Perspective: The Role of Numeracy in Health Care

Numeracy, the “ability to understand and use numbers in daily life” is an important but understudied component of literacy. Numeracy-related tasks are common in healthcare and include understanding nutrition information, interpreting blood sugar readings and other clinical data, adjusting medications, and understanding probability in risk communication. While literacy and numeracy are strongly correlated, we have identified many patients with adequate reading ability but poor numeracy skills. Better tools to measure numeracy and more studies to assess the unique contribution of numeracy are needed. This research can contribute to developing interventions to improve outcomes for patients with poor numeracy

Accessing primary health care: A meta-ethnography of the experiences of British South Asian patients with diabetes, coronary heart disease or a mental health problem

Objectives: To develop an explanatory framework of the problems accessing primary care health services experienced by British South Asian patients with a long-term condition or mental health problem. Methods: This study used meta-ethnographic methods. Published qualitative studies were identified from a structured search of six databases and themes synthesized across studies to develop a new explanatory framework. Results: Initial searches identified 951 potentially relevant records from which a total of 27 articles were identified that met inclusion and exclusion criteria. Twelve of these articles were chosen on the basis of their quality and relevance. These 12 articles described themes relating to the cultural, spatial and temporal dimensions of patient experiences of accessing and using health care. Our interpretive synthesis showed that access to primary care among British South Asians with diabetes, coronary heart disease and psychological health problems is co-constructed and negotiated over time and space along the key domains of the candidacy model of access: from help-seeking to interactions at the interface to following treatment advice. In the case of each condition, British South Asians’ claims to candidacy were constrained where their individual as well as broader social and cultural characteristics lacked fit with professionals’ ways of working and cultural typifications. Conclusion: Interventions that positively affect professionals’ capacity to support patient claims to candidacy are likely to help support British South Asians overcome a broad range of barriers to care for physical and mental health problems. </jats:p

Patient Navigators Connecting Patients to Community Resources to Improve Diabetes Outcomes

BACKGROUND: Despite the recognized importance of lifestyle modification in reducing risk of developing type 2 diabetes and in diabetes management, the use of available community resources by both patients and their primary care providers (PCPs) remains low. The patient navigator model, widely used in cancer care, may have the potential to link PCPs and community resources for reduction of risk and control of type 2 diabetes. In this study we tested the feasibility and acceptability of telephone-based nonprofessional patient navigation to promote linkages between the PCP office and community programs for patients with or at risk for diabetes. METHODS: This was a mixed-methods interventional prospective cohort study conducted between November 2012 and August 2013. We included adult patients with and at risk for type 2 diabetes from six primary care practices. Patient-level measures of glycemic control, diabetes care, and self-efficacy from medical records, and qualitative interview data on acceptability and feasibility, were used. RESULTS: A total of 179 patients participated in the study. Two patient navigators provided services over the phone, using motivational interviewing techniques. Patient navigators provided regular feedback to PCPs and followed up with the patients through phone calls. The patient navigators made 1028 calls, with an average of 6 calls per patient. At follow-up, reduction in HbA1c (7.8 ± 1.9% vs 7.2 ± 1.3%; P = .001) and improvement in patient self-efficacy (3.1 ± 0.8 vs 3.6 ± 0.7; P < .001) were observed. Qualitative analysis revealed uniformly positive feedback from providers and patients. CONCLUSIONS: The patient navigator model is a promising and acceptable strategy to link patient, PCP, and community resources for promoting lifestyle modification in people living with or at risk for type 2 diabetes

Narratives to enhance smoking cessation interventions among African-American smokers, the ACCE project

BACKGROUND: Low-income, African-American smokers are less likely to have resources to aid in quitting smoking. Narrative communication may provide an enhancement to traditional smoking cessation interventions like NRT, medications, or behavioral treatments for this audience. After extensive pilot testing of stories and personal experiences with smoking cessation from African-Americans from a low-income community, we conducted a randomized control trial using stories to augment routine inpatient treatment among African-Americans at an urban Southern hospital (N = 300). RESULTS: Differences in smoking cessation outcomes between the intervention (stories DVD + routine clinical treatment) and control (routine clinical treatment) arms were compared using self-report and carbon monoxide measurement at 6-months. Compared to control, individuals who viewed the intervention stories DVD reported greater intentions to quit. Although continuous quitting marginally favored the intervention, our main result did not reach statistical significance (p = 0.16). CONCLUSION: Narrative communication via storytelling to promote smoking cessation among African-Americans in the South is one method to communicate smoking cessation. Results suggest this may not be sufficient as a stand-alone augmentation of routine clinical treatment for continuous smoking cessation. Smoking cessation efforts need to continually assess different means of communicating to smokers about quitting. CLINICAL TRIALS REGISTRATION: The ClinicalTrials.gov Identifier is NCT00101491. This trial was registered January 10, 2005

Development of A Tool to Assess Resident Physicians’ Perceived Competence for Patient-centered Obesity Counseling

Physicians report a number of barriers to obesity counseling, among them low perceived competence in the ability to counsel. While there is increasing recognition of the need for resident training on counseling, implementation requires residency programs to have the necessary curricula and tools to evaluate training effectiveness. This study’s objective was to describe the development and psychometric testing of the Perceived Competence for Obesity Counseling (PCOC) scale. Items were generated based on constructs from the 5A’s counseling framework, review of the obesity literature, and expert opinion. The 20-item scale was piloted among 74 resident physicians. Exploratory factor analysis was conducted to identify the number and nature of factors in the scale.  Pearson's correlation was used to assess scale validity of the total scores and sub-scale scores association with residents’ overall confidence in counseling and outcome expectancy for obesity counseling. Analyses suggested a 3-factor solution. After the removal of cross loading items, eighteen items were retained; eleven items loaded on the first factor, four items on the second factor, and three on the third factor. Cronbach's alpha for the 18-item PCOC scale was 0.95 indicating internal consistency. The PCOC scale was significantly correlated with resident’s overall confidence in counseling (r = 0.60, p < 0.01) and outcome expectancy for obesity counseling (r = 0.41, p < 0.01). This pilot study suggests PCOC is holds promise as a valid and reliable measure of resident’s perceived competence for obesity counseling. Future studies are needed to assess the scale’s association with counseling skills

The Key Driver Implementation Scale (KDIS) for practice facilitators: Psychometric testing in the “Southeastern collaboration to improve blood pressure control” trial

Background Practice facilitators (PFs) provide tailored support to primary care practices to improve the quality of care delivery. Often used by PFs, the “Key Driver Implementation Scale” (KDIS) measures the degree to which a practice implements quality improvement activities from the Chronic Care Model, but the scale’s psychometric properties have not been investigated. We examined construct validity, reliability, floor and ceiling effects, and a longitudinal trend test of the KDIS items in the Southeastern Collaboration to Improve Blood Pressure Control trial. Methods The KDIS items assess a practice’s progress toward implementing: a clinical information system (using their own data to drive change); standardized care processes; optimized team care; patient self-management support; and leadership support. We assessed construct validity and estimated reliability with a multilevel confirmatory factor analysis (CFA). A trend test examined whether the KDIS items increased over time and estimated the expected number of months needed to move a practice to the highest response options. Results PFs completed monthly KDIS ratings over 12 months for 32 primary care practices, yielding a total of 384 observations. Data was fitted to a unidimensional CFA model; however, parameter fit was modest and could be improved. Reliability was 0.70. Practices started scoring at the highest levels beginning in month 5, indicating low variability. The KDIS items did show an upward trend over 12 months (all p < .001), indicating that practices were increasingly implementing key activities. The expected time to move a practice to the highest response category was 9.1 months for standardized care processes, 10.2 for clinical information system, 12.6 for self-management support, 13.1 for leadership, and 14.3 months for optimized team care. Conclusions The KDIS items showed acceptable reliability, but work is needed in larger sample sizes to determine if two or more groups of implementation activities are being measured rather than one

Development and validation of the Diabetes Numeracy Test (DNT)

<p>Abstract</p> <p>Background</p> <p>Low literacy and numeracy skills are common. Adequate numeracy skills are crucial in the management of diabetes. Diabetes patients use numeracy skills to interpret glucose meters, administer medications, follow dietary guidelines and other tasks. Existing literacy scales may not be adequate to assess numeracy skills. This paper describes the development and psychometric properties of the Diabetes Numeracy Test (DNT), the first scale to specifically measure numeracy skills used in diabetes.</p> <p>Methods</p> <p>The items of the DNT were developed by an expert panel and refined using cognitive response interviews with potential respondents. The final version of the DNT (43 items) and other relevant measures were administered to a convenience sample of 398 patients with diabetes. Internal reliability was determined by the Kuder-Richardson coefficient (KR-20). An <it>a priori </it>hypothetical model was developed to determine construct validity. A shortened 15-item version, the DNT15, was created through split sample analysis.</p> <p>Results</p> <p>The DNT had excellent internal reliability (KR-20 = 0.95). The DNT was significantly correlated (p < 0.05) with education, income, literacy and math skills, and diabetes knowledge, supporting excellent construct validity. The mean score on the DNT was 61% and took an average of 33 minutes to complete. The DNT15 also had good internal reliability (KR-20 = 0.90 and 0.89). In split sample analysis, correlations of the DNT-15 with the full DNT in both sub-samples was high (rho = 0.96 and 0.97, respectively).</p> <p>Conclusion</p> <p>The DNT is a reliable and valid measure of diabetes related numeracy skills. An equally adequate but more time-efficient version of the DNT, the DNT15, can be used for research and clinical purposes to evaluate diabetes related numeracy.</p

Developing a Research Agenda for Cardiovascular Disease Prevention in High-Risk Rural Communities

The National Institutes of Health convened a workshop to engage researchers and practitioners in dialogue on research issues viewed as either unique or of particular relevance to rural areas, key content areas needed to inform policy and practice in rural settings, and ways rural contexts may influence study design, implementation, assessment of outcomes, and dissemination. Our purpose was to develop a research agenda to address the disproportionate burden of cardiovascular disease (CVD) and related risk factors among populations living in rural areas. Complementary presentations used theoretical and methodological principles to describe research and practice examples from rural settings. Participants created a comprehensive CVD research agenda that identified themes and challenges, and provided 21 recommendations to guide research, practice, and programs in rural areas

Disparities in Postdischarge Ambulatory Care Follow‐Up Among Medicaid Beneficiaries With Diabetes, Hospitalized for Heart Failure

Background Ambulatory follow‐up for all patients with heart failure (HF) is recommended within 7 to 14 days after hospital discharge to improve HF outcomes. We examined postdischarge ambulatory follow‐up of patients with comorbid diabetes and HF from a low‐income population in primary and specialty care. Methods and Results Adults with diabetes and first hospitalizations for HF, covered by Alabama Medicaid in 2010 to 2019, were included and the claims analyzed for ambulatory care use (any, primary care, cardiology, or endocrinology) within 60 days after discharge using restricted mean survival time regression and negative binomial regression. Among 9859 Medicaid‐covered adults with diabetes and first hospitalization for HF (mean age, 53.7 years; SD, 9.2 years; 47.3% Black; 41.8% non‐Hispanic White; 10.9% Hispanic/Other [Other included non‐White Hispanic, American Indian, Pacific Islander and Asian adults]; 65.4% women, 34.6% men), 26.7% had an ambulatory visit within 0 to 7 days, 15.2% within 8 to 14 days, 31.3% within 15 to 60 days, and 26.8% had no visit; 71% saw a primary care physician and 12% a cardiology physician. Black and Hispanic/Other adults were less likely to have any postdischarge ambulatory visit (P<0.0001) or the visit was delayed (by 1.8 days, P=0.0006 and by 2.8 days, P=0.0016, respectively) and were less likely to see a primary care physician than non‐Hispanic White adults (adjusted incidence rate ratio, 0.96 [95% CI, 0.91–1.00] and 0.91 [95% CI, 0.89–0.98]; respectively). Conclusions More than half of Medicaid‐covered adults with diabetes and HF in Alabama did not receive guideline‐concordant postdischarge care. Black and Hispanic/Other adults were less likely to receive recommended postdischarge care for comorbid diabetes and HF