Kidney Transplant Referrals Lower for Health-Illiterate Patients

Kidney Transplant Referrals Lower for Health-Illiterate Patients

By John Gever, Senior Editor, MedPage Today

Published: December 04, 2008

Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.

SAN FRANCISCO, Dec. 4 -- Medically unsophisticated patients were markedly less likely to get a kidney transplant referral, even when they were just as needy as more health-literate counterparts, researchers here said.

Hemodialysis patients judged to have low health literacy were referred for transplant evaluation at less than one-quarter the rate of clinically similar patients with adequate health literacy, reported Vanessa Grubbs, M.D., of the University of California San Francisco, and colleagues online in the Clinical Journal of the American Society of Nephrology.

Health literacy, they explained, is "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions."

Patients with low health literacy -- roughly 30% of the general population, according to earlier studies -- have trouble understanding what their physicians tell them as well as written materials they may receive.

They are also less able to successfully navigate the healthcare system, Dr. Grubbs and colleagues said.

The researchers hypothesized that health literacy may play a role in previously documented disparities in access to kidney transplant.

"Patients with inadequate health literacy may be less likely to report wanting a transplant because of a lack of understanding of what transplantation entails," they said.

"Furthermore, nephrologists may be less willing to refer, and transplant centers less willing to wait-list, patients with inadequate health literacy because of perceived patient inability to follow through with prescribed regimens necessary for transplanted graft survival."

They found that health literacy indeed seemed to affect referrals, but not the chance of being placed on a transplant wait-list once referred.

Dr. Grubbs and colleagues looked at the experiences of 62 patients on hemodialysis in the San Francisco area, with ages ranging from 18 to 75.

They administered a standard, short-form test of health literacy to participants, with 20 determined to have inadequate health literacy.

Age, income level, and education, but not race or gender, were significantly associated with health literacy scores (P<0.05).

Transplant evaluation referrals were given to 47 patients in the sample. Dr. Grubbs and colleagues did not report how many of these had adequate versus inadequate health literacy.

But they reported a hazard ratio of 0.22 (95% CI 0.08 to 0.60) that a patient with inadequate health literacy would receive a referral, after adjusting for race, gender, age at start of dialysis, income, comorbid conditions, and availability of support.

Among participants who received referrals, the mean time from dialysis start to referral was 15.3 months for those with adequate literacy versus 23.5 months for the inadequately literate (P=0.6).

Dr. Grubbs and colleagues also found that, among the 47 patients evaluated for transplant, low health literacy made no difference in the likelihood of being placed on a transplant wait-list (adjusted HR 0.80, 95% CI 0.39 to 1.61).

On the other hand, the mean time between referral and placement on a transplant wait-list was significantly longer for those with poor health literacy (mean 6.6 months versus 2.1 months, P=0.05).

Dr. Grubbs and colleagues could not determine specific reasons for the low rate of referrals or the apparent delay in wait-listing for patients with poor health literacy.

Regardless, they said, the study clearly points to a lack of standardized practices in referrals which deserves exploration.

Among the possible explanations to examine:

... Nephrologists may be less willing to refer patients they perceive as less equipped to follow the prescribed regimens necessary for transplanted graft survival.
... Less-literate patients may not request evaluations or may reject them when offered.
... Various health complications or patient uncertainty may have influenced the findings.

The researchers added that if the problem is with patients' difficulty in comprehending the transplant evaluation process, there are remedial measures available.

"Multimedia approaches and 'teach-to-goal' methods have been cited as ways of overcoming inadequate health literacy," Dr. Grubbs and colleagues said.

"Furthermore, streamlining the transplant evaluation process to entail a short hospital stay rather than an outpatient procedure would overcome the difficulty some patients may have when trying to navigate a busy healthcare center."

The researchers acknowledged that the small sample size limits interpretation of the results.

Its retrospective design and focus on access to wait-lists was another limitation, although they said a prospective study of dialysis patients would be difficult to organize.

In addition, their instrument for assessing health literacy only evaluates comprehension of written information, not the ability to navigate other aspects of the healthcare system, including face-to-face communication.
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The study was funded by the Clough Memorial Endowment Fund and the National Institutes of Health.
No potential conflicts of interest were reported.

Primary source: Clinical Journal of the American Society of Nephrology
Source reference:
Grubbs V, et al "Health literacy and access to kidney transplantation," Clin J Am Soc of Nephrol 2008; DOI: 10.2215/CJN.03290708.

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http://www.medpagetoday.com/Nephrology/KidneyTransplantation/12024

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