Health Literacy Burden Is Associated With Access to Liver Transplantation

Addressing Current Deficits in Patient Education Materials Through Crowdsourcing

BACKGROUND

Patient education materials are commonly reported to be difficult to understand.

OBJECTIVES

We aimed to use crowdsourcing to improve patient education materials at our institution.

METHODS

This was a department-wide quality improvement project to increase organizational health literacy. There are 6 phases of this pilot study: (1) evaluating preexisting patient education materials, (2) evaluating online patient education materials at the society (the American Society of Plastic Surgeon) and government level (Medline Plus), (3) redesigning our patient education material and reevaluating the education material, (4) crowdsourcing to evaluate understandability of the new patient education material, (5) data analysis, and (6) incorporating crowdsourcing suggestions to the patient education material.

RESULTS

Breast-related patient education materials are not easy to read at the institution level, the society level, and the government level. Our new implant-based breast reconstruction patient education material is easy to read as demonstrated by the crowdsourcing evaluation. More than 90% of the participants reported our material is "very easy to understand" or "easy to understand." The crowdsourcing process took 1.5 days, with 700 workers responding to the survey. The total cost was $9. After incorporating participants' feedback into the finalized material, the readability of the material is at the recommended reading level. The material also had the recommended length (between 400 and 800 words).

DISCUSSION

Our study demonstrated a pathway for clinicians to efficiently obtain a large amount of feedback to improve patient education materials. Crowdsourcing is an effective tool to improve organizational health literacy.

Comparison of Patient Education Materials Generated by Chat Generative Pre-Trained Transformer Versus Experts: An Innovative Way to Increase Readability of Patient Education Materials

INTRODUCTION

Improving patient education materials may improve patient outcomes. This study aims to explore the possibility of generating patient education materials with the assistance of a large language model, Chat Generative Pre-Trained Transformer (ChatGPT). In addition, we compare the accuracy and readability of ChatGPT-generated materials versus expert-generated materials.

METHODS

Patient education materials in implant-based breast reconstruction were generated by experts and ChatGPT independently. Readability and accuracy of the materials are the main outcomes. Readability of the materials was compared using Flesch-Kincaid score. Accuracy of the materials generated by ChatGPT was evaluated by 2 independent reviewers. Content errors are categorized into information errors, statistical errors, and multiple errors (errors more than 2 types).

RESULTS

The content generated by experts had higher readability. The Flesch-Kincaid score is at the 7.5 grade for expert-generated materials, whereas the content generated by ChatGPT is at the 10.5 grade (despite ChatGPT being asked to generate content at the seventh grade level). The accuracy of ChatGPT-generated content is 50%, with most errors being information errors. ChatGPT often provides information about breast reduction or breast augmentation, despite being asked specifically about breast reconstruction. Despite its limitation, ChatGPT significantly reduced the time required to generate patient education materials. Although it takes experts 1 month to generate patient education materials, ChatGPT generates materials within 30 minutes.

CONCLUSIONS

ChatGPT can be a powerful starting tool to generate patient education materials. However, its readability and accuracy still require improvements.

Community-level social vulnerability and individual socioeconomic status on liver transplant referral outcome

BACKGROUND

Recent endeavors emphasize the importance of understanding early barriers to liver transplantation (LT) by consistently collecting data on patient demographics, socioeconomic factors, and geographic social deprivation indices.

METHODS

In this retrospective single-center cohort study of 1657 adults referred for LT evaluation, we assessed the association between community-level vulnerability and individual socioeconomic status measures on the rate of waitlisting and transplantation. Patients' addresses were linked to Social Vulnerability Index (SVI) at the census tract-level to characterize community-level vulnerability. Descriptive statistics were used to describe patient characteristics. Multivariable cause-specific HRs were used to assess the association between community-level vulnerability, individual measures of the socioeconomic status, and LT evaluation outcomes (waitlist and transplantation).

RESULTS

Among the 1657 patients referred for LT during the study period, 54% were waitlisted and 26% underwent LT. A 0.1 increase in overall SVI correlated with an 8% lower rate of waitlisting (HR 0.92, 95% CI 0.87-0.96, p < 0.001), with socioeconomic status, household characteristics, housing type and transportation, and racial and ethnic minority status domains contributing significantly to this association. Patients residing in more vulnerable communities experienced a 6% lower rate of transplantation (HR 0.94, 95% CI 0.91- 0.98, p = 0.007), with socioeconomic status and household characteristic domain of SVI significantly contributing to this association. At the individual level, both government insurance and employment status were associated with lower rates of waitlisting and transplantation. There was no association with mortality prior to waitlisting or mortality while on the waitlist.

CONCLUSION

Our findings indicate that both individual and community measures of the socioeconomic status (overall SVI) are associated with LT evaluation outcomes. Furthermore, we identified individual measures of neighborhood deprivation associated with both waitlisting and transplantation.

Pretransplant Patient Education in Solid-organ Transplant: A Narrative Review

Education for pretransplant, solid-organ recipient candidates aims to improve knowledge and understanding about the transplant process, outcomes, and potential complications to support informed, shared decision-making to reduce fears and anxieties about transplant, inform expectations, and facilitate adjustment to posttransplant life. In this review, we summarize novel pretransplant initiatives and approaches to educate solid-organ transplant recipient candidates. First, we review approaches that may be common to all solid-organ transplants, then we summarize interventions specific to kidney, liver, lung, and heart transplant. We describe evidence that emphasizes the need for multidisciplinary approaches to transplant education. We also summarize initiatives that consider online (eHealth) and mobile (mHealth) solutions. Finally, we highlight education initiatives that support racialized or otherwise marginalized communities to improve equitable access to solid-organ transplant. A considerable amount of work has been done in solid-organ transplant since the early 2000s with promising results. However, many studies on education for pretransplant recipient candidates involve relatively small samples and nonrandomized designs and focus on short-term surrogate outcomes. Overall, many of these studies have a high risk of bias. Frequently, interventions assessed are not well characterized or they are combined with administrative and data-driven initiatives into multifaceted interventions, which makes it difficult to assess the impact of the education component on outcomes. In the future, well-designed studies rigorously assessing well-defined surrogate and clinical outcomes will be needed to evaluate the impact of many promising initiatives.

A scoping review of inequities in access to organ transplant in the United States

Background

Organ transplant is the preferred treatment for end-stage organ disease, yet the majority of patients with end-stage organ disease are never placed on the transplant waiting list. Limited access to the transplant waiting list combined with the scarcity of the organ pool result in over 100,000 deaths annually in the United States. Patients face unique barriers to referral and acceptance for organ transplant based on social determinants of health, and patients from disenfranchised groups suffer from disproportionately lower rates of transplantation. Our objective was to review the literature describing disparities in access to organ transplantation based on social determinants of health to integrate the existing knowledge and guide future research.

Methods

We conducted a scoping review of the literature reporting disparities in access to heart, lung, liver, pancreas and kidney transplantation based on social determinants of health (race, income, education, geography, insurance status, health literacy and engagement). Included studies were categorized based on steps along the transplant care continuum: referral for transplant, transplant evaluation and selection, living donor identification/evaluation, and waitlist outcomes.

Results

Our search generated 16,643 studies, of which 227 were included in our final review. Of these, 34 focused on disparities in referral for transplantation among patients with chronic organ disease, 82 on transplant selection processes, 50 on living donors, and 61 on waitlist management. In total, 15 studies involved the thoracic organs (heart, lung), 209 involved the abdominal organs (kidney, liver, pancreas), and three involved multiple organs. Racial and ethnic minorities, women, and patients in lower socioeconomic status groups were less likely to be referred, evaluated, and added to the waiting list for organ transplant. The quality of the data describing these disparities across the transplant literature was variable and overwhelmingly focused on kidney transplant.

Conclusions

This review contextualizes the quality of the data, identifies seminal work by organ, and reports gaps in the literature where future research on disparities in organ transplantation should focus. Future work should investigate the association of social determinants of health with access to the organ transplant waiting list, with a focus on prospective analyses that assess interventions to improve health equity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01616-x.

Liver health literacy and social stigma of liver disease: A general population e-survey

BACKGROUND

Health literacy is increasingly recognized as an essential determinant for the health of the population. Liver patients report perceived stigma to be a considerable problem. Little is however known about liver health literacy in the general population and to what extent liver disease is considered stigmatizing in comparison with other chronic diseases. We aimed to explore these knowledge gaps.

METHODS

We performed an exploratory e-survey in a statistically representative sample of 500 Swedes from the general population. A questionnaire developed for this purpose investigated awareness, attention, knowledge and attitudes towards liver health and compared some aspects with other common health problems.

FINDINGS

Few worry (23%), think (28%), discuss with their doctor (31%) or hear about liver health in the news (19%). Few (18%) had a liver test in the last year and knew (23%) what is considered a normal liver test. More knew what is considered normal blood pressure (89%), blood sugar (74%) and BMI (73%). Few (22%) talk about liver health, mainly (50%) because abuse is presumed. Many (36%) believe that cirrhosis is only caused by alcohol, 31% that the liver produces urine and 21% that you can survive without a liver. Only mental illness (78%) and obesity (74%) were considered more stigmatizing than liver cirrhosis (61%).

INTERPRETATION

The study confirms often held views that liver health receives less attention than many other health areas. Knowledge about liver health is generally poor, and liver cirrhosis carries significant social stigma. Improving public awareness and knowledge about liver health, and thereby ameliorating stigma, should be essential parts of policy objectives and action plans to improve liver health in Europe.

FUNDING

This research was supported by a general grant from the Bengt Ihre Foundation.

Do Social Determinants Define "Too Sick" to Transplant in Patients With End-stage Liver Disease?

BACKGROUND

Delisting for being "too sick" to be transplanted is subjective. Previous work has demonstrated that the mortality of patients delisted for "too sick" is unexpectedly low. Transplant centers use their best clinical judgment for determining "too sick," but it is unclear how social determinants influence decisions to delist for "too sick." We hypothesized that social determinants and Donor Service Area (DSA) characteristics may be associated with determination of "too sick" to transplant.

METHODS

Data were obtained from the Scientific Registry of Transplant Recipients for adults listed and removed from the liver transplant waitlist from 2002 to 2017. Patients were included if delisted for "too sick." Our primary outcome was Model for End-Stage Liver Disease (MELD) score at waitlist removal for "too sick." Regression assessed the association between social determinants and MELD at removal for "too sick."

RESULTS

We included 5250 delisted for "too sick" at 127 centers, in 53 DSAs, over 16 years. The mean MELD at delisting for "too sick" was 25.8 (SD ± 11.2). On adjusted analysis, social determinants including age, race, sex, and education predicted the MELD at delisting for "too sick" (P < 0.05).

CONCLUSIONS

There is variation in delisting MELD for "too sick" score across DSA and time. While social determinants at the patient and system level are associated with delisting practices, the interplay of these variables warrants additional research. In addition, center outcome reports should include waitlist removal rate for "too sick" and waitlist death ratios, so waitlist management practice at individual centers can be monitored.