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Health Literacy and Outcomes in Patients With Heart Failure: A Prospective Community Study

Published:December 05, 2017DOI:



      To examine the impact of health literacy on hospitalizations and death in a population of patients with heart failure (HF).

      Patients and Methods

      Residents from the 11-county region in southeast Minnesota with a first-ever International Classification of Diseases, Ninth Revision code 428 or Tenth Revision code 150 (n=5121) from January 1, 2013, through December 31, 2015, were identified and prospectively surveyed to measure health literacy using established screening questions. A total of 2647 patients returned the survey (response rate, 52%); 2487 patients with complete health literacy data were retained for analysis. Health literacy, measured as a composite score on three 5-point scales, was categorized as adequate (≥8) or low (<8). Cox proportional hazards regression and Andersen-Gill models were used to examine the association of health literacy with mortality and hospitalization.


      Of 2487 patients (mean age, 73.5 years; 53.6% male [n=1333]), 10.5% (n= 261) had low health literacy. After mean ± SD follow-up of 15.5±7.2 months, 250 deaths and 1584 hospitalizations occurred. Low health literacy was associated with increased mortality and hospitalizations. After adjusting for age, sex, comorbidity, education, and marital status, the hazard ratios for death and hospitalizations in patients with low health literacy were 1.91 (95% CI, 1.38-2.65; P<.001) and 1.30 (95% CI, 1.02-1.66; P=.03), respectively, compared with patients with adequate health literacy.


      Low health literacy is associated with increased risks of hospitalization and death in patients with HF. The clinical evaluation of health literacy could help design interventions individualized for patients with low health literacy.

      Abbreviations and Acronyms:

      HF (heart failure), HR (hazard ratio), REP (Rochester Epidemiology Project), S-TOFHLA (Short Test of Functional Health Literacy in Adults)
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        • Roger V.L.
        Epidemiology of heart failure.
        Circ Res. 2013; 113: 646-659
        • Gerber Y.
        • Weston S.A.
        • Redfield M.M.
        • et al.
        A contemporary appraisal of the heart failure epidemic in Olmsted County, Minnesota, 2000 to 2010.
        JAMA Intern Med. 2015; 175: 996-1004
        • Mozaffarian D.
        • Benjamin E.J.
        • et al.
        • Writing Group Members
        Heart disease and stroke statistics-2016 update: a report from the American Heart Association.
        Circulation. 2016; 133: e38-e360
        • Heidenreich P.A.
        • Albert N.M.
        • Allen L.A.
        • et al.
        Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association.
        Circ Heart Fail. 2013; 6: 606-619
        • Gerber Y.
        • Weston S.A.
        • Enriquez-Sarano M.
        • et al.
        Mortality associated with heart failure after myocardial infarction: a contemporary community perspective.
        Circ Heart Fail. 2016; 9: e002460
        • Dunlay S.M.
        • Redfield M.M.
        • Weston S.A.
        • et al.
        Hospitalizations after heart failure diagnosis: a community perspective.
        J Am Coll Cardiol. 2009; 54: 1695-1702
        • Desai A.S.
        • Stevenson L.W.
        Rehospitalization for heart failure: predict or prevent?.
        Circulation. 2012; 126: 501-506
        • Hall M.J.
        • Levant S.
        • DeFrances C.J.
        Hospitalization for congestive heart failure: United States, 2000-2010.
        NCHS Data Brief. 2012; : 1-8
        • Manemann S.M.
        • Chamberlain A.M.
        • Boyd C.M.
        • et al.
        Skilled nursing facility use and hospitalizations in heart failure: a community linkage study.
        Mayo Clin Proc. 2017; 92: 490-499
        • Riegel B.
        • Moser D.K.
        • Anker S.D.
        • et al.
        State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association.
        Circulation. 2009; 120: 1141-1163
      1. Arena R, Lavie CJ. Preventing bad and expensive things from happening by taking the healthy living polypill: everyone needs this medicine [published online March 13, 2017]. Mayo Clin Proc.

        • Institute of Medicine (US) Committee on Health Literacy
        Health Literacy: A Prescription to End Confusion.
        National Academies Press, Washington, DC2004: p.4
        • Noureldin M.
        • Plake K.S.
        • Morrow D.G.
        • Tu W.
        • Wu J.
        • Murray M.D.
        Effect of health literacy on drug adherence in patients with heart failure.
        Pharmacotherapy. 2012; 32: 819-826
        • Macabasco-O'Connell A.
        • DeWalt D.A.
        • Broucksou K.A.
        • et al.
        Relationship between literacy, knowledge, self-care behaviors, and heart failure-related quality of life among patients with heart failure.
        J Gen Intern Med. 2011; 26: 979-986
        • Cox S.R.
        • Liebl M.G.
        • McComb M.N.
        • et al.
        Association between health literacy and 30-day healthcare use after hospital discharge in the heart failure population.
        Res Social Adm Pharm. 2017; 13: 754-758
        • Howard D.H.
        • Gazmararian J.
        • Parker R.M.
        The impact of low health literacy on the medical costs of Medicare managed care enrollees.
        Am J Med. 2005; 118: 371-377
        • Peterson P.N.
        • Shetterly S.M.
        • Clarke C.L.
        • et al.
        Health literacy and outcomes among patients with heart failure.
        JAMA. 2011; 305: 1695-1701
        • McNaughton C.D.
        • Cawthon C.
        • Kripalani S.
        • Liu D.
        • Storrow A.B.
        • Roumie C.L.
        Health literacy and mortality: a cohort study of patients hospitalized for acute heart failure.
        J Am Heart Assoc. 2015; 4
        • Moser D.K.
        • Robinson S.
        • Biddle M.J.
        • et al.
        Health literacy predicts morbidity and mortality in rural patients with heart failure.
        J Card Fail. 2015; 21: 612-618
        • Wu J.R.
        • Holmes G.M.
        • DeWalt D.A.
        • et al.
        Low literacy is associated with increased risk of hospitalization and death among individuals with heart failure.
        J Gen Intern Med. 2013; 28: 1174-1180
        • McNaughton C.D.
        • Collins S.P.
        • Kripalani S.
        • et al.
        Low numeracy is associated with increased odds of 30-day emergency department or hospital recidivism for patients with acute heart failure.
        Circ Heart Fail. 2013; 6: 40-46
        • Rocca W.A.
        • Yawn B.P.
        • St Sauver J.L.
        • Grossardt B.R.
        • Melton III, L.J.
        History of the Rochester Epidemiology Project: half a century of medical records linkage in a US population.
        Mayo Clin Proc. 2012; 87: 1202-1213
        • St Sauver J.L.
        • Grossardt B.R.
        • Leibson C.L.
        • Yawn B.P.
        • Melton III, L.J.
        • Rocca W.A.
        Generalizability of epidemiological findings and public health decisions: an illustration from the Rochester Epidemiology Project.
        Mayo Clin Proc. 2012; 87: 151-160
        • St Sauver J.L.
        • Grossardt B.R.
        • Yawn B.P.
        • et al.
        Data resource profile: the Rochester Epidemiology Project (REP) medical records-linkage system.
        Int J Epidemiol. 2012; 41: 1614-1624
        • Chew L.D.
        • Bradley K.A.
        • Boyko E.J.
        Brief questions to identify patients with inadequate health literacy.
        Fam Med. 2004; 36: 588-594
        • Chew L.D.
        • Griffin J.M.
        • Partin M.R.
        • et al.
        Validation of screening questions for limited health literacy in a large VA outpatient population.
        J Gen Intern Med. 2008; 23: 561-566
        • Wallace L.S.
        • Rogers E.S.
        • Roskos S.E.
        • Holiday D.B.
        • Weiss B.D.
        Screening items to identify patients with limited health literacy skills.
        J Gen Intern Med. 2006; 21: 874-877
        • Wallace L.S.
        • Cassada D.C.
        • Rogers E.S.
        • et al.
        Can screening items identify surgery patients at risk of limited health literacy?.
        J Surg Res. 2007; 140: 208-213
        • Charlson M.E.
        • Pompei P.
        • Ales K.L.
        • MacKenzie C.R.
        A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
        J Chronic Dis. 1987; 40: 373-383
        • Deyo R.A.
        • Cherkin D.C.
        • Ciol M.A.
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
        J Clin Epidemiol. 1992; 45: 613-619
        • Nelson W.
        Recurrent Events, Data Analysis for Product Repairs, Disease Recurrences, and Other Applications.
        Society for Industrial and Applied Mathematics, Philadelphia, PA2003 (ASA-SIAM Series on Statistics and Applied Probability)
        • Paasche-Orlow M.K.
        • Wolf M.S.
        The causal pathways linking health literacy to health outcomes.
        Am J Health Behav. 2007; 31: S19-S26
        • Williams M.V.
        • Baker D.W.
        • Parker R.M.
        • Nurss J.R.
        Relationship of functional health literacy to patients' knowledge of their chronic disease: a study of patients with hypertension and diabetes.
        Arch Intern Med. 1998; 158: 166-172
        • Matsuoka S.
        • Tsuchihashi-Makaya M.
        • Kayane T.
        • et al.
        Health literacy is independently associated with self-care behavior in patients with heart failure.
        Patient Educ Couns. 2016; 99: 1026-1032
        • Hawkins M.A.
        • Dolansky M.A.
        • Levin J.B.
        • et al.
        Cognitive function and health literacy are independently associated with heart failure knowledge.
        Heart Lung. 2016; 45: 386-391
        • Chen A.M.
        • Yehle K.S.
        • Albert N.M.
        • et al.
        Relationships between health literacy and heart failure knowledge, self-efficacy, and self-care adherence.
        Res Social Adm Pharm. 2014; 10: 378-386
        • Baker D.W.
        • Dewalt D.A.
        • Schillinger D.
        • et al.
        The effect of progressive, reinforcing telephone education and counseling versus brief educational intervention on knowledge, self-care behaviors and heart failure symptoms.
        J Card Fail. 2011; 17: 789-796
        • DeWalt D.A.
        • Malone R.M.
        • Bryant M.E.
        • et al.
        A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170].
        BMC Health Serv Res. 2006; 6: 30
        • DeWalt D.A.
        • Schillinger D.
        • Ruo B.
        • et al.
        Multisite randomized trial of a single-session versus multisession literacy-sensitive self-care intervention for patients with heart failure.
        Circulation. 2012; 125: 2854-2862
        • Di Palo K.E.
        • Patel K.
        • Assafin M.
        • Pina I.L.
        Implementation of a patient navigator program to reduce 30-day heart failure readmission rate.
        Prog Cardiovasc Dis. 2017; 60: 259-266
        • Ziaeian B.
        • Fonarow G.C.
        The prevention of hospital readmissions in heart failure.
        Prog Cardiovasc Dis. 2016; 58: 379-385
        • Baker D.W.
        • DeWalt D.A.
        • Schillinger D.
        • et al.
        “Teach to goal”: theory and design principles of an intervention to improve heart failure self-management skills of patients with low health literacy.
        J Health Commun. 2011; 16: 373-388