title: The relationship between functional health literacy and the use of the health system by diabetics in Switzerland.
abstract: BACKGROUND
  Observational studies from the USA have suggested that patients with low health literacy (HL) have higher health care costs and use an inefficient mix of health care services. To date, there were no studies from Europe that investigated the impact of HL on the use of the health system. The purpose of this study was to measure functional HL among persons having type 2 diabetes and to investigate the relationship between functional HL and health care costs and utilization.
  
  
  METHODS
  The study population were insured persons of the basic health insurance plan of the largest health insurer in Switzerland. Persons selected for participation had been reimbursed for diabetes medications in 2010-11, were aged 35-70 years and did not live in a long-term care institution. The level of functional HL was measured by one screening question. The following dependent variables were used: total costs, outpatient costs, inpatient costs, days admitted and number of physician visits attended. All multiple regression analyses were adjusted for age, gender, education, duration of diabetes, treatment with insulin (yes/no) and other chronic disease (yes/no).
  
  
  RESULTS
  High levels of functional HL were associated with lower total costs (P = 0.007), lower outpatient costs (P = 0.004) and less physician visits (P = 0.001). In the standard insurance plan with free access to all health professionals subgroup, the effects found were more pronounced.
  
  
  CONCLUSIONS
  Persons with low functional HL need extra medical support, and therefore have higher health care costs.
authors.affiliation: 1 Helsana Insurance Company Ltd, Zurich, Switzerland jasmin.franzen@helsana.ch.
authors.forename: Jasmin
authors.initials: J
authors.lastname: Franzen
authors.affiliation: 2 Institute of Communication & Health, University of Lugano, 6900 Lugano, Switzerland.
authors.forename: Sarah
authors.initials: S
authors.lastname: Mantwill
authors.affiliation: 1 Helsana Insurance Company Ltd, Zurich, Switzerland.
authors.forename: Roland
authors.initials: R
authors.lastname: Rapold
authors.affiliation: 2 Institute of Communication & Health, University of Lugano, 6900 Lugano, Switzerland.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Schulz
mesh_terms: D000328:Adult; D000368:Aged; D015897:Comorbidity; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D005260:Female; D057220:Health Literacy; D006296:Health Services / Q000706:statistics & numerical data*; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use*; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D013557:Switzerland
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin