– by Dr. Irving Loh, MD
As a follow up of my last post on pharmacologic therapy of heart failure, I’d like to review a topic that is easy to overlook, but has profound implications for what happens to our heart failure patients.
Let’s start off with the obvious that is appreciated by all of us who have cared for heart failure patients longitudinally, whether one is a cardiologist, internist, family practitioner or advanced practice nurse: heart failure is a complicated disease with many exacerbating and mitigating factors, and patients’ doing well often require a knife edge equilibrium maintained over a long time. The lifestyle, dietary monitoring, daily weights, symptoms and medication changes to maintain that tenuous balance can be overwhelming, not only for the healthcare providers, but the patient and caregivers.
If not done well, the best case scenario is the unexpected encounter which is a euphemism for an urgent visit to the doctor or a trip to the ER, possibly involving re-hospitalization. The worse case scenario is…worse than those events.
In a report out of Vanderbilt University and published in the Journal of the American Heart Association (1), senior author Dr. Candance McNaughton and her colleagues followed 1379 patients hospitalized between 2010 and 2013 for heart failure AND completed the Brief Health Literacy Screen administered by nurses. Brief meant three questions: did they have problems learning about their heart failure, were they confident filling out their medical forms, and how often did someone help them read hospital materials.
After factoring in age, sex, race, insurance, education level, comorbidities and hospital length of stay, the patients deemed to have “low health literacy” were thirty percent more likely to die than those with higher scores. Subsequent ER visits or 90-day re-hospitalizations were not correlated to scores, which is not well explained.
Regardless, it would seem that the diagnosis of heart failure warrants a greater focus on care coordination and education than many other chronic diseases. That heart failure tends to be a disease of the elderly compounds the problem of healthcare literacy. And we, as healthcare providers, may make the grievous error of assuming that just because we tell our patients something, that they understand what we told them. Factor in language barriers and suboptimal support infrastructures and we have a whole lot of trouble ahead.
My turn. Surmounting low health literacy is a team sport. Integrating the cost into the health-economic ecosystem is necessary because of the reduced downstream expenses and mortality make the investment prudent. This does require a global or “big picture” view, not traditionally seen in our for-profit payer system, but recognized in vertically integrated or “closed” systems.
Short of widespread primary prevention, society needs effective chronic disease management and care coordination to compensate for low health literacy. Creating this out of whole cloth is a complex and costly for each healthcare environment, though many have attempted and succeeded. But our market-based and technologically savvy colleagues have built multidisciplinary care “circles” or platforms to engage patients and their care teams to facilitate and coordinate care, much of it involving education and providing support. Examples of which I am aware (disclaimer: because I am an advisor or have a consultant relationship) include Tiatros, HealthLoop, Conversa Health and UMotif (international), and I am sure there are many others with which I am less familiar. My point is that these clever colleagues have potential solutions for low health literacy if our own care environments are unable to meet the needs of our chronic disease patients. Existing and ongoing outcomes research will provide objective health-economic data to verify if these interventions improve their quality and quantity of life.
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1. bit.ly/1bf6ZON Health Literacy and Mortality: A Cohort Study of Patients Hospitalized for Acute Heart Failure. J Am Heart Assoc, online 29 April 2015; doi: 10.1161/JAHA. 115.001799
Dr. Irving Kent Loh MD, FACC, FAHA (Epidemiology & Prevention), FCCP, FACP is a board certified internist and sub-specialty board certified cardiac specialist with an emphasis on preventive cardiology. He founded and directs the Ventura Heart Institute, which conducts education, research and preventive cardiovascular programs. Dr. Loh is a former Assistant Professor of Medicine at UCLA School of Medicine. He is Chief Medical Officer and Co-founder of Infermedica, an artificial intelligence company for enhancing clinical decision support for patients and healthcare providers.