explore associations among health literacy and the time from release to first clinic appointment, number of emergency room visits before first clinic appointment and confidence in adhering to medication. Our study found that almost 60% of the sample had inadequate health literacy. Inadequate health literacy was associated with decreased confidence in taking medications following release and an increased likelihood of visiting the emergency department prior to primary care. Early engagement may improve health risks for this population of individuals that is at high risk of death, acute care utilization, and hospitalization following release.

Readability of Patient Educational Materials for Total Hip and Knee Arthroplasty.

This study aimed to evaluate patient education materials that are focused on total hip arthroplasty (THA) and total knee arthroplasty (TKA) using health literacy best practices and plain language principles as frameworks. Readability assessments were conducted on a sample of nine patient education documents that are commonly given to THA and TKA surgery patients. Mean readability scores were compared across the sample. The mean readability grade level for the nine arthroplasty educational documents analyzed in this study was 11th grade (10.5). The mean readability ranged from 9th to 12th grade. The documents in this study were written at levels that exceed recommendations by health literacy experts. Health literacy best practices and plain language principles were suggested to reduce the demands on patients so that the documents are easier to understand. Incorporating health literacy best practices into patient education materials for THA and TKA can contribute to improved communication with patients that is necessary for patient understanding and satisfaction. (Journal of Surgical Orthopaedic Advances 27(1):72-76, 2018).

A Perioperative Patient Support System Was Unable to Mitigate the Risk of Hospital Readmission for Total Hip Arthroplasty Patients With High American Society of Anesthesiologists Grades.

BACKGROUND: Utilization of a patient support system including a patient "navigator" to maintain patient engagement upon discharge home has successfully reduced the number of hospital readmissions after arthroplasty procedures. Although successful in a general patient population, the ability of the support system to reduce readmissions in subsets of "high-risk" patients has not been evaluated. METHODS: We identified 878 primary total hip arthroplasties (THAs) performed at a single institution between 2013 and 2015. A binary regression was used to determine if a model of patient factors could accurately predict readmission, and the individual effects of each factor on readmissions were assessed. RESULTS: No combination of patient factors was able to accurately predict the need for hospital readmission. However, those with American Society of Anesthesiologists (ASA) grades 3 or 4 (32/375 [8.8%]) were twice as likely to be readmitted than those with ASA grades 1 or 2 (23/503 [4.4%], P = .02; odds ratio = 2.0 [95% CI = 1.2-3.6], P = .01). CONCLUSION: Maintaining routine communication with the patient and surgeon's office throughout the postoperative period successfully reduced readmission rates for those with low ASA grades; however, implementing this program did not lessen the risk of readmission for patients with greater comorbidity burdens. Future studies are necessary to determine if interventions to medically optimize patients with high ASA grades can reduce readmission rates, but until such time, risk adjustment methodologies are necessary to avoid financial penalties for readmissions for high-ASA grade patients that have been repeatedly demonstrated to be at an inherently increased risk.

Readability of Patient Education Materials in Hand Surgery and Health Literacy Best Practices for Improvement.

PURPOSE: This study aimed to update a portion of a 2008 study of patient education materials from the American Society for Surgery of the Hand Web site with new readability results, to compare the results to health literacy best practices, and to make recommendations to the field for improvement. METHODS: A sample of 77 patient education documents were downloaded from the American Society for Surgery of the Hand Web site, handcare.org, and assessed for readability using 4 readability tools. Mean readability grade-level scores were derived. Best practices for plain language for written health materials were compiled from 3 government agency sources. RESULTS: The mean readability of the 77 patient education documents in the study was 9.3 grade level. This reading level is reduced from the previous study in 2008 in which the overall mean was 10.6; however, the current sample grade level still exceeds recommended readability according to best practices. CONCLUSIONS: Despite a small body of literature on the readability of patient education materials related to hand surgery and other orthopedic issues over the last 7 years, readability was not dramatically improved in our current sample. Using health literacy as a framework, improvements in hand surgery patient education may result in better understanding and better outcomes for patients seeing hand surgeons. CLINICAL RELEVANCE: Improved understanding of patient education materials related to hand surgery may improve preventable negative outcomes that are clinically significant as well as contribute to improved quality of life for patients.

Assessment of medication adherence app features, functionality, and health literacy level and the creation of a searchable Web-based adherence app resource for health care professionals and patients.

OBJECTIVES: To assess the features and level of health literacy (HL) of available medication adherence apps and to create a searchable website to assist health care providers (HCP) and patients identify quality adherence apps. PRACTICE DESCRIPTION: Medication nonadherence continues to be a significant problem and leads to poor health outcomes and avoidable health care expense. The average adherence rate for chronic medications, regardless of disease state, is approximately 50% leaving significant room for improvement. PRACTICE INNOVATION: Smartphone adherence apps are a novel resource to address medication nonadherence. With widespread smartphone use and the growing number of adherence apps, both HCP and patients should be able to identify quality adherence apps to maximize potential benefits. INTERVENTIONS: Assess the features, functionality and level of HL of available adherence apps and create a searchable website to help both HCP and patients identify quality adherence apps. EVALUATION: Online marketplaces (iTunes, Google Play, Blackberry) were searched in June of 2014 to identify available adherence apps. Online descriptions were recorded and scored based on 28 author-identified features across 4 domains. The 100 highest-scoring apps were user-tested with a standardized regimen to evaluate their functionality and level of HL. RESULTS: 461 adherence apps were identified. 367 unique apps were evaluated after removing "Lite/Trial" versions. The median initial score based on descriptions was 15 (max of 68; range: 3 to 47). Only 77 apps of the top 100 highest-scoring apps completed user-testing and HL evaluations. The median overall user-testing score was 30 (max of 73; range: 16 to 55). CONCLUSION: App design, functionality, and level of HL varies widely among adherence apps. While no app is perfect, several apps scored highly across all domains. The website www.medappfinder.com is a searchable tool that helps HCP and patients identify quality apps in a crowded marketplace.

Effect of Total Joint Arthroplasty Surgical Day of the Week on Length of Stay and Readmissions: A Clinical Pathway Approach.

BACKGROUND: The demand for total joint arthroplasty (TJA) is increasing at the same time that alternative payment models place increased scrutiny on the cost of these procedures. Using a clinical pathway model, this study aimed to examine the effect of day of surgery on length of stay (LOS). METHODS: A retrospective electronic chart review was conducted on 2968 cases over 20 months at a single hospital. Least square means analysis of the effect of surgical day of the week on LOS was conducted using Statistical Analysis Software 9.3, followed by Tukey's multiple comparison test. Logistic regression assessed the effect of surgical day of week on readmission. RESULTS: Within the primary TJA group, there was no significant difference in mean LOS for each day of the week (1.17, 1.32, 1.29, 1.27, and 1.27 for Monday through Friday, respectively). Of all days, mean LOS for revision TJA (1.51, 1.57, 1.57, 2.49, and 2.03) only differed significantly for Thursday (P < .0001), although in adjusted analysis with age and American Society of Anesthesiologist, this difference was no longer significant (P = .3954). Readmission was likewise not significantly affected by surgical day of week (chi sq = 1.426, P = .8396) in the sample. CONCLUSION: As the volume of joint arthroplasties increases and alternative payment models are implemented, programs that promote decreased LOS regardless of operative day of the week are critical. Practices can use clinical pathway models to reduce costs related to LOS while maintaining a high level of patient care.

Health Literacy and Opioid Use in Orthopaedic Patients.

Opioid misuse has been linked to patient health literacy. This study aimed to estimate the prevalence of low health literacy in a sample of orthopaedic patients on opioids. Data were extracted from an electronic medical record database using queries that included an 8-month time frame, active status in an orthopaedic clinic, ICD-10 codes for opioids, and health literacy screening results. In the study sample of 8963 orthopaedic patients, 7103 had opioids in their current chart. Of those patients with opioids in their chart, 1547 had inadequate health literacy as measured by a validated health literacy screening question. Because approximately 22% of orthopaedic patients on opioids may also be at high risk for low health literacy, practices should consider identifying these patients and following national recommendations to tailor patient education so that these patients can better understand the risks, benefits, and dosing of opioids.

Readability of Online Patient Educational Materials on Pain Management.

Low health literacy is associated with a poorer ability to understand and follow health instructions and advice, poorer health outcomes, and poorer use of health care services. Patients with low health literacy have difficulty accessing and understanding online health materials that are not written in plain language. This study assessed the readability of patient education materials that are focused on pain, a significant contributor to clinical outcomes after orthopaedic surgery. Results revealed that the overall mean readability level of the documents that were accessed online was higher than the 10th grade. Efforts should focus on making patient education easier to understand for the nearly 80 million Americans who struggle with health literacy.

A need for health literacy curriculum: knowledge of health literacy among U.S. audiologists and speech-language pathologists in Arkansas.

CONTEXT: We assessed the general knowledge of health literacy and the impact of limited health literacy on patients and to society in United States (US) audiologists and speech-language pathologists in Arkansas. METHODS: A 10-item survey was completed by 198 professionals and students in communication sciences and disorders in Arkansas. The 10-items were divided into one demographic question, six patient-related health literacy questions, and three systems-related health literacy questions. RESULTS: Most professionals and students were aware that limited health literacy can be an obstacle for patients, but they were only somewhat or not aware of existing data on the average US adult reading grade level, the readability of clinic forms, or the estimated economic healthcare cost as a result of low health literacy. DISCUSSION: Increasing the awareness of health literacy and the impact of limited health literacy among all healthcare providers would be a worthwhile endeavor. More work is needed to study health literacy in various patient populations and to develop effective approaches to combat low health literacy in the field of communication sciences and disorders, as well as other healthcare disciplines, across the globe. This study suggests that health literacy awareness training may be needed, not only in Arkansas, but also throughout the US and other countries. The outcome should bridge the health literacy and communication gap between providers and their patients.

The Effects of Self-Esteem, Coping, and Voice-Related Quality of Life on Communicative Participation Before and After BOTOX® Treatment for Spasmodic Dysphonia.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to (1) investigate the percent change in communicative participation in individuals with spasmodic dysphonia (SD) pre- and post-BOTOX® treatment; and (2) to investigate if percent change in communicative participation is predicted by change in self-esteem, coping, and/or Voice-Related Quality of Life (V-RQOL) pre- and post-BOTOX® treatment. STUDY DESIGN/METHODS: A cross-sectional study of 49 patients was conducted across three clinics, with each participant completing the Rosenberg Self-Esteem Scale, the Voice Disability Coping Questionnaire (VDCQ), the V-RQOL instrument, and the Communication Participation Item Bank (CPIB) before BOTOX® treatment and 10-14 days following BOTOX® treatment. DATA ANALYSIS: For Research Question 1, a paired t test was applied to test the equality of means for CPIB and to test the pre-post changes among other composite measurements before and after the BOTOX® treatment. For Research Question 2, a multivariable linear regression model was applied with percent change in CPIB as a main outcome, and change in Rosenberg Self-Esteem Scale, VDCQ, and the V-RQOL as independent variables (or covariates) in order to test the associations. RESULTS: The results indicated that pre- and post-BOTOX® measures of communicative participation are not statistically significantly different among the participants with SD. There was a strong positive correlation between change in coping and voice-related QOL. CONCLUSIONS: A better understanding of the relationship between communicative participation and voice-related QOL is warranted. Item analysis of the V-RQOL and the VDCQ may illustrate coping strategies and functional impairments and provide further information regarding highly variable communicative participation among individuals with SD.

An Investigation of the Relationship between Adherence to Voice Therapy for Muscle Tension Dysphonia and Employment, Social Support, and Life Satisfaction.

PURPOSE: The purpose of this study was to investigate whether a relationship exists between employment status, perception of life quality (ie, vocal impairment, health, life satisfaction, and social support), and adherence to voice therapy for persons with muscle tension dysphonia (MTD). This study extends recent work as it evaluates investigating the impact of social support and life satisfaction on adherence to voice therapy for MTD. METHOD: A cross-sectional study of 45 individuals diagnosed with MTD who participated in voice therapy between January 2014 and December 2015 at the University of Arkansas for Medical Science's Voice and Swallowing Center in Little Rock, Arkansas participated in this study. Participants provided information regarding employment status and completed the Satisfaction with Life Scale and the Quality of Relationships Inventory. RESULT: Sixty percent of participants completed voice therapy. Patients who completed voice therapy were more likely to report gainful employment (P = 0.038) or less confidence in a specific and significant personal relationship (P = 0.004). CONCLUSION: This study discovered a moderate effect between employment status and adherence to voice therapy for MTD as well as relationship confidence and adherence.