The Case for Screening Surgery Patients for Low Health Literacy

UH Clinical Update | April 2022

New study finds low health literacy lengthens hospital stays and increases use of post-acute resources for cancer surgery patients, but has potential for mitigation with early identification and intervention

Low health literacy has all kinds of deleterious effects for patients and for the healthcare system as a whole. Patients who have reduced ability to read and discuss health-related information are less likely to follow screening guidelines and care recommendations from their doctor. They also have poorer clinical outcomes, as has been demonstrated in patients with asthma, diabetes, congestive heart failure and end-stage renal disease. Low health literacy also been linked to hospital readmissions and ED visits in some groups of patients.

Luke Rothermel, MD

Now a new study has found a similar pattern with patients recovering from cancer surgery – the first time this effect has been shown in this patient population. In research published in the prestigious Journal of the National Comprehensive Cancer Network, UH Seidman Cancer Center surgical oncologist Luke Rothermel, MD, and colleagues found that patients undergoing surgery for cancer at a free-standing NCI-designated Comprehensive Cancer Center who had low health literacy had significantly longer length of hospital stay, even after controlling for sociodemographic variables. Study results also show that these patients needed more post-acute services, such as home-based physical therapy or occupational therapy, home nursing or discharge to a skilled nursing or rehabilitation facility, again after controlling for sociodemographic variables and clinical variables related to outcomes of interest.

On average, length of stay was 2.04 days less for those with even marginal or adequate health literacy than for those with low health literacy, as measured on the quick, four-question BRIEF health literacy screening tool. At the same time, patients with marginal and adequate health literacy were 77% less likely to need post-acute care than those with low health literacy.

These effects weren’t attributable to any deficits in patient care at the study site, Dr. Rothermel says.

“The hospital in Florida where we did the study was an excellent cancer center,” he says. “It was efficient, it was effective, and the pieces were in place to get people the resources that they need. But because it was not proactively evaluating patients who may have difficulty in understanding their care and translating the instructions we were giving them, there was a deficit that was unrecognized and therefore unaddressed. Based on my clinical experience, I suspected that longer length of stay would be affected by low health literacy, also setting up increased use of post-acute care services.”

“A proactive realignment of resources, such as high-touch interaction with the clinical team, patient navigation with a nurse navigator, social work, home care assistance earlier in the perioperative period could help these patients adhere to standard treatment courses and mitigate the impact of low health literacy on clinical outcomes,” he says. “When people don’t have the ability to process the information we are recommending for them and they can’t act on the communications we give, then we need to set up more resources on the back end to help them.”

This study suggests that not all patients will require the proactive alignment of resources. For patients with low health literacy, however, he says, early identification can help them receive the support they need as they recover, such as tailored educational materials or telephone follow-ups. As a bonus, the wider circle of supportive health professionals all talking about the same care goals – being on the same page -- might help patients understand them better, he adds. Repetition from multiple sources may help break through the fog.

Fortunately, Dr. Rothermel says, many of these services are already in place at UH Seidman Cancer Center. The patient education team reviews and edits new documents to make sure they’re written at an appropriate grade level for most patients to understand. In addition, each disease team within UH Seidman employs patient navigators to ensure that patients treated for cancer here have all the information that they need when presenting for care, making the care process efficient.  For patients with advanced disease, the patient navigator has an even more pivotal role.

“That patient navigator can evaluate what the patient brings to the table, including their barriers to care like low health literacy,” Dr. Rothermel says. “The role of the navigator at UH Seidman is also evolving so that it’s even more of a high-touch, personal experience.”

Dr. Rothermel, in fact, is beginning a research project with the patient navigators on the UH Seidman Breast Cancer Team to survey newly diagnosed patients on a variety of factors before their treatment begins. The goal is to see how different patient factors affect the rest of the care. One area being assessed in these patients is their level of health literacy.

For now, Dr. Rothermel says, he hopes the results of his recent health literacy study will help inform discussions about resource allocation at other cancer centers and hospital systems.

“The impact of low health literacy has been hard to measure,” he says. “Finding increased health resource utilization for patients with lower health literacy is actually pretty compelling to a hospital system that is trying to apply its resources effectively, both from a patient experience perspective and a cost perspective. If we can get the ball rolling early and decrease length of stay, it will be a targeted resource investment. The proactive approach to this would be very valuable in multiple ways.”