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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Good news for HMO's and the delivery of preventive services.
correction
Disparities of care related to limited health literacy
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Beverly B. Green MD, MPH, Associate Director Department of Preventive Care Group Health of Puget Sound
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Dr. Weiss notes that it is not surprising that Fischella and colleagues that low educational level was associated with decreased use of important preventive services (tobacco cessation, mammograms, influenza shots). The good news however, was that for those who received care at a HMO this relationship was reversed. Funny thing is though, that this was not surprise. Also, HMO patients regardless of their demographic characteristics, were more likely receive more preventive care services than non HMO members, even though having access to regular care was similar in both groups. Until recently, traditional medical care has been centered on the one -on-one doctor patient interaction at a clinic visit, missing many opportunities to positively influence patient health outcomes. There is an emerging consensus that multifaceted, multilevel, interventions are most effective in improving care. In order to successfully plan and execute the required strategies, care planning is being increasingly conducted by the use of systems planning models, such as the Chronic Care Model first described by Wagner, Austin and Von Korff in 1996 (1,2). Important aspects of this model include the use of evidence based guidelines with decision support, information systems that can capture and communicate needed care events, designing health care delivery that can be both proactive and reactive to patient care needs, engaging patients to play an important role in their own care management, and institutional support of quality of care improvements. The Chronic Care Model has been shown to be successful in improving health outcomes for a variety of chronic conditions (3,4,5). It can be also be adapted to improve preventive care management. Almost all HMO’s document tobacco use and provider advice to quit, most have reminder and outreach systems for breast cancer screening and influenza vaccination, and many have instituted care registries for depression. These integrated systems are an integral part of “reaching” and “delivering” important care services and it remains a strategic challenge as to how to integrate these services in less organized care systems. Fischella and colleagues findings add more proof to the success of “systems design” constructs. The good news and surprise is, that a problem that we have long grappled with, providing preventive care for people of disparities, can be improved. (1) Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996; 74(4):511-44. (2)Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manag Care Q 1996; 4(2):12-25. (3)McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. Improvement in diabetes care using an integrated population-based approach in a primary care setting. Disease Management 2000; 3(2):75. (4) Boudreau DM, Capoccia KL, Sullivan SD, Blough D K, Ellsworth AJ, Clark DL, Katon WJ, Walker EA, Stevens NG. Collaborative care model to improve outcomes in major depression. Ann Pharmacother 2002; 36(4):585-91. (5) Stewart S, Marley JE, Horowitz JD. Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study. Lancet 1999; 354(9184):1077-83. Competing interests: None declared |
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Mary Kay Ness, Family physician private practice.
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Nothing earthshaking. Just that Dr. Fiscella and Dr. Franks were writing from University of Rochester in Rochester, New York, not Rochester, Minnesota. Competing interests: None declared |
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Barry D Weiss, Physician University of Arizona College of Medicine
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It is not surprising that Fischella and colleagues found a relationship between patients' education levels and the rates at which they obtain preventive health-care services. Indeed, this relationship has been known for years. It exists both in industrialized and non- industrialized nations of the world.(1,2) As the authors point out, the relationship between health outcomes and education is likely mediated by health literacy. Research has shown that individuals with limited literacy levels obtain preventive health services at lower rates than their more literate counterparts.(3,4) The relationship between literacy and health outcomes is independent of other sociodemogrpahic variables, and it is stronger than the relationship between education and health outcomes.(1) And, while education level is often used as an explicit or implicit proxy for literacy, as it was in the Fischella article, is not a particularly good proxy. Education level is only a measure of how long an individual attended school. It does not tell us anything about what they learned in school. Indeed, some 25 percent of individuals who scored at the very lowest literacy-skill level on the National Adult Literacy Survey were high school graduates.(5) In summary, the key finding of the Fishella article - that education is related to health outcomes - is not surprising. Had the investigators been able to study the relationship between literacy and those same outcomes, an even stronger relationship would have been found. Barry D Weiss, MD Department of Family and Community Medicine University of Arizona College of Medicine (1) Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association (Parker R, Williams M, Weiss BD, et al). Health literacy: Report of the Council on Scientific Affairs. Journal of the American Medical Association. 1999; 281:552-557. (2) Weiss BD, Hart G, Pust RH. The relationship between illiteracy and health. Journal of Health Care for the Poor and Underserved. 1991; 1:43-55.5) (3) Davis, T.C., Arnold, C., Berkel, H.J., Nandy, I., Jackson, R.H., & Glass J. (1996). Knowledge and attitude on screening mammography among low-literate, low income women. Cancer, 78(9), 1912-1920. (4) Davis TC. Dolan NC. Ferreira MR. Tomori C. Green KW. Sipler AM. Bennett CL. The role of inadequate health literacy skills in colorectal cancer screening. Cancer Investigation. 19(2):193-200, 2001. (5) Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, D.C.: National Center for Education Statistics, U.S. Department of Education; September, 1993 Competing interests: None declared |
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