Abstract
This report aimed to present health literacy as an evidence-based intervention tool that could help in reducing readmission within 30 days following the discharge of acute myocardial infarction patients. Low health literacy was identified as a major factor that contributed to significant cases of hospital readmission within 30 days after discharges. Hence, clinicians and hospitals have developed interventions to reduce readmissions. Findings suggest that health literacy is a single, independent, factor that could predict 30-day readmission.
Hence, health literacy intervention has been developed to educate patients and caregivers to manage their conditions after discharge. It observed that patients with sufficient health literacy levels tend to score relatively well on medication instructions, treatment regimen, and self-care management among others. This report, therefore, demonstrates that improved health literacy among acute myocardial infarction patients could help to improve the quality of care outcomes and cut costs associated with early rehospitalization. It also observed that health literacy cut off levels are required for various populations and data used for validation should be reliable.
Critical Analysis of Health Literacy Intervention
According to Bailey et al. (2015), about 20% of Medicare supported patients are rehospitalized within 30 days following hospital discharge. The cost is estimated at $17.4 billion every year (Cafagna & Seghieri, 2017; Bailey et al., 2015). Consequently, under the Affordable Care Act 2010, the Hospital Readmission Reduction Program (HRRP) was introduced with the sole aim of reducing cases of readmission and their related costs, thereby leading to enhanced quality of care. The Centers for Medicare & Medicaid Services (CMS) started to penalize hospitals that had exceeded the national average of 30-day all-cause readmission rates to attain the goal of reducing instances of readmission after 30 days of hospital discharge.
Readmission cases of acute myocardial infarction (AMI) were also affected. In the financial year 2013, for instance, over 2200 healthcare facilities were penalized $280 million, and this figure is only expected to rise tremendously. This implies that hospitals should not underestimate the potential impacts of readmissions. It affects the financial health of the hospital and reduces the quality of care (Bailey et al., 2015). Additionally, readmission for acute myocardial infarction after 30 days following hospitalization is considered as an imperative hospital performance indicator. Hence, clinicians and hospitals have shown significant interest in comprehending and enhancing issues related to 30-day deaths and readmission rates (Cafagna & Seghieri, 2017).
Further, research suggests that short-term mortality for acute myocardial infarction, heart failure, and other diseases is a predictor of short-term mortality for a wide range of other diseases involving surgical and medical procedures. As such, they reflect the general quality of hospital quality outcomes. Hospital readmission also highlights adverse health outcomes. Evidence shows that between 5% and 59% of readmission within 30 days could be avoided (Cafagna & Seghieri, 2017). Thus, efforts to understand potential interventions that could reduce cases of readmission within 30 days for acute myocardial infarction following hospital discharge could improve healthcare quality, outcome, and reduce costs. This report aims to present health literacy as an evidence-based intervention tool that can help in reducing readmission within 30 days following the discharge of acute myocardial infarction patients.
Health Literacy for Reducing Readmission
Health literacy refers to an individual’s ability to acquire, process, and comprehend health information required to make informed health decisions (Bailey et al., 2015). In this case, health literacy in patients is a major factor that influences hospital readmission after discharge. Bailey et al. (2015) cited an outcome of the National Assessment of Adult Literacy (NAAL) 2003, which showed that more than a third of the US adults (36%) had “below or basic literacy skills” (p. e006975). This section of the population was most likely to face challenges communicating with healthcare providers, reading and interpreting medication requirements, understanding self-care requirements, and operating within the complex healthcare system. Failure to observe or perform such requirements significantly enhanced the chances of readmission risks among the affected populations. Notwithstanding its limitations, a lack of health literacy is considered as a complex but modifiable risk (Bailey et al., 2015).
Empirical Evidence
In-person literacy evaluation established that a fair agreement was present based on the derived estimates of Pearson Correlation coefficients (Bailey et al., 2015). Patients on Medicare who participated in the study and had above basic literacy skills based on the developed health literacy estimates scored 18% lower for cases of potential readmission for acute myocardial infarction within 30 days and 21% lower incidence rate of 30-day readmission compared with patients with basic or below basic literacy (Bailey et al., 2015). Once demographic and clinical variations were adjusted, the 30-day readmission risk was 12% less while the incidence rate was 16% less for patients who possessed above basic literacy. Bailey et al. (2015) concluded that, based on a predictive model measurement, health literacy was an important independent predictor of 30-day readmissions for acute myocardial infarction. It was presented as a modifiable, evidence-based risk factor that should be considered in patient education to reduce cases of readmission.
Supporting Evidence
Past findings demonstrate that health literacy guided interventions have positive outcomes on health (Berkman et al., 2011). Differences in health literacy or lack of it thereof were consistently related to enhanced cases of readmission, multiple cases emergency care use, low use of medication, inappropriate adherence to medication instructions, low ability to read and understand labels, messages and overall poorer health and increased deaths (Berkman et al., 2011). Despite the notable importance of health literacy in reducing instances of readmission, only a few epidemiological studies have shown that a lack of health literacy is a possible risk factor for readmission. According to (Bailey et al., 2015), extremely few studies have focused on the relationship between health literacy and 30-day readmission. More importantly, Bailey et al. (2015) claimed that a lack of health literacy could be more readily improved or changed relative to other patient and system-level issues.
A lack of effective measurement has been the major limiting factor in the study of health literacy for most epidemiological and health services phenomena, implying that suitable measurement tools are difficult to find. For instance, currently validated literacy measurement tools are seen as difficult to use, time-consuming, and logistically technical with much in-person controls (Bailey et al., 2015). To enhance health literacy capabilities to reduce 30-day readmission, an alternative method was introduced based on a predictive model of health literacy to assess and approximate the average health literacy of a patient based on data obtained from the US census. A past assessment of the predictive model demonstrated that it could predict health literacy based on the measurement of the NAAL, accounting for about 30% of the difference in average NAAL scores and outdoing one-item variables, such as education and income (Bailey et al., 2015).
It is important to note that the health literacy predictive tool requires further validation procedures. No relationship was also established between the commonly used test-based measures and the newly developed health literacy estimates. Nevertheless, Bailey et al. (2015) noted that if the health literacy predictive model was validated, then it could be applied universally to explain the association between health literacy and a wide variety of health outcomes on a large-scale than previously attained by the direct test-based tools. Also, the predictive model acts as a substitute for health literacy, and it depends on the various socioeconomic and demographic elements (Damiani et al., 2015), which are normally difficult to obtain from large data sets because they are missing or wrongly captured. Therefore, the evaluation of the association between such variables and health outcomes is usually difficult based on such data sets with missing or inaccurate data.
Many factors are responsible for early readmission for acute myocardial infarction (Ferdinand et al., 2017). Generally, environmental factors, lack of health literacy, inadequate discharge planning, comorbidities, and non-adherence to medication therapy are examples of factors that lead to 30-day readmissions (Wiggins, Rodgers, Cook, & Page, 2013). Specifically, for health literacy, it is observed that patients with limited health literacy are at greater risk of 30-day readmissions (Snyderman, Salzman, Mills, Hersh, & Parks, 2014). Hence, it is necessary to identify patients who have limited or less than basic health literacy. Snyderman et al. (2014) observed that limited health literacy could be associated with significant cases of medication errors and non-adherence to medication therapies. Further, patients who have low health literacy could face challenges related to medication identification.
Such patients also require enhanced communication and empowerment. In such instances, both verbal and written strategies when educating patients concerning their self-care practices, such as observing changes in symptoms, adhering to diets, observing behavior restrictions, and following medication requirements, are applicable (Snyderman et al., 2014). Still, on communication, research suggests that patients with low health literacy often report “unsatisfactory patient-doctor communication at the time of discharge” (Mitchell, Sadikova, Jack, & Paasche-Orlow, 2012). This observation could imply that some physicians may fail to notice or are insensitive to challenges related to understanding medication requirements and discharge instructions patients often face after the discharge. Such factors have contributed to increased cases of 30-day readmissions.
However, Mitchell et al. (2012) claimed that limited evidence was available to demonstrate the independent association between rehospitalization within 30 days following discharge and low health literacy. A research finding demonstrated that a short one-on-one patient education meeting led to fewer cases of readmission in patients with heart conditions, but a different study also showed that the effects of patient education on readmission was not significant independently (Snyderman et al., 2014). Health literacy education should also be extended to caregivers, which offers an opportunity to reduce readmissions. Thus, clinicians should engage family members in patients’ discharge planning, preparation, physicians’ follow-ups, and patient management throughout the care period, especially for patients who have complex conditions or impaired functional capabilities. Educated caregivers have a general feeling of being more prepared and ready to deliver effective care to discharged patients in home settings.
Mitchell et al. (2012) also determined that low health literacy was “a significant, independent, and modifiable risk factor for 30-day hospital reutilization after discharge” (p. 325). In this regard, interventions intended to reduce early, unplanned, hospital readmission following the discharge should account for health literacy among acute myocardial infarction patients to avoid adverse impacts of low health literacy.
Low health literacy may hinder patients from comprehending their discharge instructions, including a sufficient understanding of diagnosis and treatment requirements (Mitchell et al., 2012; Cafagna & Seghieri, 2017). Evidence demonstrates that patients with low health literacy have tendencies to misread indicated dosing and appointment dates (Mitchell et al., 2012). Conversely, patients who have sufficient health literacy tend to do well. Further, patients with low health literacy may also encounter challenges related to self-management instruction following hospital discharge. For instance, it could be difficult to comprehend symptoms associated with side effects of medications, appropriate mitigation procedures, appreciating changes in symptoms of diseases, responding aptly, and accessing and using regular and close outpatient services. These challenges may face such patients, and they demonstrate why low health literacy is associated with frequent readmission within 30 days after discharges.
Findings obtained after analyses of involving health literacy research bring attention to the need to develop interventions specifically for reducing the rate of unexpected rehospitalization by concentrating on health literacy among acute myocardial infarction patients. Such tools aim to assess the level of patient and caregiver education and assistance needed to ensure the effective management of patients after discharges. The Agency for Healthcare Research and Quality, for instance, has provided an evidence-based intervention toolkit to improve the level of health literacy. The toolkit focuses on four areas to tackle health literacy challenges.
They include:
- using simple to understand spoken communication,
- changing or simplifying written communication,
- teaching self-care and empowerment, and
- strengthening support offered to patients.
In this regard, it is expected that such toolkits can create an environment in which all patients receive optimal care irrespective of their health literacy levels. As health literacy continues to develop, researchers and practitioners still need to identify appropriate cut-offs for levels of health literacy (Berkman et al., 2011). Moreover, new measurement tools should be robust to evaluate other related skills, especially oral or spoken health literacy and other factors that could influence the outcomes of health literacy. Priorities should be given to features of health literacy interventions that assess new strategies of learning to motivate patients, methods for instructions orally, evaluating the effectiveness of existing interventions, cost-effectiveness, and any policies that support interventions.
Conclusion
This research presented health literacy as an evidence-based intervention tool that could be used to reduce instances of readmission within 30 days following hospital discharge of acute myocardial infarction patients. Findings demonstrate that low health literacy was significantly linked to a higher rate of hospital readmission within 30 days following discharges. Thus, patient health literacy plays a critical role in influencing the quality of care outcomes and low health literacy could be a critical barrier to the safe transition of patients from an inpatient hospital to home. Clinicians and hospitals should, therefore, consider health literacy interventions to enhance patient education to ensure effective care transition, lessen health literacy challenges after discharge, and eliminate needless intricacy for self-care patients. While health literacy intervention tool is effective for reducing 30-day readmission, it is imperative to determine cutoffs for literacy levels for various populations, such tools should always be validated to improve accuracy, and predictive models applied should be based on a validated algorithm.
References
Bailey, S. C., Fang, G., Annis, I. E., O’Conor, R., Paasche-Orlow, M. K., & Wolf, M. S. (2015). Health literacy and 30-day hospital readmission after acute myocardial infarction. BMJ Open, 5(6), e006975. Web.
Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., Viera, A., Crotty, K.,… Viswanathan, M. (2011). Health literacy interventions and outcomes: An updated systematic review. Evidence Report/Technology Assessment, (199), 1-941.
Cafagna, G., & Seghieri, C. (2017). Educational level and 30-day outcomes after hospitalization for acute myocardial infarction in Italy. BMC Health Services Research, 17, 18. Web.
Damiani, G., Salvatori, E., Silvestrini, G., Ivanova, I., Bojovic, L., Iodice, L., & Ricciardi, W. (2015). Influence of socioeconomic factors on hospital readmissions for heart failure and acute myocardial infarction in patients 65 years and older: Evidence from a systematic review. Clinical Interventions in Aging, 10, 237–245. Web.
Ferdinand, K. C., Senatore, F. F., Clayton-Jeter, H., Cryer, D. R., Lewin, J. C., Nasser, S. A.,… Califf, R. M. (2017). Improving medication adherence in cardiometabolic disease: Practical and regulatory implications. Journal of the American College of Cardiology, 69(4), 437-5 1. Web.
Mitchell, S. E., Sadikova, E., Jack, B. W., & Paasche-Orlow, M. K. (2012). Health literacy and 30-day postdischarge hospital utilization. Journal of Health Communication: International Perspectives, 17(sup 3), 325-338. Web.
Snyderman, D., Salzman, B., Mills, G., Hersh, L., & Parks, S. (2014). Strategies to help reduce hospital readmissions. Journal of Family Practice, 63(8), 430-438.
Wiggins, B. S., Rodgers, J. E., Cook, A. M., & Page, R. L. (2013). Discharge counseling for patients with heart failure or myocardial infarction: A best practices model developed by members of the American College of Clinical Pharmacy’s cardiology practice and research network based on the hospital to home (H2H) initiati. Pharmacotherapy, 33(5), 558–580. Web.