title: Numeracy and literacy independently predict patients' ability to identify out-of-range test results.
abstract: BACKGROUND
  Increasing numbers of patients have direct access to laboratory test results outside of clinical consultations. This offers increased opportunities for both self-management of chronic conditions and advance preparation for clinic visits if patients are able to identify test results that are outside the reference ranges.
  
  
  OBJECTIVE
  Our objective was to assess whether adults can identify laboratory blood test values outside reference ranges when presented in a format similar to some current patient portals implemented within electronic health record (EHR) systems.
  
  
  METHODS
  In an Internet-administered survey, adults aged 40-70 years, approximately half with diabetes, were asked to imagine that they had type 2 diabetes. They were shown laboratory test results displayed in a standard tabular format. We randomized hemoglobin A1c values to be slightly (7.1%) or moderately (8.4%) outside the reference range and randomized other test results to be within or outside their reference ranges (ie, multiple deviations). We assessed (1) whether respondents identified the hemoglobin A1c level as outside the reference range, (2) how respondents rated glycemic control, and (3) whether they would call their doctor. We also measured numeracy and health literacy.
  
  
  RESULTS
  Among the 1817 adult participants, viewing test results with multiple deviations increased the probability of identifying hemoglobin A1c values as outside the reference range (participants with diabetes: OR 1.47, 95% CI 1.12-1.92, P=.005; participants without diabetes: OR 1.50, 95% CI 1.13-2.00, P=.005). Both numeracy and health literacy were significant predictors of correctly identifying out-of-range values. For participants with diabetes, numeracy OR 1.32 per unit on a 1-6 scale (95% CI 1.15-1.51, P<.001) and literacy OR 1.59 per unit of a 1-5 scale (95% CI 1.35-1.87, P<.001); for participants without diabetes, numeracy OR 1.36 per unit (95% CI 1.17-1.58, P<.001) and literacy OR 1.33 per unit (95% CI 1.12-1.58, P=.001). Predicted probabilities suggested 77% of higher numeracy and health literacy participants, but only 38% of lower numeracy and literacy participants, could correctly identify the hemoglobin A1c levels as outside the reference range. Correct identification reduced perceived blood glucose control (mean difference 1.68-1.71 points on a 0-10 scale, P<.001). For participants with diabetes, increased health literacy reduced the likelihood of calling one's doctor when hemoglobin A1c=7.1% (OR 0.66 per unit, 95% CI 0.52-0.82, P<.001) and increased numeracy increased intention to call when hemoglobin A1c=8.4% (OR 1.36 per unit, 95% CI 1.10-1.69, P=.005).
  
  
  CONCLUSIONS
  Limited health literacy and numeracy skills are significant barriers to basic use of laboratory test result data as currently presented in some EHR portals. Regarding contacting their doctor, less numerate and literate participants with diabetes appear insensitive to the hemoglobin A1c level shown, whereas highly numerate and literate participants with diabetes appear very sensitive. Alternate approaches appear necessary to make test results more meaningful.
authors.affiliation: Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, United States. bzikmund@umich.edu.
authors.forename: Brian J
authors.identifier: http://orcid.org/0000-0002-1637-4176
authors.initials: BJ
authors.lastname: Zikmund-Fisher
authors.forename: Nicole L
authors.identifier: http://orcid.org/0000-0001-8864-8327
authors.initials: NL
authors.lastname: Exe
authors.forename: Holly O
authors.identifier: http://orcid.org/0000-0003-4192-0682
authors.initials: HO
authors.lastname: Witteman
mesh_terms: D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000032:analysis; D003625:Data Collection; D003924:Diabetes Mellitus, Type 2 / Q000097:blood*; D057286:Electronic Health Records; D005260:Female; D006442:Glycated Hemoglobin; D057220:Health Literacy; D055991:Health Records, Personal; D006801:Humans; D020407:Internet; D008297:Male; D055641:Mathematical Concepts; D008875:Middle Aged; D012648:Self Care
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin
keywords: electronic health records; literacy; numeracy; patient education as topic