Readability and Non-English Language Resources of Heart Transplant Center Websites in the United States

Outcomes After Heart Transplantation Among Non-Native English-Speaking Recipients

INTRODUCTION

Effective communication and understanding are imperative for heart transplant (HT) recipients who require lifelong adherence to treatment plans and medications. Whether non-native English speaking (NNES) recipients have inferior outcomes compared to native English-speaking recipients (NES) has not been studied post-HT.

METHODS

We reviewed adult HT recipients at Columbia University Irving Medical Center from January 2005-December 2022; primary language was determined by chart review. Baseline characteristics and patient-level zip codes, which were used to derive the socioeconomic status (SES) index by using data from the Agency for Healthcare Research and Quality (AHRQ), were included. Mortality at 1 year and 5 years was compared between NNES and NES recipients. Survival curves were estimated using the Kaplan-Meier method, and log-rank testing was used to compare survival between groups. Secondary outcomes, including all-cause hospitalization, hospitalization for infection and rejection at 1 year, as well as rejection and cardiac allograft vasculopathy at 5 years, were analyzed using cumulative incidence functions with Gray testing to detect differences between groups. Multivariable Cox proportional hazard models were used to determine whether there was an association between NNES and primary and secondary outcomes.

RESULTS

Of 1066 HT recipients, 103 (10%) were NNES. NNES recipients were more likely to identify as non-White, to have Medicaid as the primary payer and to have lower educational attainment. On average, NNES recipients resided in zip codes with higher levels of unemployment and lower household incomes. Overall, NNES had lower median AHRQ SES indices (51 vs 55; P < 0.001). After adjustment for clinical factors, including socioeconomic status, race/ethnicity and education level, mortality at 1 and 5 years for NNES and NES recipients were not significantly different, although there was a trend toward improved survival rates in the NNES group (1-year adjusted hazard ratio (HR) 0.24, 95% CI 0.06-1.01; P = 0.05; 5-year adjusted HR 0.48, 95% CI 0.22-1.03; P = 0.06). Similarly, there were no differences in need for rehospitalization, infection requiring hospitalization or rejection at 1 year.

CONCLUSIONS

There were no significant differences in outcomes at 1 year and 5 years post-HT between NNES and NES. Availability of interpreter services and educational resources in multiple languages are paramount to maintaining effective communication and equitable outcomes.

Readability and Accessibility of Patient-Education Materials for Heart Failure in the United States

Online education materials are widely used by patients and caregivers to understand the management of complex chronic diseases such as heart failure (HF). Organizations such as the American Medical Association and National Institutes of Health recommend that materials be written at a 6th-grade reading level. The current study examined the readability and accessibility of online education materials for patients with HF. Whole page texts from each included website were entered into an online readability calculator. Five validated readability indices (Flesch-Kincaid Grade Level, Flesch Reading Ease Scale, Gunning Fog Index, Coleman-Liau Index, and Simple Measure of Gobbledygook (SMOG Index)) were used to evaluate each source. Websites were categorized by source (government, public and private). The availability of audiovisual accessibility features and content in non-English languages were assessed for each website. Of the 36 online resources analyzed, the median readability level was 9th-10th grade according to the Flesch-Kincaid Grade Level and college level, according to the Flesch Reading Ease Scale. The Gunning Fog Index and Coleman-Liau Index both showed median readability scores corresponding to a 12th grade reading level, whereas the SMOG Index showed a median score corresponding to that of the 9th grade. Only 10 websites (28%) offered information in languages other than English, and none provided comprehensive accessibility features for users with disabilities. Common online educational materials for patients with HF are characterized by higher readability levels than those recommended by the National Institutes of Health and the American Medical Association, and there were limited multilingual and accessibility options, potentially limiting the accessibility of resources to patients and caregivers.