title: Low literacy is associated with increased risk of hospitalization and death among individuals with heart failure.
abstract: BACKGROUND
  Low literacy increases the risk for many adverse health outcomes, but the relationship between literacy and adverse outcomes in heart failure (HF) has not been well studied.
  
  
  METHODS
  We studied a cohort of ambulatory patients with symptomatic HF (NYHA Class II-IV within the past 6 months) who were enrolled in a randomized controlled trial of self-care training recruited from internal medicine and cardiology clinics at four academic medical centers in the US. The primary outcome was combined all-cause hospitalization or death, with a secondary outcome of hospitalization for HF. Outcomes were assessed through blinded interviews and subsequent chart reviews, with adjudication of cause by a panel of masked assessors. Literacy was measured using the short Test of Functional Health Literacy in Adults. We used negative binomial regression to examine whether the incidence of the primary and secondary outcomes differed according to literacy.
  
  
  RESULTS
  Of the 595 study participants, 37 % had low literacy. Mean age was 61, 31 % were NYHA class III/IV at baseline, 16 % were Latino, and 38 % were African-American. Those with low literacy were older, had a higher NYHA class, and were more likely to be Latino (all p < 0.001). Adjusting for site only, participants with low literacy had an incidence rate ratio (IRR) of 1.39 (95 % CI: 0.99, 1.94) for all-cause hospitalization or death and 1.36 (1.11, 1.66) for HF-related hospitalization. After adjusting for demographic, clinical, and self-management factors, the IRRs were 1.31 (1.06, 1.63) for all-cause hospitalization and death and 1.46 (1.20, 1.78) for HF-related hospitalization.
  
  
  CONCLUSIONS
  Low literacy increased the risk of hospitalization for ambulatory patients with heart failure. Interventions designed to mitigate literacy-related disparities in outcomes are warranted.
authors.affiliation: School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7460, USA. jiarongw@email.unc.edu
authors.forename: Jia-Rong
authors.initials: JR
authors.lastname: Wu
authors.forename: George M
authors.initials: GM
authors.lastname: Holmes
authors.forename: Darren A
authors.initials: DA
authors.lastname: DeWalt
authors.forename: Aurelia
authors.initials: A
authors.lastname: Macabasco-O'Connell
authors.forename: Kirsten
authors.initials: K
authors.lastname: Bibbins-Domingo
authors.forename: Bernice
authors.initials: B
authors.lastname: Ruo
authors.forename: David W
authors.initials: DW
authors.lastname: Baker
authors.forename: Dean
authors.initials: D
authors.lastname: Schillinger
authors.forename: Morris
authors.initials: M
authors.lastname: Weinberger
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Broucksou
authors.forename: Brian
authors.initials: B
authors.lastname: Erman
authors.forename: Christine D
authors.initials: CD
authors.lastname: Jones
authors.forename: Crystal W
authors.initials: CW
authors.lastname: Cene
authors.forename: Michael
authors.initials: M
authors.lastname: Pignone
mesh_terms: D000368:Aged; D005260:Female; D057220:Health Literacy; D006333:Heart Failure / Q000401:mortality / Q000628:therapy*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic / Q000379:methods; D011379:Prognosis; D011446:Prospective Studies; D011594:Psychometrics; D012648:Self Care / Q000379:methods*; D012959:Socioeconomic Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology