Health Literacy in Orthopaedic Trauma Patients

Caring for Underserved Populations in Orthopedic Trauma

Contemporary care of patients with orthopedic trauma is complex from surgical, cultural, administrative, financial, and linguistic perspectives. Surgeons must understand patients' backgrounds and resources to have an idea of the manner in which care can be delivered most effectively. Recognizing patients from traditionally underserved or vulnerable groups will help the surgeon to individualize their approach to the care of each individual patient. Understanding patient funding, or lack thereof, will inform the provider as to the extent of the resources and access available to the patient and assist in planning episodes of care.

Improving Patient Recall Following Operative Orthopaedic Trauma

BACKGROUND

Orthopaedic trauma patients may experience poor recall regarding their injury and treatment, impairing postoperative outcomes. We sought to evaluate the impact of a standardized postoperative educational protocol on patient recall, adherence to the treatment plan, and satisfaction.

METHODS

Two hundred and twenty adult, English-speaking patients with surgically treated lower-extremity fractures were prospectively included. One hundred and ten patients in the educational intervention cohort met with a non-physician study member after surgery but before hospital discharge. They were given a written questionnaire evaluating knowledge of key aspects of their injury and treatment plan. For incorrectly answered questions, the study team member told the patient the correct answer (e.g., "No, you broke your tibia."). Immediately after, the patient was verbally asked the question again (e.g., "Which bone did you break?"), repeating the process until the answer was correct. The 110 patients in the control cohort did not receive this "teach-back" protocol. During their first postoperative appointment, all 220 patients completed a follow-up questionnaire assessing recall, adherence to the treatment plan, and satisfaction.

RESULTS

The control cohort correctly answered 64% of recall-oriented questions versus 89% in the intervention cohort (p < 0.001). Eighty-two percent of control patients versus 89% patients in the intervention cohort adhered to postoperative weight-bearing restrictions (p = 0.09). Eighty-four percent of controls adhered to their deep venous thrombosis prophylaxis regimen versus 99% of the intervention cohort (p < 0.001). On a 5-point Likert scale, controls were less satisfied with their overall orthopaedic care compared with patients in the intervention cohort (mean of 4.38 ± 0.84 versus 4.54 ± 0.63 points; p = 0.02), although this difference was less than the minimal clinically relevant difference of 10% that was defined at study onset. On propensity score-weighted multivariable analysis, receipt of the postoperative educational intervention was the only modifiable factor associated with improvement in patient recall (26% improvement [95% confidence interval, 20% to 31%]; p < 0.001).

CONCLUSIONS

Some orthopaedic trauma patients' nonadherence to surgeon recommendations and dissatisfaction with care may be mitigated by postoperative education. This standardized postoperative educational protocol improves orthopaedic trauma patients' recall, adherence to their treatment plan, and satisfaction in a manner requiring minimal time.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Limited Health Literacy Among Patients With Orthopedic Injuries: A Cross-sectional Survey of Patients Who Underwent Orthopedic Trauma Surgery in a County Hospital Setting

BACKGROUND

Patients with limited health literacy have difficulty understanding their injuries and postoperative treatment, which can negatively affect their outcomes.

MATERIALS AND METHODS

This cross-sectional questionnaire-based study of 103 adult patients sought to quantify patients' health literacy at a single county hospital's orthopedic trauma clinic and to examine their ability to understand injuries and treatment plans. Demographics, Newest Vital Sign (NVS) health literacy assessment, and knowledge scores were used to assess patients' comprehension of their injuries and treatment plan. Patients were grouped by NVS score (NVS <4: limited health literacy). Fisher's exact tests and t tests were used to compare demographic and comprehension scores. Multivariate logistic regression analysis was used to examine the association among low health literacy, sociodemographic variables, and knowledge scores.

RESULTS

Of the 103 patients, 75% were determined to have limited health literacy. Patients younger than 30 years were more likely to have adequate literacy (50% vs 23%, P=.01). Patients who spoke Spanish as their primary language were 8.77 times more likely to have limited health literacy with respect to sociodemographic factors (odds ratio, 8.77; 95% CI, 1.03-76.92; P=.04). Low health literacy was 3.52 and 4.14 times more likely to predict discordance in answers to specific bone fractures and the narcotics prescribed (P=.04 and P=.02, respectively).

CONCLUSION

Spanish-speaking patients have demonstrated limited health literacy and difficulty understanding their injuries and postoperative treatment plans compared with English-speaking patients. Patients with low health literacy are more likely to be unsure regarding which bone they fractured or their prescribed opiates. [Orthopedics. 2024;47(4):249-255.].

The influence of hospital and home environments on physical activity and sedentary behaviour: Perceptions of people recovering from fractures

BACKGROUND

A lack of evidence exists contrasting the factors that influence physical activity and sedentary behaviour in both hospital and home settings before and after discharge from acute hospitalisation for fractures.

OBJECTIVE

To describe and compare perceptions of environmental influences on physical activity in hospital and home settings in people recovering from fractures.

METHOD

Semi-structured interviews were conducted with patients hospitalised following fractures (hip fracture or multi-trauma), exploring the barriers and enablers to physical activity within hospital and home settings. Interviews were conducted within two weeks of hospital discharge, audio recorded and transcribed prior to thematic analysis via a framework approach.

RESULTS

Between December 2022 and May 2023, 12 semi-structured interviews were undertaken with an equal number of participants who sustained an isolated hip fracture or multi-trauma. The median (IQR) age of participants was 60 (52-68) years, with half being male, and the majority sustaining their injuries via transport crashes. Three main themes that influenced physical activity behaviours in hospital and home settings were: having the opportunity, having a reason, and having support and assistance to be active.

CONCLUSION

During the period of reduced physical capability following fracture, patients need to be provided with opportunities and motivation to be active, particularly within the hospital setting. Findings from this study will assist clinicians to better support people recovering from fractures via greater engagement in physical activity within hospital and home settings.

Lost in the Shuffle: Low Health Literacy in Geriatric Fracture Patients and Families Regarding Post-Acute Care-A Prospective Study

INTRODUCTION

This study aims to evaluate health literacy (HL) in geriatric orthopaedic trauma patients and their families as it relates to their post-acute care (PAC) in skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs).

METHODS

This nonrandomized controlled clinical trial included patients aged 65 years and older treated for acute fracture at a Level 1 trauma center and discharged to either IRF or SNF. First 106 patients enrolled served as the control group and received standard discharge instructions. The second 101 patients were given a set of oral and written instructions regarding PAC detailing important questions to ask upon arrival to their facility.

RESULTS

The mean HL score for all patients/families was 2.4 out of 5. No significant difference was noted in HL scores (2.4 versus 2.3) or median LOS (22 versus 28 days) between the control and intervention groups. Family involvement (68%) slightly improved HL scores (2.6 versus 1.9, P < 0.001). Patients discharged to IRF had better HL scores (3.4 versus 2.3, P < 0.001), shorter LOS (median 15 vs 30 days, P < 0.001), and trended toward improved knowledge of discharge goals (48.1% versus 35.6%) than those in SNF.

CONCLUSION

System-wide solutions are necessary to improve geriatric HL and optimize outcomes in orthopaedic trauma.

Health literacy in orthopaedic lower limb trauma patients: A cross-sectional survey study

INTRODUCTION

The aim of this study was to investigate orthopaedic lower limb trauma patients' comprehension regarding the affected bone, the surgical implant used, and postoperative instructions, and to evaluate the relationship between sociodemographic features and health literacy.

HYPOTHESIS

There is a relationship between health literacy levels, the medical awareness of orthopaedic trauma patients and sociodemographic characteristics.

MATERIAL AND METHODS

The cross-sectional survey study was conducted from June to September 2021 in the orthopaedic clinic of a level 1 trauma centre. The study group consisted of 225 patients with a surgically treated unilateral lower limb fracture. The questionnaire consisted of 3 parts: (1) sociodemographic information, (2) knowledge about ongoing orthopaedic treatment, and (3) 16-item version of The European Health Literacy Survey (HLS-EU-Q16).

RESULTS

Of the patients in the study, 46% were not aware that they were using thromboembolism prophylaxis, and 10% did not use the prophylaxis. More than half of the patients did not know which bone was fractured, three-quarters did not know what type of implant had been used for the fracture fixation, and approximately 90% of the patients did not know their weight-bearing status and the expected healing time after surgery. Inadequacy of HLS-EU-Q16 score with a median of 34.4, (range, 0-50) was 38.7% (n=87).

DISCUSSION

Orthopaedic lower limb trauma patients demonstrated inadequate health literacy with low comprehension of their injuries, surgeries, and discharge schemes. This study's results show the need to promote more effective communication between orthopaedic trauma patients and healthcare providers. Identifying inadequate health literacy in patients and developing appropriate interventions before discharge may help improve outcomes.

LEVEL OF EVIDENCE

II; cross sectional.

Social Media and Digital Footprints in Orthopaedic Trauma: An Analysis of 1465 Orthopaedic Trauma Association Members

OBJECTIVES

The purpose of this study was to quantify social media usage among Orthopaedic Trauma Association (OTA) members.

METHODS

All active OTA members were searched for involvement among common social media platforms. Surgeons were then classified as "active" on any given social media site if they posted within the past 6 months. Surgeons were also identified by the region they practiced in, sex, and their practice setting (academic vs. private). Finally, a surgeon's score and number of reviews from common physician review websites were examined.

RESULTS

A total of 1465 OTA members were included in the analysis. Most surgeons were male (89.1% [n = 1305]) and practiced in a private setting (54.5% [n = 799]). A total of 590 surgeons (40.3%) had at least one form of social media account. Social media sites most used were LinkedIn with 48.7% (n = 713) and ResearchGate with 29.2% (n = 428). Academic surgeons were more likely to have a ResearchGate, LinkedIn, and Twitter account while private surgeons were more likely to have a personal website ( P < 0.05). Finally, there was no correlation between surgeons more active on social media and average scores on Vitals.com or Healthgrade.com ( P > 0.05).

CONCLUSIONS

Most orthopaedic trauma surgeons do not have professional social media accounts. Although social media may help spread scholarship, having a professional social media account does not correlate with better online physician reviews or increased online reviews among orthopaedic trauma surgeons.

Patient Adherence Following Knee Surgery: Evidence-Based Practices to Equip Patients for Success

Patient adherence with postoperative wound care, activity restrictions, rehabilitation, medication, and follow-up protocols is paramount to achieving optimal outcomes following knee surgery. However, the ability to adhere to prescribed postoperative protocols is dependent on multiple factors both in and out of the patient's control. The goals of this review article are (1) to outline key factors contributing to patient nonadherence with treatment protocols following knee surgery and (2) to synthesize current management strategies and tools for optimizing patient adherence in order to facilitate efficient and effective implementation by orthopaedic health care teams. Patient adherence is commonly impacted by both modifiable and nonmodifiable factors, including health literacy, social determinants of health, patient fear/stigma associated with nonadherence, surgical indication (elective vs. traumatic), and distrust of physicians or the health care system. In addition, health care team factors, such as poor communication strategies or failure to follow internal protocols, and health system factors, such as prior authorization delays, staffing shortages, or complex record management systems, impact patient's ability to be adherent. Because the majority of factors found to impact patient adherence are nonmodifiable, it is paramount that health care teams adjust to better equip patients for success. For health care teams to successfully optimize patient adherence, focus should be paid to education strategies, individualized protocols that consider patient enablers and barriers to adherence, and consistent communication methodologies for both team and patient-facing communication.

The complexity of patient adherence in orthopaedics: A qualitative study to identify barriers and develop strategies for adherence partnerships

INTRODUCTION

While the importance of patient adherence to treatment protocols is firmly accepted, a definition for adherence and mechanisms to address non-adherence are not well established. The goals of this study were to define adherence and identify barriers and enablers for adherence partnerships through the lens of the orthopaedic healthcare team.

METHODS

The qualitative study was designed using concepts from grounded theory. Eight focus groups, comprised of orthopaedic healthcare team members, were conducted to identify factors influencing orthopaedic patient adherence to treatment plans.

RESULTS

Healthcare team members identified a range of factors affecting patient adherence. Participants conveyed that patient non-adherence can be a deliberate decision but can also result from barriers faced by the patient. Synthesis of themes identified distinct phases of adherence and culminated in the creation of a preliminary model that encapsulates healthcare team and patient factors impacting adherence, which was entitled, The Barriers and Enablers to Treatment Adherence (BETA) Model.

CONCLUSION

The study findings alleviate the patient from the sole burden of adherence, recognising the influences that the healthcare team and system have on patients' ability to adhere. The BETA model of patient adherence represents the first step to mitigating non-adherence by providing a foundation for programmatic research aimed at developing and evaluating interventions and management strategies that empower healthcare teams to effectively equip patients for adherence, leading to optimised patient outcomes following orthopaedic interventions.

Health Literacy in Orthopaedics

Health literacy is a dynamic, multifaceted skill set that relies on patients, healthcare providers, and the healthcare system. In addition, health literacy assessment provides an avenue for evaluating patient understanding and offers insights into their health management capabilities. Inadequate health literacy results in poor patient outcomes and compromised care by considerably hindering successful communication and comprehension of relevant health information between the patient and the provider. In this narrative review, we explore why limited health literacy poses serious implications for orthopaedic patient health and safety, expectations, treatment outcomes, and healthcare costs. Furthermore, we elaborate on the complexity of health literacy, provide an overview of key concepts, and offer recommendations for clinical practice and research investigations.

Perceptions of an Interactive Trauma Recovery Information Booklet

BACKGROUND

Previous research has shown that people with traumatic injuries have unmet information needs with respect to their injuries, management, and recovery. An interactive trauma recovery information booklet was developed and implemented to address these information needs at a major trauma center in Victoria, Australia.

OBJECTIVE

The aim of this quality improvement project was to explore patient and clinician perceptions of a recovery information booklet introduced into a trauma ward.

METHODS

Semistructured interviews with trauma patients, family members, and health professionals were undertaken and thematically analyzed using a framework approach. In total, 34 patients, 10 family members, and 26 health professionals were interviewed.

RESULTS

Overall, the booklet was well accepted by most participants and was perceived to contain useful information. The design, content, pictures, and readability were all positively appraised. Many participants used the booklet to record personalized information and to ask health professionals questions about their injuries and management.

CONCLUSION

Our findings highlight the usefulness and acceptability of a low-cost interactive booklet intervention to facilitate the provision of quality of information and patient-health professional interactions on a trauma ward.

Orthopaedic trauma patient non-adherence to follow-up visits at a level 1 trauma center serving an urban and rural population

OBJECTIVE

To assess key demographic and psychosocial variables that may be associated with non-adherence to clinic visits following orthopaedic trauma injuries to patients in an urban and rural population.

METHODS

This retrospective review included all operative and non-operative patients presenting to a Level I academic trauma center serving an urban and rural population in the Midwest following an orthopaedic injury. The study tracked patient attendance to scheduled orthopaedic trauma follow-up clinic visits after a scheduled visit in the clinic following a trauma-related injury.

RESULTS

Data were obtained for 5816 unique orthopaedic trauma patients who had 21,066 post-treatment follow-up visits scheduled. 1627 "no-show" appointments were recorded. Factors associated with no-shows included male sex, age between 26 and 35 years, self-reported race other than white, employment listed as disabled, household income below $25,000, education less than a high school level, uninsured, Medicaid insured, and relationship status reported as single.

CONCLUSIONS

In the present study, key demographic and psychosocial factors were significantly associated with patient adherence to scheduled follow-up appointments after treatment for orthopaedic trauma. Identifying patients at higher risk for nonadherence will allow healthcare teams to educate patients, providers, and staff, link patients to resources to enhance adherence, and work with their institutions to develop and implement protocols for improving adherence to follow-up appointments.

Health Literacy in Orthopedic Surgery: A Systematic Review

Background: Limited health literacy has been associated with adverse health outcomes. Undergoing orthopedic surgery often requires patients to make complex decisions and adhere to complicated instructions, suggesting that health literacy skills might have a profound impact on orthopedic surgery outcomes. Purpose: We sought to review the literature for studies investigating the level of health literacy in patients undergoing orthopedic surgery and also to assess how those studies report factors affecting health equity. Methods: We conducted a systematic search of PubMed, Embase, and Cochrane Library for all health literacy studies published in the orthopedic surgery literature up to February 8, 2022. Search terms included synonyms for health literacy and for all orthopedic surgery subspecialties. Two reviewers independently extracted study data in addition to indicators of equity reporting using the PROGRESS+ checklist (Place of Residence, Race/Ethnicity, Occupation, Gender/sex, Religion, Education, Social capital, Socioeconomic status, plus age, disability, and sexual orientation). Results: The search resulted in 616 studies; 9 studies remained after exclusion criteria were applied. Most studies were of arthroplasty (4/9; 44%) or trauma (3/9; 33%) patients. Validated health literacy assessments were used in 4 of the included studies, and only 3 studies reported the rate of limited health literacy in the patients studied, which ranged between 34% and 38.5%. At least one PROGRESS+ item was reported in 88% (8/9) of the studies. Conclusions: We found a paucity of appropriately designed studies that used validated measures of health literacy in the field of orthopedic surgery. The potential impact of health literacy on orthopedic patients and their outcomes has yet to be elucidated. Thoughtful, high-quality trials across diverse demographics and geographies are warranted.

Preventing subsequent injury: Healthcare providers' perspectives on untapped potential

INTRODUCTION

Many individuals who experience an injury go on to have subsequent injuries. This study examined the views of health professionals about potential opportunities to prevent subsequent injuries.

METHODS

Semi-structured individual interviews were held with a range of health professionals involved in treating injuries. Interviews examined opportunities for the prevention of subsequent injuries, particularly opportunities that may be implemented by health professionals. A thematic analysis of the data was undertaken.

RESULTS

Thirteen health professionals were interviewed, including physiotherapists, occupational therapists, and emergency department staff. Opportunities to prevent subsequent injuries aligned with the Dahlgren-Whitehead model of health determinants, representing opportunities to focus on demographic factors (e.g. older adults), individual lifestyle factors (e.g. alcohol consumption), social and community networks (e.g. social isolation), living and working conditions (e.g. access to preventive healthcare), and general socioeconomic, cultural, and environmental conditions (e.g. changes in legislation).

CONCLUSIONS

Health professionals identified a number of opportunities for subsequent injury prevention, ranging from individually oriented interventions to broader societal interventions. Within their roles, health professionals highlighted potential opportunities to provide education, modify attitudes, engage in multi-disciplinary teamwork, and serve as advocates. Use of these strategies could help to reduce the disability burden presented by subsequent injuries.

Musculoskeletal Health Literacy is Associated With Outcome and Satisfaction of Total Knee Arthroplasty

BACKGROUND

The purpose of this study was to investigate if there is an association between musculoskeletal health literacy with outcome and satisfaction after total knee arthroplasty (TKA).

METHODS

A cross-sectional study was performed at our tertiary center to include patients between one and six years postoperatively after primary TKA. Patients were provided a survey including basic demographics, validated musculoskeletal health literacy scale (Literacy in Musculoskeletal Problems), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and TKA satisfaction (whether they would choose to undergo the same operation again). Patients were categorized as either low or normal health literacy based on number of questions (cutoff 6 out of 9) answered correctly on the Literacy in Musculoskeletal Problems. Statistical analysis included multivariate regression with significance at P < .05.

RESULTS

Four hundred fifty-three individuals fully completed the survey of eligible participants. Two hundred ninety-six individuals (65.3%) had normal health literacy, and one hundred fifty-seven individuals (34.7%) had low health literacy. Average WOMAC (/96) was 18.0 ± 19.7 in the low and 12.1 ± 15.4 in the normal health literacy groups. Patients with low health literacy had significantly higher WOMAC (worse function) than those with normal health literacy (P = .001). Patients with normal musculoskeletal health literacy were significantly more likely to undergo the same operation again (P = .01, odds ratio 2.163).

CONCLUSION

This study shows that patients with low musculoskeletal health literacy have worse outcome scores and are less likely to be satisfied with their TKA. By identifying these patients preoperatively, emphasis can be placed on enhancing procedure expectations and understanding to improve outcome measures and overall satisfaction.

Assessing Readability of Patient Education Materials on Breast Reconstruction by Major US Academic Hospitals as Compared With Nonacademic Sites

PURPOSE

Women undergoing postmastectomy breast reconstruction face many complex choices. A myriad of online patient education materials exist to assist in decision making. Understanding of these materials, termed health literacy, affects surgical decision making and outcomes. The National Institutes of Health recommends writing patient education materials at a sixth- to seventh-grade reading level. The primary goal of this study was to assess readability of online breast reconstruction materials.

METHODS AND MATERIALS

Resources were collected from every academic hospital with a plastic surgery residency program, 97 in total. These data were compared with the top nonacademic Web sites ranked by search engine results, 14 in total. Materials were analyzed using 3 validated readability assessment scales: Coleman-Liau Index, SMOG (Simplified Measure of Gobbledygook) Readability Formula, and Flesch-Kincaid Grade Level. Average readability was analyzed, and results were compared using a 1-way analysis of variance to assess for significance between the different tools and a 2-sided t test to assess for significance between academic and nonacademic readability results.

RESULTS

The mean readability scores across the academic programs were a Coleman-Liau Index of 13.38 (standard Deviation [SD] 2.81, 13th to 14th grade), Flesch-Kincaid Grade Level of 13.04 (SD = 3.9, 13th grade), and SMOG Readability of 13.64 (SD = 2.99, 13th to 14th grade). For the 14 nonacademic sites, results showed a Coleman-Liau Index of 11.93 (SD = 1.14, 12th grade), Flesch-Kincaid of 11.82 (SD = 2.33, 11th to 12th grade), and SMOG Readability of 10.91 (SD = 1.79, 11th grade). One-way analysis of variance demonstrated no significant differences in mean readability scores across the 3 readability tools used (academic F = 2.7804, P = 0.06; nonacademic F = 1.14, P = 0.33). Two-tailed t test results demonstrated that there was statistical significance between readability of the academic in comparison with nonacademic search engine results (t = 2.04, P = 0.04).

CONCLUSIONS

Average readability across all Web sites were much higher than the recommended reading level, at a 13th to 14th grade reading level for academic institutions, and an 11th to 12th grade for nonacademic Web sites. Plastic surgeons may contribute to improving patient understanding and perioperative outcomes through revising patient education materials.

The Canadian Orthopaedic Trauma Society

AIMS

This study reviews the past 30 years of research from the Canadian Orthopedic Trauma Society (COTS), to identify predictive factors that delay or accelerate the course of randomized controlled trials in orthopaedic trauma.

METHODS

We conducted a methodological review of all papers published through the Canadian Orthopaedic Trauma Society or its affiliates. Data abstracted included: year of publication; journal of publication; study type; number of study sites; sample size; and achievement of sample size goals. Information about the study timelines was also collected, including: the date of study proposal to COTS; date recruitment began; date recruitment ended; and date of publication.

RESULTS

In total, 22 studies have been published through the COTS working group, 13 of which are randomized controlled trials (RCTs). In total, 1,423 individual patients have been involved in COTS studies, a mean of 110 patients per trial (22 to 424). Each study was conducted across a mean of approximately six centres (1 to 11) and took nearly ten years (mean 119.9 months (59 to 188)) from presentation of concept to publication. The mean length of enrolment was 63 months (26 to 113) and the mean time from cessation of enrolment to publication 51 months (19 to 78). Regardless of sample size, the only factor associated with a decreased length of enrolment was a higher number of clinical sites (p = 0.041). Neither study sample size nor length of enrolment were associated with total time to publication.

CONCLUSION

Over the last three decades, COTS has developed a multinational strategy to produce high-quality evidence in the field of orthopaedic trauma through 13 multicentre RCTs. Future efficiencies can be realized by recruitment of more clinical sites, improving connectivity between the sites, and the promotion of national streamlined ethics processes. Cite this article: Bone Joint J 2021;103-B(5):898-901.

Health literacy and clinical outcomes in patients with total knee arthroplasty in different rehabilitation settings: An exploratory prospective observational study

BACKGROUND

Limited health literacy is associated with negative clinical outcomes. Although research on health literacy has increased in recent years, there is still a lack of evidence for orthopaedic patients undergoing joint replacement and in the rehabilitation sector.

OBJECTIVES

The aims of this study were to assess health literacy of patients undergoing total knee arthroplasty (TKA) and to observe its course during rehabilitation. Furthermore, we aimed to investigate associations between health literacy and clinical outcomes as well as differences regarding rehabilitation settings.

METHODS

In this prospective observational study, data about (n = 92) patients' health literacy and clinical outcomes were collected. Baseline assessments were conducted preoperatively (T0) and followed-up after three (T1) and six (T2) months. Health literacy was assessed with the European Health Literacy Questionnaire, pain scores, functional restrictions and activity levels with standardised patient-reported outcome measures (PROMs). Subgroup analyses were conducted regarding inpatient and outpatient rehabilitation.

RESULTS

Out of 92 patients, 77 completed postoperative rehabilitation between T0 and T1. Health literacy improved from T0 to T1 (p < 0.001) and subsequently remained constant until T2. Although the study showed an average improvement in health literacy scores in post-discharge rehabilitation, subgroup analyses indicated that patients did not achieve higher levels of health literacy. Pain scores were higher in patients undergoing outpatient rehabilitation (p = 0.022). No differences were found in other outcomes regarding rehabilitation settings and health literacy.

CONCLUSIONS

Based on our results, there seems to be no association between health literacy and clinical outcomes. Furthermore, the results regarding health literacy over the rehabilitation period indicated a need for enhancement of educational strategies to strengthen health literacy in the context of inpatient and outpatient orthopaedic rehabilitation.

Prospective Evaluation of Health Literacy and Its Impact on Outcomes in Emergency General Surgery

BACKGROUND

Health literacy (HL) is an important component of national health policy. The aim of our study was to assess the prevalence of low HL (LHL) and determine its impact on outcomes after emergency general surgery (EGS).

METHODS

We performed a (2016-2017) prospective cohort analysis of adult EGS patients. HL was assessed using the Short Assessment of HL score. LHL was defined as Short Assessment of HL score <14. Outcomes were the prevalence of LHL, compliance with medications, wound/drain care, 30-d complications, 30-d readmission, and time to resuming activities of daily living.

RESULTS

We enrolled 900 patients. The mean age was 43 ± 11 y. Overall, 22% of the patients had LHL. LHL patients were more likely to be Hispanics (59% versus 15%, P < 0.01), uninsured (50% versus 20%, P < 0.01), have lower socioeconomic status (80% versus 40%, P < 0.02), and are less likely to have completed college (5% versus 60%, P < 0.01) compared with HL patients. On regression analysis, LHL was associated with lower medication compliance (OR: 0.81, [0.4-0.9], P = 0.02), inadequate wound/drain care (OR: 0.75, [0.5-0.8], P = 0.01), 30-d complications (OR: 1.95, [1.3-2.5], P < 0.01), and 30-d readmission (OR: 1.51, [1.2-2.6], P = 0.02). The median time of resuming activities of daily living was longer in patients with LHL than HL patients (4 d versus 7 d, P < 0.01).

CONCLUSIONS

One in five patients undergoing EGS has LHL. LHL is associated with decreased compliance with discharge instructions, medications, and wound/drain care. Health literacy must be taken into account when discussing the postoperative plan and better instruction is needed for patients with LHL.

LEVEL OF EVIDENCE

Level III.

STUDY TYPE

Prognostic.

Comparison of health literacy in privately insured and public hospital orthopaedic patients

Objective The aim of the present study was to quantify and compare patient health literacy between privately insured and public orthopaedic patients. Methods As part of the present cross-sectional study, elective postoperative orthopaedic patients across two sites were recruited and asked to complete a questionnaire at the first postoperative out-patient review. Patients were divided into three groups: (1) a public group (Public); (2) a private group (Private-pre); and (3) a private group that completed the questionnaire immediately after the out-patient review (Private-post). The questionnaire consisted of six questions regarding surgical management, expected recovery time and postoperative instructions. Patients were further asked to grade their satisfaction regarding information received throughout their management. Results In all, 150 patients completed the questionnaire, 50 in each of the three groups. Patients in the Public, Private-pre and Private-post groups answered a mean 2.74, 3.24 and 4.70 of 6 questions correctly respectively. The Private-pre group was 1.46-fold more likely to demonstrate correct health literacy than the Public group, whereas the Private-post group was 2.44-fold more likely to demonstrate improved health literacy than the Private-pre group. Patient satisfaction with information received was not associated with health literacy. Conclusion Limited health literacy in orthopaedic patients continues to be an area of concern. Both private and public orthopaedic patients demonstrated poor health literacy, but private patients demonstrated significant improvement after the out-patient review. What is known about the topic? Limited health literacy is a growing public health issue worldwide, with previous literature demonstrating a prevalence of low health literacy of 26% and marginal health literacy of 20% among all patient populations. Of concern, limited health literacy has been shown to result in a range of adverse health outcomes, including increased mortality and chronic disease morbidity. It has also been associated with an increased rate of hospitalisation and use of healthcare resources. Previous work in the orthopaedic trauma setting has found poor levels of health literacy and poor understanding of diagnosis, management and prognosis in the Australian public health system. Promisingly, it has been shown that simple, targeted interventions can improve patient health literacy. What does this paper add? This study further highlights that health literacy exhibited by orthopaedic patients is poor, particularly among patients in the public healthcare system. The present study is the first to have demonstrated that health literacy is poor among patients in both the public and private healthcare systems, despite these patients having distinctly different demographics. Promisingly, the present study shows that, unlike public orthopaedic out-patient review, private orthopaedic out-patient review appears to be effective in increasing patient health literacy regarding their orthopaedic condition and its management. What are the implications for practitioners? Health literacy is essential for patients to effectively communicate with doctors and achieve good health outcomes. Healthcare professionals need to be aware that a large proportion of patients have poor health literacy and difficulty understanding health-related information, particularly pertaining to that surrounding diagnosis, management and prognosis. This study highlights the need for healthcare professionals to ensure that they communicate with patients at an appropriate level to ensure patient understanding during the pre-, peri- and postoperative stages of management. Further, healthcare professionals should be aware that there is potential to improve patient health literacy at routine out-patient review, provided that this opportunity is used as an educational resource.

Osteosarcoma Online Resources: A Quantitative Assessment of the Understandability and Readability of Web-based Patient Education Material (Preprint)

Background

Patients often turn to web-based resources following the diagnosis of osteosarcoma. To be fully understood by average American adults, the American Medical Association (AMA) and National Institutes of Health (NIH) recommend web-based health information to be written at a 6th grade level or lower. Previous analyses of osteosarcoma resources have not measured whether text is written such that readers can process key information (understandability) or identify available actions to take (actionability). The Patient Education Materials Assessment Tool (PEMAT) is a validated measurement of understandability and actionability.

Objective

The purpose of this study was to evaluate web-based osteosarcoma resources using measures of readability, understandability, and actionability.

Methods

Using the search term “osteosarcoma,” two independent Google searches were performed on March 7, 2020 (by AGS), and March 11, 2020 (by TRG). The top 50 results were collected. Websites were included if they were directed at providing patient education on osteosarcoma. Readability was quantified using validated algorithms: Flesh-Kincaid Grade Ease (FKGE), Flesch-Kincaid Grade-Level (FKGL). A higher FKGE score indicates that the material is easier to read. All other readability scores represent the US school grade level. Two independent PEMAT assessments were performed with independent scores assigned for both understandability and actionability. A PEMAT score of 70% or below is considered poorly understandable or poorly actionable. Statistical significance was defined as P≤.05.

Results

Two searches yielded 53 unique websites, of which 37 (70%) met the inclusion criteria. The mean FKGE and FKGL scores were 40.8 (SD 13.6) and 12.0 (SD 2.4), respectively. No website scored within the acceptable NIH or AHA recommended reading level. Only 4 (11%) and 1 (3%) website met the acceptable understandability and actionability threshold. Both understandability and actionability were positively correlated with FKGE (ρ=0.55, P<.001; ρ=0.60, P<.001), but were otherwise not significantly associated with other readability scores. There were no associations between readability (P=.15), understandability (P=.20), or actionability (P=.31) scores and Google rank.

Conclusions

Overall, web-based osteosarcoma patient educational materials scored poorly with respect to readability, understandability, and actionability. None of the web-based resources scored at the recommended reading level. Only 4 achieved the appropriate score to be considered understandable by the general public. Authors of patient resources should incorporate PEMAT and readability criteria to improve web-based resources to support patient understanding.

The role of health literacy in orthopaedic rehabilitation after total knee and hip arthroplasty: A scoping review

BACKGROUND

Health literacy (HL) is a key aspect in empowering patient education as part of orthopaedic rehabilitation after total knee or hip arthroplasty (TKA/THA).

OBJECTIVES

This scoping review aims to demonstrate the prevalence of patient-related outcome measures in studies on the effectiveness of orthopaedic rehabilitation of older people after TKA/THA. The review also focuses on the identification of outcome measures that assess patients' HL or HL-related aspects.

METHODS

A scoping literature search was conducted using the JBI methodology for scoping reviews. The databases MEDLINE (PubMed), CINAHL Complete, The Cochrane Library, Academic Search Elite, and ERIC were searched with keywords and phrases to find relevant literature. Identified outcome measures were conceptually analysed in a peer reviewed procedure. Those with suspected HL-related content were analysed at item level. Text analyses were performed using MAXQDA.

RESULTS

117 papers were included in this review. 45 patient-related outcome measures could be found, 2 of which assess HL-related aspects. No paper could be found that assessed patients' HL in orthopaedic rehabilitation after TKA/THA.

CONCLUSIONS

HL has hitherto been of limited importance in orthopaedic rehabilitation. Health professionals are responsible for assessing patients' health literacy and developing appropriate strategies for patient education in the context of orthopaedic rehabilitation.

Patient comprehension of hip arthroscopy: an investigation of health literacy

Several studies have demonstrated that patients have significant impairments in understanding their injury and appropriate course of management in orthopedic surgery. The purpose of this investigation is to determine if patients are able to obtain a fundamental understanding of the requisite care associated with hip arthroscopy. Any patient who elected to have hip arthroscopy was prospectively recruited to participate in the study. All patients were told they would be asked to complete a questionnaire about their surgery and post-operative instructions. The answers to each question of the questionnaire they would receive at the first post-operative visit were verbally given to each patient during the pre-operative visit. They were also given a post-operative instruction sheet on the day of surgery that contained answers to the questionnaire. At the first post-operative visit, all patients were then asked to complete a multiple-choice questionnaire prior to seeing the surgeon. A total of 56 patients (14 males, 42 females) were enrolled. All patients reported they had read the post-operative instruction sheet. The average number of correct answers was 6.5 ± 0.6 (95% CI 6 - 7) out of 11 questions (59% correct response rate ±18% [95% CI 52 - 66%]). Although we made significant pre-operative oral and written efforts to help patients achieve an elementary level of health literacy regarding their forthcoming hip arthroscopy, many patients did not achieve satisfactory comprehension. Even with instruction and information given verbally and physically (via post-operative instruction sheet) patients did not obtain satisfactory comprehension of their surgical procedure. New ways (through video, simplified cartoons or verbal explanations) must be considered in educating patients concerning surgical procedures to increase comprehension and health literacy.

Patient Comprehension of Common Orthopedic Terminology

Background:

Medical terminology is often complex and confusing to lay people. Even common terms used by health care professionals often have other meanings and can easily be misinterpreted.

Objective:

This study aimed to identify patient comprehension of common orthopedic terminology across multiple hospital settings.

Methods:

A cross-sectional study was conducted from September 2016 until November 2016 at an Academic Level 1 trauma center. One hundred and fifty emergency department patients and 150 orthopedic inpatients with isolated orthopedic injuries were included. Participants completed a questionnaire consisting of 12 multiple-choice questions determining patient comprehension of common orthopedic terminology.

Key Results:

Total comprehension scores on the questionnaire were scored as number correct out of 11. In the emergency department, the mean total score was 5.01 compared to 5.45 in orthopedic inpatients (p = .046). Patients in both groups demonstrated poor understanding of medical terms (including fracture, ruptured tendon) and anatomical terms. In contrast, nonmedical terminology such as broken bone was better understood. Fifty-seven percent of participants stated that they understood their orthopedic condition completely. Notably, there was no correlation (r = .15) between comprehension and participants describing that they completely understood their orthopedic condition.

Conclusions:

Emergency department patients and orthopedic inpatients demonstrate poor comprehension of orthopedic terminology. Health care professionals should assume a poor level of comprehension during their interactions with orthopedic patients and ensure that patient communication is clear, concise, and informative to facilitate better patient comprehension, informed consent, and an improved doctor-patient relationship. [HLRP: Health Literacy Research and Practice. 2019;3(3):e187–e193.]

Plain Language Summary:

This study evaluated patient comprehension of common orthopedic terminology in orthopedic inpatients and patients presenting to the emergency department with orthopedic injuries. This study found that patients demonstrate poor understanding of terminology used commonly by health care professionals, and that patients demonstrated little insight into their lack of comprehension. These findings have implications for doctor-patient communication, informed consent, and patient satisfaction.

The development and internal validation of a model to predict functional recovery after trauma

Objective

To develop and internally validate the PROgnosis of functional recovery after Trauma (PRO-Trauma) prediction model.

Design

A prospective single-center longitudinal cohort study. Patients were assessed at 6 weeks and 12 months post-injury.

Methods

Patients that presented at the emergency department with an acute traumatic injury, were prompted for participation. Patients that completed the assessments at 6 weeks and 12 months post injury were included. Exclusion criteria: age < 18, age > 65, pathologic fractures, injuries that resulted in severe neurologic deficits. The predicted outcome, functional recovery, was defined as a Short Musculoskeletal Function Assessment (SMFA-NL) Problems with Daily Activities (PDA) subscale ≤ 12.2 points at 12 months post-injury (Dutch population norm). Predictors were: gender, age, living with partner, number of chronic health conditions, SMFA-NL PDA score 6 weeks post-injury, ICU admission, length of stay in hospital, injury severity score, occurrence of complications and treatment type. All predictors were obtained before 6 weeks post-injury. Missing data were multiply imputed. Predictor variables were selected using backward stepwise multivariable logistic regression. Hosmer-Lemeshow tests were used to evaluate calibration. Bootstrap resampling was used to internally validate the final model.

Results

A total of 246 patients were included, of which 104 (44%) showed functional recovery. The predictors in the final PRO-Trauma model were: living with partner, the number of chronic health conditions, SMFA-NL PDA subscale score at 6 weeks post-injury and length of stay in hospital. The apparent R² was 0.33 [0.33;0.34], the c-statistic was 0.79 [0.79;0.80]. Hosmer-Lemeshow test indicated good calibration (p = 0.92). Optimism-corrected R² was 0.28 [0.27;0.29] and the optimism-corrected Area Under the Curve was 0.77 [0.77;0.77].

Conclusion

The PRO-Trauma prediction model can be used to obtain valid predictions of attaining functional recovery after trauma at 12 months post-injury. The PRO-Trauma prediction model showed acceptable calibration and discrimination.

Health literacy and surgery expectations in total hip and knee arthroplasty patients

OBJECTIVES

This study assessed patients' health literacy and expectations for total hip (THA) and total knee (TKA) replacement surgery, and compared health literacy levels of patients and their caregivers.

METHODS

A convenience sample of 200 THA/TKA participants, patients and their caregivers, participated in this study.

RESULTS

Results demonstrated no statistical difference in health literacy between patients and their caregivers. However, patients with lower health literacy had significantly lower expectations for walking after surgery.

CONCLUSIONS

Practices should be aware that caregivers may not be any better equipped to consume and use complicated patient education materials than the patient they are assisting. Additionally, lower health literacy, rather than or in addition to race or social factors, may contribute to disparities in opting for THA/TKA because of lower expectations for walking after surgery.

PRACTICE IMPLICATIONS

Healthcare practices should develop patient educational materials that are easy for all patients and caregivers to understand, especially those with low health literacy. Additional patient education and counseling may help patients with low health literacy realistically align their expectations and mitigate barriers to consenting to surgery due to low expectations.

The experience and understanding of pain management in recently discharged adult trauma patients: A qualitative study

INTRODUCTION

Pain following injury is often intense, prolonged and debilitating. If poorly managed, this acute pain has the potential to delay rehabilitation and lead to chronic pain. Recent quantitative Australian research recommends implementing further information and interventions to improve trauma patient outcomes, however, to ensure effectiveness, exploration of the patient perspective is imperative to ensure the success of future pain management strategies. This study aimed to gain understanding about the experience of pain management using prescribed analgesic regimens of recently discharged adult trauma patients.

METHOD

Semi-structured interviews were used to explore the experiences and understandings of trauma patients in managing pain using prescribed analgesic regimens during the initial post-hospital discharge period. Twelve participants were purposively selected over a 6-month period at a level one trauma outpatient clinic based on questionnaire responses indicating pain related concerns. Qualitative data were thematically analysed.

RESULTS

The overarching finding was that injuries and inadequate pain management incapacitate the patient at home. Four main themes were developed: injury pain is unique and debilitating; patients are uninformed at hospital discharge; patients have low confidence with pain management at home; and patients make independent decisions about pain management. Patients felt they were not given adequate information at hospital discharge to support them to make effective decisions about their pain management practices at home.

CONCLUSION

There is a need for more inclusive and improved hospital discharge processes that includes patient and family education around pain management following injury. To achieve this, clinician education, support and training is essential.