Health Literacy Impact on National Healthcare Utilization and Expenditure

Document Type: Original Article

Authors

1 University of Kansas School of Pharmacy, Lawrence, KS, USA

2 Institute for Biobehavioral Health Research, National Development and Research Institutes (NDRI) New York, NY and Leawood, KS, USA

3 Ben and Maytee Fisch College of Pharmacy, University of Texas at Tyler, Tyler, TX, USA

4 Children’s Mercy Hospital, Kansas City, MO, USA

Abstract

Background
Health literacy presents an enormous challenge in the delivery of effective healthcare and quality outcomes. We evaluated the impact of low health literacy (LHL) on healthcare utilization and healthcare expenditure.
 
Methods
Database analysis used Medical Expenditure Panel Survey (MEPS) from 2005-2008 which provides nationally representative estimates of healthcare utilization and expenditure. Health literacy scores (HLSs) were calculated based on a validated, predictive model and were scored according to the National Assessment of Adult Literacy (NAAL). HLS ranged from 0-500. Health literacy level (HLL) and categorized in 2 groups: Below basic or basic (HLS <226) and above basic (HLS ≥226). Healthcare utilization expressed as a physician, nonphysician, or emergency room (ER) visits and healthcare spending. Expenditures were adjusted to 2010 rates using the Consumer Price Index (CPI). A Pvalue of 0.05 or less was the criterion for statistical significance in all analyses. Multivariate regression models assessed the impact of the predicted HLLs on outpatient healthcare utilization and expenditures. All analyses were performed with SAS and STATA®11.0 statistical software.
 
Results
The study evaluated 22 599 samples representing 503 374 648 weighted individuals nationally from 2005-2008. The cohort had an average age of 49 years and included more females (57%). Caucasian were the predominant racial ethnic group (83%) and 37% of the cohort were from the South region of the United States of America. The proportion of the cohort with basic or below basic health literacy was 22.4%. Annual predicted values of physician visits, nonphysician visits, and ER visits were 6.6, 4.8, and 0.2, respectively, for basic or below basic compared to 4.4, 2.6, and 0.1 for above basic. Predicted values of office and ER visits expenditures were $1284 and $151, respectively, for basic or below basic and $719 and $100 for above basic (P < .05). The extrapolated national estimates show that the annual costs for prescription alone for adults with LHL possibly associated with basic and below basic health literacy could potentially reach about $172 billion.
 
Conclusion
Health literacy is inversely associated with healthcare utilization and expenditure. Individuals with below basic or basic HLL have greater healthcare utilization and expendituresspending more on prescriptions compared to individuals with above basic HLL. Public health strategies promoting appropriate education among individuals with LHL may help to improve health outcomes and reduce unnecessary healthcare visits and costs.

Keywords

Main Subjects


  1. Selden CR, Zorn M, Ratzan SC, Parker RM, eds. Current Bibliographies in Medicine: Health Literacy. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services; 2000.
  2. Centers for Disease Control and Prevention (CDC). Learn About Health Literacy. http://www.cdc.gov/healthliteracy/Learn/index.html. Accessed July 15, 2012.
  3. Koh HK, Berwick DM, Clancy CM, et al. New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly 'crisis care'. Health Aff (Millwood). 2012;31(2):434-443. doi:10.1377/hlthaff.2011.1169
  4. Rudd RE. Improving Americans' health literacy. N Engl J Med. 2010;363(24):2283-2285. doi:10.1056/NEJMp1008755
  5. Pei L, Legge D, Stanton P. Policy contradictions limiting hospital performance in China. Policy Stud. 2000;21(2):99-113.
  6. Kutner M, Greenberg E, Jin Y, Paulsen C. The Health Literacy of America's Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: US Department of Education; 2006.
  7. The Joint Commission. "What did the doctor say?": Improving health literacy to protect patient safety. Oakbrook Terrace, IL: The Joint Commission; 2007.
  8. American Medical Association (AMA). Health literacy. http://www.ama-assn.org/ama/pub/about-ama/ama-foundation/our-programs/public-health/health-literacy-program.page? Accessed July 27, 2012. Published 2012.
  9. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107. doi:10.1059/0003-4819-155-2-201107190-00005
  10. Mottus R, Johnson W, Murray C, Wolf MS, Starr JM, Deary IJ. Towards Understanding the Links Between Health Literacy and Physical Health. Health Psychol. 2013. doi:10.1037/a0031439
  11. Hartman M, Martin AB, Benson J, Catlin A. National health spending in 2011: overall growth remains low, but some payers and services show signs of acceleration. Health Aff (Millwood). 2013;32(1):87-99. doi:10.1377/hlthaff.2012.1206
  12. Chen JZ, Hsu HC, Tung HJ, Pan LY. Effects of health literacy to self-efficacy and preventive care utilization among older adults. Geriatr Gerontol Int. 2013;13(1):70-76. doi:10.1111/j.1447-0594.2012.00862.x
  13. Cho YI, Lee SY, Arozullah AM, Crittenden KS. Effects of health literacy on health status and health service utilization amongst the elderly. Soc Sci Med. 2008;66(8):1809-1816. doi:10.1016/j.socscimed.2008.01.003
  14. Hardie NA, Kyanko K, Busch S, Losasso AT, Levin RA. Health literacy and health care spending and utilization in a consumer-driven health plan. J Health Commun. 2011;16(suppl 3):308-321. doi:10.1080/10810730.2011.604703
  15. Lincoln A, Paasche-Orlow MK, Cheng DM, et al. Impact of health literacy on depressive symptoms and mental health-related: quality of life among adults with addiction. J Gen Intern Med. 2006;21(8):818-822. doi:10.1111/j.1525-1497.2006.00533.x
  16. Welch VL, VanGeest JB, Caskey R. Time, costs, and clinical utilization of screening for health literacy: a case study using the Newest Vital Sign (NVS) instrument. J Am Board Fam Med. 2011;24(3):281-289. doi:10.3122/jabfm.2011.03.100212
  17. Davis TC, Crouch MA, Long SW, et al. Rapid assessment of literacy levels of adult primary care patients. Fam Med. 1991;23(6):433-435.
  18. Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25(6):391-395.
  19. Osborn CY, Weiss BD, Davis TC, et al. Measuring adult literacy in health care: performance of the newest vital sign. Am J Health Behav. 2007;31 Suppl 1:S36-46. doi:10.5555/ajhb.2007.31.supp.S36
  20. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients' literacy skills. J Gen Intern Med. 1995;10(10):537-541.
  21. Agency for Healthcare Research and Qual (AHRQ). Medical Expenditure Panel Survey. http://meps.ahrq.gov/mepsweb/. Accessed December 1, 2011. Published 2011.
  22. Vernon JA, Trujillo A, Rosenbaum S, DeBuono B. Low Health Literacy: Implications for National Health Care Policy. Washington, DC: George Washington University School of Public Health and Health Services; 2007.
  23. Medical Expenditure Panel Survey (MEPS). MEPS topics: Prescribed drug use/events and expenditures. http://meps.ahrq.gov/mepsweb/data_stats/MEPS_topics.jsp?topicid=46Z-1. Accessed December 26, 2012. Published 2009.
  24. Medical Expenditure Panel Survey (MEPS). MEPS HC-118A: 2008 Prescribed Medicines. Rockville, MD: Center for Financing, Access, and Cost Trends; 2010.
  25. Martin LT, Ruder T, Escarce JJ, et al. Developing predictive models of health literacy. J Gen Intern Med. 2009;24(11):1211-1216. doi:10.1007/s11606-009-1105-7
  26. Statistics USBoL. CPI inflation calculator. http://www.bls.gov/data/inflation_calculator.htm. Accessed January 1, 2013. Published 2013.
  27. Terza JV, Basu A, Rathouz PJ. Two-stage residual inclusion estimation: addressing endogeneity in health econometric modeling. J Health Econ. 2008;27(3):531-543. doi:10.1016/j.jhealeco.2007.09.009
  28. Cameron AC, Trivedi PK. Regression Analysis of Count Data. Cambridge, UK: Cambridge University Press; 1998.
  29. Mackun P, Wilson S. Population Distribution and Change: 2000-2010. Washington, DC: US Census Bureau; 2011.
  30. Chen AY, Escarce JJ. Effects of family structure on children's use of ambulatory visits and prescription medications. Health Serv Res. 2006;41(5):1895-1914. doi:10.1111/j.1475-6773.2006.00584.x
  31. Pylypchuk Y, Sarpong EM. Comparison of health care utilization: United States versus Canada. Health Serv Res. 2013;48(2 Pt 1):560-581. doi:10.1111/j.1475-6773.2012.01466.x
  32. Friedland RB, O'Neill G. Understanding Health Literacy: New Estimates of the High Costs of Inadequate Health Literacy. Washington, DC: US Government Printing Office; 1998:57-91.
  33. Wolf MS, Curtis LM, Waite K, et al. Helping patients simplify and safely use complex prescription regimens. Arch Intern Med. 2011;171(4):300-305. doi:10.1001/archinternmed.2011.39
  34. Davis TC, Wolf MS, Bass PF 3rd, et al. Literacy and misunderstanding prescription drug labels. Ann Intern Med. 2006;145(12):887-894.
  35. Noureldin M, Plake KS, Morrow DG, Tu W, Wu J, Murray MD. Effect of health literacy on drug adherence in patients with heart failure. Pharmacotherapy. 2012;32(9):819-826. doi:10.1002/j.1875-9114.2012.01109.x
  36. Murray MD, Tu W, Wu J, Morrow D, Smith F, Brater DC. Factors associated with exacerbation of heart failure include treatment adherence and health literacy skills. Clin Pharmacol Ther. 2009;85(6):651-658. doi:10.1038/clpt.2009.7
  37. Murray MD, Young J, Hoke S, et al. Pharmacist intervention to improve medication adherence in heart failure: a randomized trial. Ann Intern Med. 2007;146(10):714-725.
  38. Gazmararian J, Jacobson KL, Pan Y, Schmotzer B, Kripalani S. Effect of a pharmacy-based health literacy intervention and patient characteristics on medication refill adherence in an urban health system. Ann Pharmacother. 2010;44(1):80-87. doi:10.1345/aph.1M328
  39. Gazmararian JA, Beditz K, Pisano S, Carreon R. The development of a health literacy assessment tool for health plans. J Health Commun. 2010;15(suppl 2):93-101. doi:10.1080/10810730.2010.499986
  40. Mosher HJ, Lund BC, Kripalani S, Kaboli PJ. Association of health literacy with medication knowledge, adherence, and adverse drug events among elderly veterans. J Health Commun. 2012;17(suppl 3):241-251. doi:10.1080/10810730.2012.712611
  41. Blake SC, McMorris K, Jacobson KL, Gazmararian JA, Kripalani S. A qualitative evaluation of a health literacy intervention to improve medication adherence for underserved pharmacy patients. J Health Care Poor Underserved. 2010;21(2):559-567. doi:10.1353/hpu.0.0283
  42. Review of Findings on Chronic Disease Self-Management Program (CDSMP) Outcomes: Physical, Emotional & Health-Related Quality of Life,Healthcare Utilization and Costs. http://patienteducation.stanford.edu/research/Review_Findings_CDSMP_Outcomes1%208%2008.pdf. Published 2013.
  43. Ahn S, Basu R, Smith ML, et al. The impact of chronic disease self-management programs: healthcare savings through a community-based intervention. BMC Public Health. 2013;13:1141. doi:10.1186/1471-2458-13-1141
  44. Kripalani S, Jacobson K, Brown S MK, Rask K, Jacobson T. Development and Implementation of a Health Literacy Training Program for Medical Residents. Medical Education online. 2006;11(13):1-8.
  45. Mackert M, Ball J, Lopez N. Health literacy awareness training for healthcare workers: improving knowledge and intentions to use clear communication techniques. Patient Educ Couns. 2011;85(3):e225-e228. doi:10.1016/j.pec.2011.02.022
  46. Bowskill D, Garner L. Medicines non-adherence: adult literacy and implications for practice. Br J Nurs. 2012;21(19):1156-1159.