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INTERVIEWER 1: Life–

INTERVIEWER 2: Love–

INTERVIEWER 3: And health.

CHRISTOPHER SPRINGMANN: I’m Christopher Springmann, and you’re listening to Life Love & Health. How would you explain what health literacy is? Well, a typical definition goes like this. Health literacy is, quote, the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Now, while that sounds pretty straightforward as a communications issue, our next guest, Laura Andrade, understands all too well that health literacy starts with basic literacy, and then requires a complex group of reading, listening, analytical, and decision making skills, plus the ability to apply these skills the complex health situations, like the successful management of diabetes, heart disease, and chronic asthma. Laura, thanks so much for joining us today on Life Love & Health.

LAURA ANDRADE: Thanks so much for having me. I’m looking forward to our conversation.

CHRISTOPHER SPRINGMANN: Laura Andrade is the director of education services at Hayes Incorporated, which was created in response to a growing need in the health care industry for evidence-based assessments of health technologies. Laura, please tell me about your work at Hayes Incorporated, and give us a bit of perspective, too, about the services that Hayes, Inc. Provides. First of all, let’s talk about Hayes.

LAURA ANDRADE: Hayes is an independent health technology and comparative research and consulting company that was founded by Doctor Winifred Hayes in 1898. We’re dedicated to promoting better health outcomes through the use of evidence. And by evidence I mean that we evaluate published scientific data, and then we use that information to help our clients make informed health care decisions. For example, we might review the available evidence about a particular therapy or technology, and then, based on that analysis, we can rate the different options for our clients. As part of the education services team at Hayes, I help create and deliver educational activities for health care professionals.

CHRISTOPHER SPRINGMANN: Please tell me, Laura, typically, who are your clients?

LAURA ANDRADE: Hayes’ clients include hospitals, health systems and their clinicians, as well as health plans, government agencies, and even patients.

CHRISTOPHER SPRINGMANN: People and institutions who need to make well-informed decisions that have an enormous impact, not only on the bottom line, but also on patient care.

LAURA ANDRADE: Yes, definitely.

CHRISTOPHER SPRINGMANN: Tell me, what was the motivation for doing this research on health literacy?

LAURA ANDRADE: It’s really well known that poor health literacy is a huge problem in the United States health care system. And these days, health literacy is also the focus of unprecedented attention from government officials, hospitals, insurers, and you see it in the popular media all the time. We understand the crisis that the US health care system is experiencing in regard to managing limited resources while ensuring that every patient receives high quality of care. So we really believe that improving health literacy, and health communication in general, is an essential part of the solution for our clients, and also, frankly, for our society as a whole.

CHRISTOPHER SPRINGMANN: Managing limited resources while ensuring that every patient receives high quality care and the best outcomes, that must be an extraordinarily balancing act for your clients. By the way, at the top of the show, I defined health literacy. How did I do?

LAURA ANDRADE: You did a great job. And it is a monumental task for our clients. Your definition was fantastic. I’ll simplify it just a little bit for ease of use. Health literacy is just the ability to obtain, understand, and use health care information.

And while we’re defining terms, I want to make sure that everyone listening understands the difference between reading literacy and health literacy, because the terms aren’t synonymous, but sometimes they’re used interchangeably. Although the ability to read can be part of health literacy, it’s not the only, or even the most essential part. Health literacy involves a much more complex set of skills, and it includes reading, writing, listening, speaking, analyzing unfamiliar information that might be written or numerical.

And then, in addition, health literacy includes the ability to apply those skills to make health care decisions, and sometimes to perform medical tasks, or even modify behavior. I hope you can see that even a Shakespearian professor with excellent reading literacy might have low health literacy. Health literacy really varies by context and setting, and it’s not necessarily related to years of education or actual reading ability. So even highly educated people can be affected by low health literacy if they’re stressed or if they’re sick.
And one example– I don’t know if you remember, a few years ago, when former New York mayor Rudolph Giuliani initially thought he was cancer free, when his doctor told them that his prostate biopsy was, quote, positive, when in medical terms, and in actuality, a positive biopsy indicates the presence of cancer. So it was actually bad news.

CHRISTOPHER SPRINGMANN: And under the circumstances, and it’s not surprising, sometimes people hear what they want to hear. And assumptions are like good intentions. They don’t always produce great results. Tell me, what do your clients need and want to know about what you and Hayes have learned about health literacy and the economic social and personal impact that it has on people’s lives and the lives of institutions?

LAURA ANDRADE: It’s a great question. We’re all really interested in improving individual and public health while being fiscally responsible, and we all need and want to be a part of a solution. I believe that the greatest responsibility actually lies with the health care professionals, which are people like our clients. And what really matters most to us, both professionally and personally, is that we use all of our combined knowledge, not just to help patients obtain and understand health care information and health care services, but to help patients actually act on that health care information. We want to empower patients to take action that will improve their health.

CHRISTOPHER SPRINGMANN: There are consequences of not doing this right. And when I say not doing this, not really understanding health literacy and what needs to be done, especially from a patient standpoint. Let’s take a simple example– well, that’s a complicated example– of hospitalizations for diabetes, and I’m reading a report by the US Department of Health and Human Services and the Agency for Healthcare Research and Quality.

They say hospitalizations for diabetes complications are generally considered preventable with high quality health care and– listen to this– patient adherence to treatment. Clinical studies suggest that prevention activities, including quality outpatient care and greater patient self-management of diabetes, may prevent or reduce the prevalence of cardiovascular disease, lower extremity amputations, which are really an epidemic in this country, and multiple, and I will add the word, expensive hospitalizations associated with diabetes. So the consequences and the outcomes of patients’ care and therapy are directly related, often, to their not only understanding of what needs to be done, but their willingness to participate actively, and in a very, very committed way to the program. Is that a fairly accurate observation on my part?

LAURA ANDRADE: Yes, I would say that is accurate. We have to be a little bit careful, because there are a lot of subjective and anecdotal bits of evidence out there, and they can easily get put together into some of those statements. But by far, the vast majority of what you said is true, based on the evidence that we have, or based on the information that we have at this time.

It gets really complicated, though, when you’re evaluating that sort of thing, because people with chronic conditions, particularly something like diabetes, they have so many different factors that are going into their health care. And to treat them, and to get better outcomes for them, it often involves a lot of things. And health literacy is certainly one of those things, but we just want to be a little bit careful that we don’t oversimplify it and say, better health literacy will result in lower– everything will be better. Because it’s a little bit more complex than that.

CHRISTOPHER SPRINGMANN: Yes, you’re absolutely right. And I’m very, very glad you brought that up, because one and one very often do not make two in terms of cause and effect. There are also issues of access to health care and disparities, level of education, economics, lots of things to consider. But this is a very nice segue into a related question. Why do Hayes Incorporated clients count on you, on you, to realize, analyze, and deliver this information? What does Hayes, Inc. bring to the party?

LAURA ANDRADE: Well, our clients use our health technology assessment and comparative effectiveness services because, number one, they trust us to provide unbiased, accurate, evidence-based information. And then they can use that information to make well-informed health care and coverage decisions for patients that depend on them.

CHRISTOPHER SPRINGMANN: And there’re huge economic consequences to making the right decision. I would suspect, too– and I need some help, too– in terms of dealing with the information overload and conflicting data, that must be an extremely valuable part of what you provide to people. Not only doing the research and the analysis, but also carefully defining the issues in terms that people can readily understand and then act upon. Once again, am I close to the truth there?

LAURA ANDRADE: Absolutely. I think you really nailed it.

CHRISTOPHER SPRINGMANN: Now Hayes, Incorporated is a private, independent company, and it’s very autonomous. And my understanding is that you are not influenced by manufacturers like pharmaceutical companies, or medical device companies, or other special interests, which would create a pretty intolerable conflict of interest. Tell us about that.

LAURA ANDRADE: That’s one thing that’s really unique about Hayes. It’s something that we’re very proud of. We’re completely and totally independent, and a lot of times companies like us will get financial support from pharmaceutical companies, or medical device companies, and things like that. And that helps them cover their expenses. And there’s nothing wrong with that. It’s one way of doing it.

But we don’t do that, and we’re very, very careful to never do that. And we don’t do anything that might even create a perception of a conflict of interest.

CHRISTOPHER SPRINGMANN: It sounds like a fair comparison, on the consumer side, would be to Consumer Reports, another organization that values its autonomy. In fact, when they review products, they actually go out to the big box stores, or to an automobile dealership, and they actually buy the product, or the vehicles, as the case may be, and then test it. Well, they apparently– they don’t rely on, and they don’t, I guess, trust manufacturers to supply them with a sample of the product, because, otherwise, how would they know?

We’ll be right back with more of our interview on health literacy with Laura Andrade, director of education services at Hayes, Incorporated. Learn more at their website, hayesinc.com. That’s H-A-Y-E-S-I-N-C.com. I’m Christopher Springmann, and you’re listening to Life Love & Health.

INTERVIEWER 1: Life–

INTERVIEWER 2: Love–

INTERVIEWER 3: And health.

CHRISTOPHER SPRINGMANN: Health literacy has never been more important in American health care, especially now, if we want patients to take a larger role and more responsibility for their treatment. In fact, research links low health literacy to poorer health outcomes, higher rates of hospitalization and costs, and lower use of preventative services. For example, the Wall Street Journal reports that studies of heart attack patients show that patients who don’t fill prescriptions to help prevent another heart attack have a higher rate of death one year later. These are just some of the health literacy concerns of our guest, Laura Andrade, the director of education services at Hayes, Incorporated, which was created in response to a growing need in the health care industry for evidence-based assessments of health technologies.

As more Americans, Laura, join the health care system, a simple fact, coupled with the rise of chronic, challenging to manage conditions like, as we indicated before, asthma, diabetes, and heart disease, there is a push for patients to take more responsibility to take care of themselves, which one critic suggested was really a perfect storm scenario. Now, health literacy is not an intellectual exercise. It’s an economic and social necessity, which is a very interesting way to describe health literacy. Would you agree with that?

LAURA ANDRADE: Yes, I definitely would. A decade ago, the problem with health literacy was primarily discussed among academic researchers and university settings. But now we have popular media reporting on health literacy issues. And better health literacy has really become a component of health care quality improvement.

They might not remember the name, but everybody knows about the Patient Protection and Affordability Care Act that became law in March of 2010, and that’s health care reform. And that includes bits on patient-shared decision making. It includes bits on education and clearer language.

And then we have all sorts of other government mandates that’re coming around, like the National Act to Improve Health Literacy. And then there’s another one called the Plain Writing Act. And I’ll stop with the acts, but the bottom line is that we have a really large societal problem. And I completely agree that a solution is essential for American health care.

CHRISTOPHER SPRINGMANN: I think we’ve defined health literacy pretty accurately. And we’ve certainly discussed, in great detail, what the social, economic, and patient outcome and consequences issues are. So let’s move on to how hospitals and physicians are dealing with these issues in terms of educating their staff on how to better communicate with patients. Essentially, patients have a tendency, after a diagnosis, to move very rapidly to the treatment stage, and that isn’t necessarily the best idea. What are your thoughts about that in terms of hospitals, and physicians, and patients doing a better job communicating?

LAURA ANDRADE: Yes, absolutely. I think there’s just a ton of work to be done. And as I said earlier, I personally believe that the greatest responsibility lies with the health care professionals. Many medical professionals tend to have their own culture and their own jargon, their own language, so to speak, and as you said it’s a foreign language.

CHRISTOPHER SPRINGMANN: Well, Greek and Latin are not familiar to most people, especially medical terms.
LAURA ANDRADE: Exactly. Greek and Latin, they’re foreign languages that aren’t really used that much anymore. And then there’s other problems with language. For example, in the medical community, people use the words like risk, and probability, and range, and those types of things, all the time. But sometimes those need to be defined for patients.

And then there’s other words that we also use commonly, like diet, and that can have multiple meanings. So a clinician might be asking about diet, and they’re meaning, what specific foods do you eat, while the patient’s mind immediately goes to going on a diet, and I need to eat less and exercise more type of thing. And so there’s all sorts of room for miscommunication.

CHRISTOPHER SPRINGMANN: Well, let me interrupt you for just a moment. Even a simple directive, like take this medication, Laura, four times daily, can be confusing without further explanation. How does it work? Even the simplest of instructions can be very complicated in terms of how people, I would assume, do their best to adhere to the instructions.

LAURA ANDRADE: That is a really good example. Take this medication four times daily, it illustrates some of the ways that things break down, because the pharmacist likely will say, do you understand these directions? And the patient will say, yes. They’re easy directions. Of course I understand to take it four times daily.

It’s when the patient gets home, and then they think, well, is that every six hours? Does that mean I have to get up in the middle of the night to take it? How am I going to keep track of it?

There are all sorts of questions like that. And there are so many factors that come into play. And it’s really important that we, as health care professionals, think about those things, and we set the patient up for success, as opposed to expecting the patient to call from home and say, what does this really mean? Can you help me with these directions? We need to set the patient up for success from the start.

Another interesting thing that we’re doing at Hayes, and we’re seeing some of our clients do as well, is really stolen from the education field. Have you ever heard of the five Ps?

CHRISTOPHER SPRINGMANN: No, but I think I’m going to.

LAURA ANDRADE: It’s a neat concept. The five Ps are just purpose, personal, prior knowledge, predict, and paraphrase, which I know is a mouthful. But the idea is that if you can hit all five of those things when talking with a patient or explaining something to them, then they’ll probably not only retain the information better, but then they’ll be in a better position to act about it.

So just to give you an example, consider a patient with high blood pressure. Typically he understands the condition. He also, typically, will understand the purpose of lowering his blood pressure. He probably understands what he needs to do in terms of lifestyle changes and/or medications. And then he might even have prior knowledge about a friend with high blood pressure, or he might have even been frightened by something like a heart attack. And so that’s a lot of the Ps.

So the person understands the purpose. It’s very personal, because this person is going through it themselves. They typically can link the information to some sort of prior knowledge. They can predict what’s going to happen if they don’t take care of the problem. And then, also, they can usually paraphrase, or the physician or clinician can help them paraphrase it.

And then what we’ve found is that if you hit all five of those things, that helps the patient so that they can hit the most important thing. And that’s the belief that they have the capacity to actually change their behavior. What we’ve found is that if the patient understands the five Ps, he also has to actually see some change and success over time. And then that will make a successful outcome.

CHRISTOPHER SPRINGMANN: Essentially, what you’re discussing, Laura, is context, putting the diagnosis or the disease in a much larger context. And this segues into another very simple fact. I read a report by the US Department of Health and Human Services– I actually quoted them earlier– that providers’ communication style and attitude, and we’re talking about attitude here, in terms of how people communicate, are major factors in nearly– and I found this startling, but shouldn’t have– 75% percent of malpractice suites are the result of a bad attitude, or an attitude that doesn’t please the patient, and a communication style that doesn’t work. Maybe I shouldn’t be startled. But what are your thoughts, Laura?

LAURA ANDRADE: I think it is startling. But I also think it’s true, and I think that the whole industry is having to change the way that they think. You really hit on something.

CHRISTOPHER SPRINGMANN: Now when you talk about the industry, you mean the health care industry.

LAURA ANDRADE: The health care industry, yes, and the attitude of health care professionals. In the past, we really had this top down feeling, where a patient would go to the doctor, and the doctor would tell them what was wrong and what they needed to do, and they listened to that. And now–

CHRISTOPHER SPRINGMANN: The old doctor knows best attitude.

LAURA ANDRADE: Yes, that doctor knows best attitude. And now, we’re really shifting to more of a patient-centered focus. We’re trying to make it easier for patients to be a part of their decision making process. And when I say a part of, I mean an equal part of.

So they want the physician’s skills, and knowledge, and experience, but that’s just part– his opinion, and his thoughts, are just part of the decision making process instead of the end all.

CHRISTOPHER SPRINGMANN: Tell me, Laura. Is there strong, clear, supportive evidence linking economics with levels of health literacy?

LAURA ANDRADE: Well, no, there’s really not. Everyone would like it, and I wish that there was, but that really high quality evidence just isn’t available yet. The relationship between health literacy and health economics is really complex. It’s not so different than the relationship that we talked about before between health literacy and health outcomes. And it’s nearly impossible to isolate a specific cause and effect.
The few studies that are available tend to have many limitations. But that said, there are a bunch of small studies out there that suggest a correlation between low literacy and higher cost of care. So one example I can give you is from a small study that looked at patients with below a third grade reading level or above a third grade reading level. And then they looked at the mean cost of charges for those patients. And the patients with the low reading literacy level where $11,000 compared to $3,000 for the patients with the higher reading level. The key to this sort of information is you have to view it with a little bit of a grain of salt and a little bit of caution, because the studies are small. But the information is certainly suggested, and I think, over time, we’ll get more definitive evidence. But at this point, the answer to your question is we still have a lot to learn.

CHRISTOPHER SPRINGMANN: Well, we mentioned at the beginning of the show that the basis for health literacy, or financial literacy, as the case may be, is basic literacy. That is the core. That is the foundation. That’s where it all starts. And it would seem to make sense.

Also, highly motivated individuals who have a big picture view of the world, and have a sense of hope, who also engage family members in the process– those people have a tendency to do fairly well, because they take all this seriously. And there are individuals in their lives who are counting on them, so people have an increased sense of not only accountability, but responsibility. Do you think that’s a reasonable conclusion on my part?

LAURA ANDRADE: Absolutely. It goes back to the community effect. You’ve got the patient. You’ve got the health care system. You have the clinicians, and the patient’s family, and all the people that care about them. All of those things have to come together in order for us to solve the larger problem that we’re seeing.

CHRISTOPHER SPRINGMANN: It has just been an absolute joy, and frankly, a great educational experience for me, and very illuminating, to discuss health literacy with you today.

LAURA ANDRADE: It was my pleasure. Thanks so much for having me.

CHRISTOPHER SPRINGMANN: For more information about Laura Andrade’s work as director of education services at Hayes, Incorporated, go to hayesinc.com. That’s H-AY-E-S-I-N-C.com. I’m Christopher Springmann, and you’re listening to Life Love & Health.

INTERVIEWER 1: Life–

INTERVIEWER 2: Love–

INTERVIEWER 3: And health.