1. Evaluating the Newest Vital Sign: A More Convenient Measure of Health Literacy Lindsey McCormick, MS3 William Curry, MD, MS Penn State College of Medicine Department of Family and Community Medicine Lindsey McCormick, MS3 William Curry, MD, MS Penn State College of Medicine Department of Family and Community Medicine

2. INTRODUCTION What is health literacy? –How well patients understand and manage their healthcare What are the repercussions of inadequate health literacy? –Poorer outcomes for patients, more strain on providers How can we efficiently assess our patients’ health literacy? –Investigating new evaluation tools What is health literacy? –How well patients understand and manage their healthcare What are the repercussions of inadequate health literacy? –Poorer outcomes for patients, more strain on providers How can we efficiently assess our patients’ health literacy? –Investigating new evaluation tools

3. INTRODUCTION The work of Dr. Weiss, University of Arizona: development of the Newest Vital Sign (NVS), a 3 minute assessment of health literacy Comparing the NVS with established, more time- consuming evaluation tools: Test of Functional Health Literacy of Adults (TOFHLA) Replication of this study among a different patient population in Central Pennsylvania The work of Dr. Weiss, University of Arizona: development of the Newest Vital Sign (NVS), a 3 minute assessment of health literacy Comparing the NVS with established, more time- consuming evaluation tools: Test of Functional Health Literacy of Adults (TOFHLA) Replication of this study among a different patient population in Central Pennsylvania

4. METHODS English-speaking adults (18-65) approached randomly in Family Practice Offices in Lancaster & Dauphin counties in Pennsylvania Administration of visual acuity test, NVS, Test of Functional Health Literacy in Adults (TOFHLA), and demographic questionnaire English-speaking adults (18-65) approached randomly in Family Practice Offices in Lancaster & Dauphin counties in Pennsylvania Administration of visual acuity test, NVS, Test of Functional Health Literacy in Adults (TOFHLA), and demographic questionnaire

5. Instruments: NVS Nutrition label 6 questions asked –Requiring reading, reasoning, and math skills –Score range: 0-6 ≥ 4 adequate 3 = marginal ≤ 2 inadequate –3 to 5 minutes to complete Nutrition label 6 questions asked –Requiring reading, reasoning, and math skills –Score range: 0-6 ≥ 4 adequate 3 = marginal ≤ 2 inadequate –3 to 5 minutes to complete

6. Instruments: the TOFHLA Reading section –3 reading passages with fill-in-the-blank, multiple choice answers –50 points total Numeracy section –Prompts with verbal questions –50 points total 20 minutes to complete Total Maximum score = 100 –Scores ≥ 75 adequate –Scores 60 – 74 marginal –Scores < 60 inadequate Reading section –3 reading passages with fill-in-the-blank, multiple choice answers –50 points total Numeracy section –Prompts with verbal questions –50 points total 20 minutes to complete Total Maximum score = 100 –Scores ≥ 75 adequate –Scores 60 – 74 marginal –Scores < 60 inadequate

7. DATA ANALYSIS Means, SD, SE of mean, histograms, t tests, analysis of covariance Correlation of NVS and TOFHLA with Spearman coefficients Receiver operating curves (ROC) –Quantify NVS scores, education, & age as predictors of health literacy –Define sensitivity & specificity of NVS cut-off scores General Linear Models (GLM) procedure –Predictors of discrepancy between NVS & TOFHLA Means, SD, SE of mean, histograms, t tests, analysis of covariance Correlation of NVS and TOFHLA with Spearman coefficients Receiver operating curves (ROC) –Quantify NVS scores, education, & age as predictors of health literacy –Define sensitivity & specificity of NVS cut-off scores General Linear Models (GLM) procedure –Predictors of discrepancy between NVS & TOFHLA

8. RESULTS Participant demographics –N = 162; 88 (54%) female –Average age 41 (SD 13), range 18-65 –76% non-Hispanic white, 16% African American, 8% other –95% education level at least high school diploma 5% some high school 31% high school diploma 55% some college or college degree 9% post-graduate degree Participant demographics –N = 162; 88 (54%) female –Average age 41 (SD 13), range 18-65 –76% non-Hispanic white, 16% African American, 8% other –95% education level at least high school diploma 5% some high school 31% high school diploma 55% some college or college degree 9% post-graduate degree

9. Results: NVS Mean score 4.4, SD 1.62

10. Results: TOFHLA reading Mean score 47.5, SD 3.19

11. Results: TOFHLA numeracy Mean score 44.8, SD 4.82

12. Results: TOFHLA total Mean score 92.4, SD 6.89

13. Results # Subjects with Marginal Literacy # Subjects with Inadequate Literacy NVS20 (12.5%) Score = 3 24 (15%) Score ≤ 2 TOFHLA4 (2.5%)* 60 < Score < 75 0 (0%) Score < 60 *all scored ≤ 3 on NVS

14. STATISTICAL ANALYSIS Correlation of NVS & TOFHLA –Spearman r = 0.55 (P <0.001) ROC curve: NVS predicts marginal or inadequate literacy –Area under curve 0.91 (P <0.001) defined by TOFHLA <75 –Cut-off scores: Correlation of NVS & TOFHLA –Spearman r = 0.55 (P <0.001) ROC curve: NVS predicts marginal or inadequate literacy –Area under curve 0.91 (P <0.001) defined by TOFHLA <75 –Cut-off scores: SensitivitySpecificity NVS < 294.3%50.0% NVS < 387.3%75%

15. STATISTICAL ANALYSIS ROC curve: Education predicts marginal or inadequate health literacy –Area under curve 0.94 (P <0.001), defined by TOFHLA <75 Age not a predictor of health literacy –Area under curve 0.58 No difference found between males and females

16. STATISTICAL ANALYSIS Discrepancy: low NVS with high TOFHLA scores –36 (22%) subjects with NVS score ≤3 and TOFHLA >80 –NVS and TOFHLA scores were scaled and evaluated for predictors of this discrepancy with generalized linear model (GLM) approach –Education (P <0.001) and income (P <0.001) both negatively correlated with discrepancy –Lower education and income associated with greater differences between NVS scores and TOFHLA scores Discrepancy: low NVS with high TOFHLA scores –36 (22%) subjects with NVS score ≤3 and TOFHLA >80 –NVS and TOFHLA scores were scaled and evaluated for predictors of this discrepancy with generalized linear model (GLM) approach –Education (P <0.001) and income (P <0.001) both negatively correlated with discrepancy –Lower education and income associated with greater differences between NVS scores and TOFHLA scores

17. DISCUSSION NVS correlates with TOFHLA and is reasonable method for quickly determining health literacy in a busy outpatient setting Observed discrepancy between NVS and TOFHLA scores –NVS more reasonable than TOFHLA for predicting inadequate literacy? NVS correlates with TOFHLA and is reasonable method for quickly determining health literacy in a busy outpatient setting Observed discrepancy between NVS and TOFHLA scores –NVS more reasonable than TOFHLA for predicting inadequate literacy?

18. DISCUSSION Limitations –Lack of variation in scores (literate population) –Lack of ethnic diversity –Small sample size (N = 162) Limitations –Lack of variation in scores (literate population) –Lack of ethnic diversity –Small sample size (N = 162)

19. REFERENCES US Department of Health and Human Services. Health Communication. In: Healthy People 2010. 2nd ed. Washington, DC: US Government Printing Office; 2000. Nielson-Bohlman L, Panzer A, Kindig D, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press: 2004. Berkman N, DeWalt D, Pignon M, et al. Literacy and Health Outcomes. Summary, Evidence Report/Technology Assessment No. 87. Rockville, MD: Agency for Healthcare Research and Quality; 2004. AHRQ Publication No. 04-E007-1. Schwartzberg J, VanGeest J, Wang C, eds. Understanding Health Literacy: Inspirations for Medicine and Public Health. Chicago, Ill: American Medical Association Press; 2004. Weiss B, Mays M, Martz W, et al. Quick Assessment of Literacy in Primary Care: The Newest Vital Sign. Ann Fam Med 2005; 3:514-522. Health Literacy: The Most Important Vital Sign? Disease Management Advisor. 2006; 1: 6-8. US Department of Health and Human Services. Health Communication. In: Healthy People 2010. 2nd ed. Washington, DC: US Government Printing Office; 2000. Nielson-Bohlman L, Panzer A, Kindig D, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press: 2004. Berkman N, DeWalt D, Pignon M, et al. Literacy and Health Outcomes. Summary, Evidence Report/Technology Assessment No. 87. Rockville, MD: Agency for Healthcare Research and Quality; 2004. AHRQ Publication No. 04-E007-1. Schwartzberg J, VanGeest J, Wang C, eds. Understanding Health Literacy: Inspirations for Medicine and Public Health. Chicago, Ill: American Medical Association Press; 2004. Weiss B, Mays M, Martz W, et al. Quick Assessment of Literacy in Primary Care: The Newest Vital Sign. Ann Fam Med 2005; 3:514-522. Health Literacy: The Most Important Vital Sign? Disease Management Advisor. 2006; 1: 6-8.