title: Is low health literacy associated with increased emergency department utilization and recidivism?
abstract: OBJECTIVE
  The objective was to determine whether patients with low health literacy have higher emergency department (ED) utilization and higher ED recidivism than patients with adequate health literacy.
  
  
  METHODS
  The study was conducted at an urban academic ED with more than 95,000 annual visits that is part of a 13-hospital health system, using electronic records that are captured in a central data repository. As part of a larger, cross-sectional, convenience sample study, health literacy testing was performed using the short test of functional health literacy in adults (S-TOFHLA) and standard test thresholds identifying those with inadequate, marginal, and adequate health literacy. The authors collected patients' demographic and clinical data, including items known to affect recidivism. This was a structured electronic record review directed at determining 1) the median number of total ED visits in this health system within a 2-year period and 2) the proportion of patients with each level of health literacy who had return visits within 3, 7, and 14 days of index visits. Descriptive data for demographics and ED returns are reported, stratified by health literacy level. The Mantel-Haenszel chi-square was used to test whether there is an association between health literacy and ED recidivism. A negative binomial multivariable model was performed to examine whether health literacy affects ED use, including variables significant at the 0.1 alpha level on bivariate analysis and retaining those significant at an alpha of 0.05 in the final model.
  
  
  RESULTS
  Among 431 patients evaluated, 13.2% had inadequate, 10% had marginal, and 76.3% had adequate health literacy as identified by S-TOFHLA. Patients with inadequate health literacy had higher ED utilization compared to those with adequate health literacy (p = 0.03). Variables retained in the final model included S-TOFHLA score, number of medications, having a personal doctor, being a property owner, race, insurance, age, and simple comorbidity score. During the study period, 118 unique patients each made at least one return ED visit within a 14-day period. The proportion of patients with inadequate health literacy making at least one return visit was higher than that of patients with adequate health literacy at 14 days, but was not significantly higher within 3 or 7 days.
  
  
  CONCLUSIONS
  In this single-center study, higher utilization of the ED by patients with inadequate health literacy when compared to those with adequate health literacy was observed. Patients with inadequate health literacy made a higher number of return visits at 14 days but not at 3 or 7 days.
authors.affiliation: The Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO.
authors.forename: Richard T
authors.initials: RT
authors.lastname: Griffey
authors.forename: Sarah K
authors.initials: SK
authors.lastname: Kennedy
authors.forename: Lucy
authors.initials: L
authors.lastname: D'Agostino McGowan
authors.forename: Lucy
authors.initials: L
authors.lastname: McGownan
authors.forename: Melody
authors.initials: M
authors.lastname: Goodman
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Kaphingst
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D057220:Health Literacy; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D006786:Hospitals, Urban; D006801:Humans; D008297:Male; D008875:Middle Aged