Health Literacy and Outcomes Among Patients With Heart Failure

Study Questions:

Does low health literacy impact heart failure (HF) outcomes?


This was a retrospective cohort study of 2,156 eligible outpatients with HF of any etiology at Kaiser Permanente of Colorado. Patients had to have had at least one hospitalization with a primary diagnosis of HF, two discharges with HF as a secondary diagnosis in the setting of another primary cardiovascular discharge diagnosis, or ≥3 emergency room visits with a HF diagnosis. Eligible patients received a health literacy questionnaire via mail. Literacy test questions were scored on a 5-point scale and included: 1) How often does someone help you read hospital materials?, 2) How often do you have problems learning about your condition due to difficulty understanding hospital material?, and 3) How confident are you with filling out forms by yourself? The primary outcome of interest was mortality and all-cause hospitalization in low literacy (literacy test score >10) versus adequate literacy (score ≤10) patients obtained using Cox proportional hazards modeling.


A total of 1,494 patients completed at least one questionnaire with a median (interquartile range [IQR]) follow-up of 1.2 [0.25-1.3] years. Low health literacy patients (17.5%, n = 262) were older, of lower socioeconomic status, and had more comorbidities (e.g., psychiatric, diabetes, dementia) than those with adequate literacy. Patients with low health literacy had nearly a twofold higher adjusted risk (hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.3-3.0) of death than adequate literacy patients. There was no association between health literacy and all-cause hospitalization (adjusted HR, 1.05; 95% CI, 0.8-1.4).


The authors concluded that low health literacy was associated with higher all-cause mortality in this cohort of patients.


The authors demonstrated that low health literacy doubles the risk of death in HF. A major cause for rehospitalization after hospital discharge is patient ‘nonadherence.’ Although no difference in hospitalizations was noted between literacy groups, this study raises the question of whether ‘nonadherence’ to recommended HF therapies (and therefore poor HF outcomes) is simply a function of a patient’s ‘lack of understanding.’ While the appropriate statistical adjustments were performed for baseline differences between the groups, the low health literacy patients clearly had the odds stacked up against them—more dementia, more psychiatric illness, less education, lower incomes, and much higher requirement for hospice or nursing care. These obstacles will be hard to conquer in the outpatient setting, and only a handful of studies have demonstrated morbidity and mortality benefits with intensive HF education in ‘at-risk’ groups.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Follow-Up Studies, Health Literacy, Heart Failure, Colorado, Questionnaires, Hospitalization

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