Andrea S. Wallace

Low health literacy: Overview, assessment, and steps toward providing high-quality diabetes care

Andrea S. Wallace — Sun, 16 Sep 2012 04:56:12 PDT

Approximately half of all Americans do not understand written and verbal health information well enough to take appropriate action. For chronic conditions requiring patients' ongoing self-management, limited literacy may be a powerful barrier to achieving optimal outcomes. Because low literacy is associated with a number of psychosocial variables that also act as barriers to self-management, health literacy experts recommend that efforts to alleviate the burden introduced by low literacy be addressed not only by developing means of increasing patients' understanding, but also by integrating such efforts into systems aiming to improve self-management support across the continuum of patient care. This article provides an overview of efforts to define, assess, and improve the quality of diabetes care provided to those with limited health literacy.

Literacy-appropriate educational materials and brief counseling improve diabetes self-management

Andrea S. Wallace et al. — Sun, 16 Sep 2012 04:56:12 PDT

OBJECTIVE: In this pilot study, we evaluated the impact of providing patients with a literacy-appropriate diabetes education guide accompanied by brief counseling designed for use in primary care. METHODS: We provided the Living with Diabetes guide and brief behavior change counseling to 250 English and Spanish speaking patients with type 2 diabetes. Counseling sessions using collaborative goal setting occurred at baseline and by telephone at 2 and 4 weeks. We measured patients' activation, self-efficacy, diabetes distress, knowledge, and self-care at baseline and 3-month follow-up. RESULTS: Statistically significant (p

Race, care seeking, and utilization for chronic back and neck pain: Population perspectives

T. S. Carey et al. — Sun, 16 Sep 2012 04:56:10 PDT

We analyzed a statewide survey of individuals with chronic back and neck pain to determine whether prevalence and care use varied by patient race or ethnicity. We conducted a telephone survey of a random sample of 5,357 North Carolina households in 2006. Adults with chronic (>3 months duration or >24 episodes of pain per year), impairing back or neck pain were identified and were asked to complete a survey about their health and care utilization. 837 respondents (620 white, 183 black, 34 Latino) reported chronic back or neck pain. Whites and blacks had similar rates of chronic back pain. Back pain prevalence was lower in Latinos (10.4% 9.3-11.6] vs 6.3% 3.8-8.8]), likely due to their younger age; and the prevalence of chronic, disabling neck pain was lower in blacks (2.5% 1.9-3.1] vs 1.1% .04-1.9]). Blacks had higher pain scores in the previous 3 months (5.2 vs 5.9 P < .05), and higher Roland disability scores (0-23 point scale): 14.2 vs 16.8, P < .05. Care seeking was similar among races (83% white, 85% black, 72% Latino). Use of opioids was also similar between races, at 49% for whites, 52% for blacks, and trended lower at 35% for Latinos. We found few racial/ethnic differences in care seeking, treatment use, and use of narcotics for the treatment of chronic back and neck pain. PERSPECTIVE: This article presents new, population-based data on the issue of racial and ethnic disparities in neck- and back-pain prevalence and care. Few disparities were found; care quality issues may affect all ethnic groups similarly. Previous findings of disparities in chronic-pain management may be decreasing, or may perhaps be site specific.

Accessing asthma care: A case study of urban children

Andrea S. Wallace — Sun, 16 Sep 2012 04:56:09 PDT

The purpose of this exploratory, descriptive study was to identify factors that facilitate or impede the use of health care resources by urban children with asthma. Using an embedded case study design, the study considered the issue of health care access for urban children with asthma by focusing on attributes that impede and facilitate these children's access to health care resources. Interview, demographic, survey, and medical records data were analyzed for 34 parent-child dyads accessing asthma care in one metropolitan health care system. Interview data from 14 health care professionals were also analyzed. These findings were then compared with utilization data of 895 children accessing asthma care during 2003--2004, analyzed for significant access-related differences and predictive variables.; Both parent and health care professional participants identified a number of factors influencing children's access to asthma services, including parental beliefs, family organization, service organization, and insurance-related factors. Survey and medical records data confirmed many of these qualitative themes.; Utilization data analyses identified that age and race-related factors influence access to care. As children age, they had a reduced risk of having emergent/urgent visits and those who are Hispanic were less likely to have insurance. Insurance status was shown to influence access to care in that those who were uninsured were less likely to access allergy specialty services. In addition, those with Medicaid insurance also experience more insurance type changes. Insurance type changes were associated with a greater number of asthma related visits to all settings. Finally, a negative association was then found between asthma-related emergent/urgent care and primary care visits.; Among the many implications resulting from this study's findings was the seemingly strong influence clinical service organization and relationships between parents and providers have upon health care access patterns. Implications for nursing and recommendations for further research were also discussed.

Improving diabetes self-management using low-literacy educational materials and brief counseling

Andrea S. Wallace et al. — Fri, 25 Mar 2011 12:36:08 PDT

Conference abstract. Society of General Internal Medicine, 30th Annual Meeting, Toronto,Ontario,Canada, April 25-28, 2007

Impoverished children with asthma: A pilot study of urban healthcare access

Andrea Wallace et al. — Fri, 25 Mar 2011 12:36:07 PDT

The influence of literacy on patient-reported experiences of diabetes self-management support

Andrea S. Wallace et al. — Fri, 25 Mar 2011 12:36:05 PDT

Background: Variability in disease-related outcomes may relate to how patients experience self-management support in clinical settings. Objectives: The purpose of this study was to identify factors associated with experiences of self-management support during primary care encounters. Methods: A cross-sectional survey was conducted of 208 patients seen in a multidisciplinary diabetes program in an academic medicine clinic. Multiple regression analysis was used to test associations between patient-rated experiences of self-management support (Patient Assessment of Chronic Illness Care) and race, gender, insurance status, literacy, duration of diabetes, and intensity of care management. Results: The Patient Assessment of Chronic Illness Care ratings decreased with age (r = -.235, p = .001), were higher for women than for men (3.95 vs. 3.65, t = 2.612, p = .010), and were greater for those with more education (F = 3.927, p = .009) and greater literacy skills (t = 3.839, p < .001). The ratings did not vary between racial (t = -1.108, p = .269) or insurance (F = 1.045, p = .374) groups and were unaffected by the duration of diabetes (r = .052, p = .466) and the intensity of care management (F = 1.028, p = .360). In multivariate models, literacy was the only variable contributing significantly to variation in self-management support ratings. Discussion: Even when considering the objective intensity of health services delivered, literacy was the sole variable contributing to differences in patient ratings of self-management support. Although conclusions are limited by the cross-sectional nature of this study, the results emphasize the need to consider literacy when developing and communicating treatment plans requiring self-management skills.

Facilitating behavior change with low-literacy patient education materials

H. K. Seligman et al. — Fri, 25 Mar 2011 12:36:03 PDT

Objective: To describe a process for developing low-literacy health education materials that increase knowledge and activate patients toward healthier behaviors. Methods: We developed a theoretically informed process for developing educational materials. This process included convening a multidisciplinary creative team, soliciting stakeholder input, identifying key concepts to be communicated, mapping concepts to a behavioral theory, creating a supporting behavioral intervention, designing and refining materials, and assessing efficacy. Results: We describe the use of this process to develop a diabetes self-management guide. Conclusions: Developing low-literacy health education materials that will activate patients toward healthier behaviors requires attention to factors beyond reading level.

Successful school-based intervention for inner-city children with persistent asthma

M. E. Anderson et al. — Fri, 25 Mar 2011 12:35:58 PDT

Objective: Because children attend school daily, school-based interventions for children with persistent asthma could provide effective disease management for inner-city asthmatic children. The Kunsberg School in Denver, Colorado, enrolls children with chronic diseases, including asthma, into a daily program of school-based disease management. This study sought to determine the impact of the Kunsberg program on asthma utilization. Methods: Children attending Kunsberg (n = 18) who received primary care at Denver Health were compared with a group of matched control children who also received primary care at Denver Health, but did not attend Kunsberg (n = 36). Asthma-related utilization for an average of 2.9 years before and after Kunsberg enrollment was assessed. Results: The 18 Kunsberg and 36 control subjects were mostly minority children in low-income families, without significant demographic differences between groups. Compared with controls, the Kunsberg cohort experienced fewer hospitalizations (0.5 vs. 0.9 hospitalizations/subject/ year, p = 0.05), fewer emergency department (ED) visits (1.4 vs. 2.8 ED visits/ subject/year, p = 0.04), and fewer follow-up visits for asthma (3.7 vs. 5.0 visits/subject/ year, p = 0.01) in the time period (mean 2.9 years; range 1-6 years) following the intervention. Hospital- and clinic-based asthma utilization costs decreased 80% following enrollment in the school ($8122/year to $1588/year per child), compared to a 19% decrease in the control group. Among the Kunsberg children with hospitalizations prior to school enrollment (n = 8), hospital days decreased from 3.5 days to 0.1 days annually (p < 0.01), ED visits decreased from 2.1 to 0.6 visits annually (p = 0.02), and follow-up visits decreased from 6.8 to 2.1 visits annually (p = 0.02). As part of their school program, 89% of Kunsberg enrollees received inhaled corticosteroids daily on a monitored basis while at school. Conclusions: The Kunsberg school program improved asthma control and reduced disease severity for at-risk inner-city asthmatic children, leading to cost reduction for asthma management. Directly observed controller therapy at school can be an important component of a school-based program for children with chronic conditions.

Comfortably numb? Exploring satisfaction with chronic back pain visits

Andrea S. Wallace et al. — Fri, 25 Mar 2011 12:35:56 PDT

BACKGROUND CONTEXT: Chronic back pain is a condition characterized by high rates of disability, health-care service use, and costs. PURPOSE: The purpose of this study was to identify factors associated with patients' satisfaction with their last health-care provider visit for chronic low back pain (LBP). STUDY DESIGN/SETTING: A cross-sectional, state-level, telephone survey was administered to patients with chronic LBP. PATIENT SAMPLE: The sample consisted of 624 individuals with chronic LBP who reported seeing a health-care provider in the previous year. OUTCOME MEASURES: Dependent variables included satisfaction with last visit for LBP and intent to seek care from additional providers. Independent variables included the Roland-Morris Disability Questionnaire, 3-month pain ratings using a 0 to 10 Likert scale, the Medical Outcomes Survey Short Form 12, and self-reported health service utilization (provider type, number of visits to health-care providers, medication use during the previous month, and treatments and diagnostic tests during the previous year). METHODS: Bivariate and multivariate analyses were used to explore how demographic, insurance-related, and health-related characteristics were associated with patient satisfaction. RESULTS: Participants who were not satisfied with one or more aspects of their last clinic visit were younger (51.0 vs. 54.21 years), reported higher 3-month pain ratings (7.23 vs. 6.53), and were more commonly Hispanic (53.2% vs. 46.8% for other ethnicities) and uninsured (43.1% vs. 29.3% for other insurance groups). Those who intended to seek care from additional providers were younger (50.05 vs. 55.49 years), had higher 3-month pain ratings (7.20 vs. 6.46), had lower Short Form 12 mental health component scores (44.75 vs. 49.55) and physical component scores (30.07 vs. 31.55), and were more commonly black (54.6% vs. 45.4% for other racial groups) and uninsured (56.9% vs. 43.1% for other insurance groups). Narcotic use was associated with satisfaction (odds ratio=2.12, p=.01), whereas lack of insurance was associated with respondents' intent to seek care from additional providers (odds ratio=2.97, p<.01). CONCLUSIONS: Factors other than disability were associated with satisfaction with chronic LBP visits. Understanding the role of medication in satisfaction and its implications for the health behaviors of this highly disabled population may be particularly important. (C) 2009 Elsevier Inc. All rights reserved.

Exercise prescription for chronic back or neck pain: Who prescribes It? Who gets it? What is prescribed?

J. K. Freburger et al. — Fri, 25 Mar 2011 12:35:54 PDT

Objective. To describe exercise prescription in routine clinical practice for individuals with chronic back or neck pain because, although current practice guidelines promote exercise for chronic back and neck pain, little is known about exercise prescription in routine care. Methods. We conducted a computer-assisted telephone survey of a representative sample of individuals (n = 684) with chronic back or neck pain who saw a physician, chiropractor, and/or physical therapist (PT) in the past 12 months. Individuals were asked about whether they were prescribed exercise, the amount of supervision received, and the type, duration, and frequency of the prescribed exercise. Descriptive and multivariable regression analyses were conducted. Results. Of the 684 subjects, 48% were prescribed exercise. Of those prescribed exercise, 46% received the prescription from a PT, 29% from a physician, 21% from a chiropractor, and 4% from other. In multivariable analyses, seeing a PT or a chiropractor were the strongest predictors of exercise prescription. The likelihood of exercise prescription was increased in women, those with higher education, and those receiving worker's compensation. PTs were more likely to provide supervision and prescribe strengthening exercises compared with physicians and chiropractors, and were more likely to prescribe stretching exercises compared with physicians. Conclusion. Our findings suggest that exercise is being underutilized as a treatment for chronic back and neck pain and, to some extent, that the amount of supervision and types of exercises prescribed do not follow current practice guidelines. Exercise prescription provided by PTs appears to be most in line with current guidelines.

Goal setting in diabetes self-management: Taking the baby steps to success

D. A. DeWalt et al. — Fri, 25 Mar 2011 12:35:52 PDT

Objective: To evaluate the usefulness of a diabetes self-management guide and a brief counseling intervention in helping patients set and achieve their behavioral goals. Methods: We conducted a quasi-experimental study using a one group pretest posttest design to assess the effectiveness of a goal setting intervention along with a self-management guide. English- and Spanish-speaking patients with diabetes had one in-person session and two telephone follow-up calls with a non-clinical provider over a 12-16-week period. At each call and at the end of the study, we assessed success in achieving behavioral goals and problem solving toward those goals. Satisfaction with the self-management guide was assessed at the end of the study. Results: We enrolled 250 patients across three sites and 229 patients completed the study. Most patients chose to set goals in diet and exercise domains. 93% of patients achieved at least one behavioral goal during the study and 73% achieved at least two behavioral goals. Many patients exhibited problem solving behavior to achieve their goals. We found no significant differences in reported achievement of behavior goals by literacy or language. Patients were very satisfied with the guide. Conclusions: A brief goal setting intervention along with a diabetes self-management guide helped patients set and achieve healthy behavioral goals. Practice implications: Non-clinical providers can successfully help a diverse range of patients with diabetes set and achieve behavioral goals. (c) 2009 Elsevier Ireland Ltd. All rights reserved.

The rising prevalence of chronic low back pain

J. K. Freburger et al. — Fri, 25 Mar 2011 12:35:50 PDT

Background: National or state-level estimates on trends in the prevalence of chronic low back pain (LBP) are lacking. The objective of this study was to determine whether the prevalence of chronic LBP and the demographic, health-related, and health care-seeking characteristics of individuals with the condition have changed over the last 14 years. Methods: A cross-sectional, telephone survey of a representative sample of North Carolina households was conducted in 1992 and repeated in 2006. A total of 4437 households were contacted in 1992 and 5357 households in 2006 to identify noninstitutionalized adults 21 years or older with chronic (> 3 months), impairing LBP or neck pain that limits daily activities. These individuals were interviewed in more detail about their health and health care seeking. Results: The prevalence of chronic, impairing LBP rose significantly over the 14-year interval, from 3.9% (95% confidence interval [CI], 3.4%-4.4%) in 1992 to 10.2% (95% CI, 9.3%-11.0%) in 2006. Increases were seen for all adult age strata, in men and women, and in white and black races. Symptom severity and general health were similar for both years. The proportion of individuals who sought care from a health care provider in the past year increased from 73.1% (95% CI, 65.2%-79.8%) to 84.0% (95% CI, 80.8%-86.8%), while the mean number of visits to all health care providers were similar (19.5 [1992] vs 19.4 [2006]). Conclusions: The prevalence of chronic, impairing LBP has risen significantly in North Carolina, with continuing high levels of disability and health care use. A substantial portion of the rise in LBP care costs over the past 2 decades may be related to this rising prevalence.