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Previous research shows that Black and Hispanic patients have longer ED wait times than White patients, but these data do not reflect recent changes such as the Affordable Care Act. In addition, previous research does not account for the non-normal distribution of wait times, wherein a sizable subgroup of patients seen promptly and those not seen promptly experience long wait times. We utilized National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets (2013–2017) to examine mean ED wait time comparing visits by Black, Hispanic, and Asian patients to White patients. Using a two-part regression model, we adjusted for patient, hospital, and health system factors, and estimated differences, for each of five triage levels, in (a) likelihood of waiting at least 5 min and (b) difference in wait time among those not seen promptly. Our cohort included 38,800 White, 14,838 Black, 10,619 Hispanic, and 1257 Asian patient visits. Black (triage level 3) and Hispanic (triage levels 3 and 4) patients had longer mean wait times than White patients. Adjusted likelihood of not being seen promptly was lower among Blacks (triage levels 3, 4 and 5), Hispanics (triage level 5) and Asians (triage level 5) compared to Whites. Among those waiting at least 5 min, adjusted wait time was longer among Blacks in triage level 3 (5.2 min, 95% CI, 1.3 to 9.0) and level 4 (2.5 min, 95% CI, 0.2 to 4.9), Hispanics in triage level 4 (4.7 min, 95% CI, 1.7 to 7.7) and Asians in triage level 5 (16.3 min, 95% CI, 0.6 to 31.9) compared to Whites. Minority patients were less likely to wait to be seen, but waited longer if not seen promptly. These data exhibit that ED wait time disparities persist for African American and Hispanic patients and extend this observation to Asian patients.

Health literacy (HL) is the extent to which individuals have the capacity to obtain, process, and understand basic health information that is needed to make appropriate health decisions. As adults with inflammatory bowel disease engage in complex health decisions throughout their lives, attention is needed regarding the influence of HL on the lives of people with inflammatory bowel disease. About one-third of adults in the United States have limited HL. Limited HL is a potentially modifiable risk factor that has been associated with barriers to patient–provider communication and worse health outcomes for people with a range of chronic diseases. Gastroenterologists must recognize the role of HL in their practice. Limited HL can affect a patient's ability to understand the purpose of a screening test for colorectal cancer, understand the concept of an asymptomatic yet chronic disease, ask questions in an office visit and engage in shared decision making. Gastroenterologists must approach each patient as potentially having limited HL and use clear communication strategies in all encounters. Currently, there is a lack of training, education, and support for health care providers to meet the needs of patients with limited HL. More research is needed in inflammatory bowel disease to understand the impact of limited health literacy on health outcomes in this population and develop effective systems-based interventions to reduce the health literacy burden on patients.

Objective: To provide an evidence-based review of plausible causal pathways that could best explain well-established associations between limited health literacy and health outcomes.Methods: Through analysis of current findings in medical and public health literature on health literacy we derived a conceptual causal model.Results: Health literacy should be viewed as both a patient and a system phenomenon. Three distinct points along a continuum of health care are suggested to be influenced by health literacy: (1) access and utilization of health care, (2) patient-provider relationship, and (3) self-care.Conclusions: The conceptual model organizes what has been learned to date and underscores promising areas of future inquiry and intervention.

Digital family health history tools have been developed but few have been tested with non-English speakers and evaluated for acceptability and usability. This study describes the cultural and linguistic adaptation and evaluation of a family health history tool (VICKY: VIrtual Counselor for Knowing Your Family History) for Spanish speakers. In-depth interviews were conducted with 56 Spanish-speaking participants; a subset of 30 also participated in a qualitative component to evaluate the acceptability and usability of Spanish VICKY. Overall, agreement in family history assessment was moderate between VICKY and a genetic counselor (weighted kappa range: 0.4695 for stroke—0.6615 for heart disease), although this varied across disease subtypes. Participants felt comfortable using VICKY and noted that VICKY was very likeable and possessed human-like characteristics. They reported that VICKY was very easy to navigate, felt that the instructions were very clear, and thought that the time it took to use the tool was just right. Spanish VICKY may be useful as a tool to collect family health history and was viewed as acceptable and usable. The study results shed light on some cultural differences that may influence interactions with family history tools and inform future research aimed at designing and testing culturally and linguistically diverse digital systems.

While cancer prevention behaviors have been clearly defined, many people do not engage in these risk-reduction behaviors. Factors such as cancer prevention beliefs and limited health literacy may undermine cancer prevention behavior recommendations. This study explored the relationships between cancer prevention beliefs, health literacy, and cancer prevention behaviors. Data were analyzed from the 2013 Health Information National Trends Survey (n = 1675). Regression analyses for four cancer prevention belief (prevention is not possible, cancer is fatal, there are too many recommendations for prevention, everything causes cancer) statements were modeled, including health literacy and sociodemographic variables as predictors. In addition, separate regression analyses predicted four cancer prevention behaviors (fruit and vegetable consumption, physical activity, cigarette smoking) from cancer prevention beliefs, health literacy, and sociodemographic variables. Participants with low health literacy were more likely to hold fatalistic cancer prevention beliefs than those with higher health literacy. Cancer prevention beliefs were related to less fruit and vegetable consumption, fewer days of physical activity, and with being a nonsmoker after controlling for sociodemographic variables. Health literacy was not a significant predictor of cancer prevention behaviors. Given the relationship between health literacy and cancer prevention beliefs, research is needed to ascertain how to empower patients with low health literacy to have a more realistic understanding of cancer.

Background The Hospital Readmissions Reduction Program (HRRP), established by the Centers for Medicare and Medicaid Services (CMS) in March 2010, introduced payment-reduction penalties on acute care hospitals with higher-than-expected readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia. There is concern that hospitals serving large numbers of low-income and uninsured patients (safety-net hospitals) are at greater risk of higher readmissions and penalties, often due to factors that are likely outside the hospital’s control. Using publicly reported data, we compared the readmissions performance and penalty experience among safety-net and non-safety-net hospitals. Methods We used nationwide hospital level data for 2009-2016 from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare program, CMS Final Impact Rule, and the American Hospital Association Annual Survey. We identified as safety-net hospitals the top quartile of hospitals in terms of the proportion of patients receiving income-based public benefits. Using a quasi-experimental difference-in-differences approach based on the comparison of pre- vs. post-HRRP changes in (risk-adjusted) 30-day readmission rate in safety-net and non-safety-net hospitals, we estimated the change in readmissions rate associated with HRRP. We also compared the penalty frequency among safety-net and non-safety-net hospitals. Results Our study cohort included 1915 hospitals, of which 479 were safety-net hospitals. At baseline (2009), safety-net hospitals had a slightly higher readmission rate compared to non-safety net hospitals for all three conditions: AMI, 20.3% vs. 19.8% ( p value< 0.001); heart failure, 25.2% vs. 24.2% ( p -value< 0.001); pneumonia, 18.7% vs. 18.1% ( p -value< 0.001). Beginning in 2012, readmission rates declined similarly in both hospital groups for all three cohorts. Based on difference-in-differences analysis, HRRP was associated with similar change in the readmissions rate in safety-net and non-safety-net hospitals for AMI and heart failure. For the pneumonia cohort, we found a larger reduction (0.23%; p  < 0.001) in safety-net hospitals. The frequency of readmissions penalty was higher among safety-net hospitals. The proportion of hospitals penalized during all four post-HRRP years was 72% among safety-net and 59% among non-safety-net hospitals. Conclusions Our results lend support to the concerns of disproportionately higher risk of performance-based penalty on safety-net hospitals.

Objective: To systematically review U.S. studies examining the prevalence of limited health literacy and to synthesize these findings by evaluating demographic associations in pooled analyses. Design: We searched the literature for the period 1963 through January 2004 and identified 2,132 references related to a set of specified search terms. Of the 134 articles and published s retrieved, 85 met inclusion criteria, which were 1) conducted in the United States with≥25 adults, 2) addressed a hypothesis related to health care, 3) identified a measurement instrument, and 4) presented primary data. The authors extracted data to compare studies by population, methods, and results. Main Results: The 85 studies reviewed include data on 31,129 subjects, and report a prevalence of low health literacy between 0% and 68%. Pooled analyses of these data reveal that the weighted prevalence of low health literacy was 26% (95% confidence interval [CI], 22% to 29%) and of marginal health literacy was 20% (95% CI, 16% to 23%). Most studies used either the Rapid Estimate of Adult Literacy in Medicine (REALM) or versions of the Test of Functional Health Literacy in Adults (TOFHLA). The prevalence of low health literacy was not associated with gender (P=.38) or measurement instrument (P=.23) but was associated with level of education (P=.02), ethnicity (P=.0003), and age (P=.004). Conclusions: A pooled analysis of published reports on health literacy cannot provide a nationally representative prevalence estimate. This systematic review exhibits that limited health literacy, as depicted in the medical literature, is prevalent and is consistently associated with education, ethnicity, and age. It is essential to simplify health services and improve health education. Such changes have the potential to improve the health of Americans and address the health disparities that exist today.

IntroductionAdvance care planning (ACP) seeks to promote care delivery that is concordant with patients’ informed wishes. Scalability and cost may be barriers to widespread ACP, and video decision aids may help address such barriers.AimOur primary hypothesis was that ACP documentation would increase in Hilo after ACP video implementation. Secondary hypotheses included increased use of hospice, fewer deaths in the hospital, and decreased costs in the last month of life.SettingThe city of Hilo in Hawai‘i (population 43,263), which is served by one 276-bed hospital (Hilo Medical Center), one hospice (the Hospice of Hilo), and 30 primary care physicians.Program DescriptionThe intervention consisted of a single, 1- to 4-h training and access to a suite of ACP video decision aids.Program EvaluationPrior to implementation, the rate of ACP documentation for hospitalized patients with late-stage disease was 3.2 % (11/346). After the intervention, ACP documentation was 39.9 % (1,107/2,773) (P < 0.001). Primary care providers in the intervention had an ACP completion rate for patients over 75 years of 37.0 % (1,437/3,888) compared to control providers, who had an average of 25.6 % (10,760/42,099) (P < 0.001). The rate of discharge from hospital to hospice for patients with late-stage disease was 5.7 % prior to the intervention and 13.8 % after the intervention (P < 0.001). The average total insurance cost for the last month of life among Hilo patients was$3,458 (95 % CI $ 3,051 to 3,865) lower per patient after the intervention when compared to the control region.DiscussionImplementing ACP video decision aids was associated with improved ACP documentation, greater use of hospice, and decreased costs. Decision aids that promote ACP offer a scalable and cost-efficient medium to place patients at the center of their care.