title: Patients With Limited Health Literacy Ask Fewer Questions During Office Visits With Hand Surgeons.
abstract: BACKGROUND
  In the midst of rapid expansion of medical knowledge and decision-support tools intended to benefit diverse patients, patients with limited health literacy (the ability to obtain, process, and understand information and services to make health decisions) will benefit from asking questions and engaging actively in their own care. But little is known regarding the relationship between health literacy and question-asking behavior during outpatient office visits.
  
  
  OBJECTIVE
  (1) Do patients with lower levels of health literacy ask fewer questions in general, and as stratified by types of questions? (2) What other patient characteristics are associated with the number of questions asked? (3) How often do surgeons prompt patients to ask questions during an office visit?
  
  
  METHODS
  We audio-recorded office visits of 84 patients visiting one of three orthopaedic hand surgeons for the first time. Patient questions were counted and coded using an adaptation of the Roter Interaction Analysis System in 11 categories: (1) therapeutic regimen; (2) medical condition; (3) lifestyle; (4) requests for services or medications; (5) psychosocial/feelings; (6) nonmedical/procedural; (7) asks for understanding; (8) asks for reassurance; (9) paraphrase/checks for understanding; (10) bid for repetition; and (11) personal remarks/social conversation. Directly after the visit, patients completed the Newest Vital Sign (NVS) health literacy test, a sociodemographic survey (including age, sex, race, work status, marital status, insurance status), and three Patient-Reported Outcomes Measurement Information System-based questionnaires: Upper-Extremity Function, Pain Interference, and Depression. The NVS scores were divided into limited (0-3) and adequate (4-6) health literacy as done by the tool's creators. We also assessed whether the surgeons prompted patients to ask questions during the encounter.
  
  
  RESULTS
  Patients with limited health literacy asked fewer questions than patients with adequate health literacy (5 ± 4 versus 9 ± 7; mean difference, -4; 95% CI, -7 to -1; p = 0.002). More specifically, patients with limited health literacy asked fewer questions regarding medical-care issues such as their therapeutic regimen (1 ± 2 versus 3 ± 4; mean difference, -2; 95% CI, -4 to -1]; p < 0.001) and condition (2 ± 2 versus 3 ± 3; mean difference, -1; 95% CI, -3 to 0; p = 0.022). Nonwhite patients asked fewer questions than did white patients (5 ± 4 versus 9 ± 7; mean difference, -4; 95% CI, -7 to 0; p = 0.032). No other patient characteristics were associated with the number of questions asked. Surgeons only occasionally (29%; 24/84) asked patients if they had questions during the encounter, but when they did, most patients (79%; 19/24) asked questions.
  
  
  CONCLUSIONS
  Limited health literacy is a barrier to effective patient engagement in hand surgery care. In the increasingly tangled health-information environment, it is important to actively involve patients with limited health literacy in the decision-making process by encouraging question-asking, particularly in practice settings where most decisions are preference-sensitive. Instead of assuming that patients understand what they are told, orthopaedic surgeons may take "universal precautions" by assuming that patients do not understand unless proved otherwise.
  
  
  METHODS
  Level II, therapeutic study.
authors: Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, 800 Washington Street, TMC Box #306, Boston, MA, 02111, USA. marianofurrer@gmail.com.|Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. marianofurrer@gmail.com.
authors: Mariano E
authors: ME
authors: Menendez
authors: Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors: Bastiaan T
authors: BT
authors: van Hoorn
authors: Center for Health Communication, Moody College of Communication, The University of Texas at Austin, Austin, TX, USA.
authors: Michael
authors: M
authors: Mackert
authors: Center for Health Communication, Moody College of Communication, The University of Texas at Austin, Austin, TX, USA.
authors: Erin E
authors: EE
authors: Donovan
authors: Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors: Neal C
authors: NC
authors: Chen
authors: Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.|Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX, USA.
authors: David
authors: D
authors: Ring
mesh_terms: D000328:Adult; D000368:Aged; D003142:Communication; D032882:Comprehension; D003430:Cross-Sectional Studies; D005260:Female; D006225:Hand / Q000601:surgery*; D007722:Health Knowledge, Attitudes, Practice; D057220:Health Literacy; D006801:Humans; D008297:Male; D008875:Middle Aged; D009819:Office Visits; D000072161:Orthopedic Surgeons; D010358:Patient Participation; D010817:Physician-Patient Relations; D011795:Surveys and Questionnaires