1. From Non-compliance to Exceptionalism: Changing the low health literacy story Joseph M. Geskey, DO, MBA, CPE, FAAP, FSHM Vice President, Medical Affairs OhioHealth Doctors Hospital

2. EXERCISE  Please complete exercise at your table

3. How well do you know risk literacy?  Patient has a breast mass. Physician thinks it is probably benign. In fact, he/she thinks there is only a 1% probability that the patient has cancer. However, the radiologist says the X-ray is positive.  The chart on the right is accuracy of mammography in diagnosing benign and malignant lesions  So what is the probability that the patient has cancer? A) 79% B) 75% C) 1% D) 8% Results of X ray Malignant lesion (cancer) Benign lesion (no cancer) Positive.792.096 Negative.208.904 Source: Eddy DM (1982). In D. Kahneman, et al., Judgment under uncertainty: Heuristics and biases (pp. 249-267). Cambridge, England: Cambridge University Press

4. Solving the problem  P(ca/pos)= P(pos/ca) * P(ca) (0.792)* (0.01) ______________ _____________ = 0.077 P(pos/ca)* P(ca) + P(pos/benign) * P(benign) (0.792)*(0.01) +(0.096)*(0.99) P(ca/pos) is probability that patient has cancer, given that she has a positive x-ray report P(pos/ca) is probability that, if the patient has cancer, the radiologist will correctly diagnose it (sensitivity) P (ca) is probability that the patient has cancer (prior probability) P (benign) is prior probability that the patient has benign disease P (pos/benign) is probability that, if patient has benign lesion, the radiologist will incorrectly diagnose it as cancer (false positive)

5. Natural frequencies 1000 women 10 cancer 990 no cancer 8 pos 2neg 96 pos 894 neg p(cancer/test positive) = 8/8+96 =7.7% 60% of 4 th graders could get Bayesian problems correct if framed in natural frequencies. Source: Gigerenzer G(2013). Risk Savvy: How to Make Good Decisions. New York: Penguin Group

6. What stories do we tell ourselves? ”Non- compliant ” “All words begin as servants, eager to oblige and assume whatever function may be assigned them, but, that accomplished, they become masters, imposing the will of their predefined intention and dominating the essence of human discourse.” --M Frank Pajares

7. Do we understand the burden of chronic illness?  67 year old with diabetes, hypertension and high cholesterol.  In order to be “compliant”, estimated that patient would have to attend to 3,000 behaviors (prescription, travel to pharmacy, reduce salt and fat at each meal, exercise 3-4 times per week, make to doctors appointments, get blood tests before each appointment, check blood sugar, get flu shots, take meds in am and pm...) Source: Danielle Ofri, November 15, 2012 New York Times

8. What role does illness play in literacy?  26% patients with COPD develop Mild Cognitive Impairment over 5 years Singh et al. JAMA Neurol. 2014;71(5):581-588. doi:10.1001/jamaneurol.2014.94.  50% of patients hospitalized with COPD exacerbations had at least mild impairment of processing speed, and in a significant proportion, the loss was in the pathologic range. Dodd et al. Chest. 2013;144(1):119-127. doi:10.1378/chest.12-2099  Cardiologists suspected that 12% of their CHF patients had memory impairment. However, 45.6% had memory impairment (23.4% severe). Hanon et al. Am J Cardiol 2014;113:1205-10.

9. The Newest Vital Sign 1.If you eat the entire container, how many calories will you eat? 2.If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice scream could you have? 3.Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g of saturated fat each day, which includes one serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day? 4.If you usually eat 2,500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving? 5.Pretend you are allergic to the following: penicillin, peanuts, latex gloves and bee stings. Is it safe for you to eat this ice cream? 6.If patient responds “no” to question 5): Why not?

10. PAM-13

11. Exercise  Complete the NVS and PAM-13 with the person next to you  Switch Roles

12. 4 Stages of Patient Activation

13. Doctors Hospital Research Project  CHF/COPD Inpatient  NVS 0-1  PAM 13  Enrolled into 4 one hour home education sessions  Measure 30-day readmits, PAM- 13 and NVS scores  Results to date  60 enrolled, 9.5% 30-day readmission rate  DH readmission rate for COPD & CHF currently ~18.5%  PAM-13 scores have increased by one level  No change in literacy English preferred language; No dementia; Ability to use OHHR

14. Research Intervention  Level 1: Establish role in self-care -Discuss experiences related to healthcare an disappointments with outcome  Level 2: Confidence and Knowledge -Understand disease // Discuss lifestyle behaviors// Medication education  Level 3: Skills & Behavior - Set behavioral goals // Link symptom improvement to behavior Level 4: Skills and Behavior under different situations -Explore potential “difficult times” & establish problem-solving approach to achieve success

15. Goals of Disease Management VS

16. “Have to” “Choose to” “Self motivation, rather than external motivation, is at the heart of creativity, responsibility, healthy behavior and lasting change” Motivational Goal

17. From non-compliance to exceptionalism  Start with patient’s goal  Teach to level of activation  Use Teach Back to confirm understanding  Anticipate problems and how to overcome them

18. Exercises  60 year old patient with heart failure admitted to hospital for 6 th time in 6 month. NVS=0, PAM-13 reveals patient to be Stage 1. Unsure about medications, diet, exercise, doesn’t understand how to manage when gaining weight How would you design an educational intervention? How would you assess understanding?  62 year old patient diagnosed with heart failure after suffering from a heart attack 1 year ago. On review had “ham” on Easter dinner with family. Although scored a 1 on NVS, is highly activated with PAM-13 Stage 4. Knows medications, and disease. Gets a little confused when he has to alter his medications based on weight?  How would you design an educational intervention?  How would you assess understanding?