Abstract
Rationale, aims, and objectives: Clinical studies show equivalent health outcomes from interventional procedures and treatment with medication only for stable angina patients. However, patients may be subject to overuse or access barriers for interventional procedures and may exhibit suboptimal adherence to medications. Our objective is to evaluate whether community-level health literacy is associated with treatment selection and medication adherence patterns. Method: The sample included Medicare fee-for-service beneficiaries (20% random sample) with stable angina in 2007-2013. We used an area-level health literacy variable because of the lack of an individual measure in claims. We measured the association between (a) area-based health literacy with treatment selection (medication only, percutaneous coronary intervention [PCI], or coronary artery bypass grafting (CABG) surgery) and (b) area-based health literacy with medication adherence. We controlled for other factors including demographics, co-morbidity burden, dual eligibility, and area deprivation index. Results: We identified 8300 patients of whom 8.7% lived in a low health literacy area. Overall, 56% of patients received medication only, 28% received PCI, and 15% received CABG. Patients in low health literacy areas were less likely to receive CABG (−3.5 percentage points; 95% CI, −6.8 to −0.3) than were patients in high health literacy areas, but the significance was sensitive to specification. Overall, 81.5% and 71.5% of patients were adherent to antianginals and statins, respectively. Living in low health literacy areas was associated with lower adherence to antianginals (−3.3 percentage points; 95% CI, −6.1 to −0.6) but not statins. Conclusions: Low area-based health literacy was associated with being less likely to receive CABG and lower adherence, but the differences between low and high health literacy areas were small and sensitive to model specification. Individual factors such as dual eligibility status and race/ethnicity had stronger associations with outcomes than had area-based health literacy, suggesting that this area-based measure was inadequate to account for social determinants in this study.
Original language | English (US) |
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Pages (from-to) | 1711-1721 |
Number of pages | 11 |
Journal | Journal of Evaluation in Clinical Practice |
Volume | 26 |
Issue number | 6 |
DOIs | |
State | Published - Dec 2020 |
Funding
The database infrastructure used for this project was funded by the Pharmacoepidemiology Gillings Innovation Lab (PEGIL) for the Population-Based Evaluation of Drug Benefits and Harms in Older US Adults (GIL200811.0010), the Center for Pharmacoepidemiology, Department of Epidemiology, UNC Gillings School of Global Public Health, the CER Strategic Initiative of UNC's Clinical Translational Science Award (UL1TR001111), the Cecil G. Sheps Center for Health Services Research, UNC, and the UNC School of Medicine. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was partially supported by a National Research Service Award Pre-Doctoral/Post-Doctoral Traineeship from the Agency for Healthcare Research and Quality sponsored by The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill (grant number T32-HS000032). Health literacy estimates were generated through research supported by National Institute on Aging (grant number R01AG046267) (PIs: Bailey/Fang). The database infrastructure used for this project was funded by the Pharmacoepidemiology Gillings Innovation Lab (PEGIL) for the Population‐Based Evaluation of Drug Benefits and Harms in Older US Adults (GIL200811.0010), the Center for Pharmacoepidemiology, Department of Epidemiology, UNC Gillings School of Global Public Health, the CER Strategic Initiative of UNC's Clinical Translational Science Award (UL1TR001111), the Cecil G. Sheps Center for Health Services Research, UNC, and the UNC School of Medicine. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was partially supported by a National Research Service Award Pre‐Doctoral/Post‐Doctoral Traineeship from the Agency for Healthcare Research and Quality sponsored by The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill (grant number T32‐HS000032). Health literacy estimates were generated through research supported by National Institute on Aging (grant number R01AG046267) (PIs: Bailey/Fang). Schuyler Jones has research grants from the Agency for Healthcare Research and Quality, AstraZeneca, American Heart Association, Bristol‐Myers Squibb, Doris Duke Charitable Foundation, Merck, and Patient‐Centered Outcomes Research Institute. He has received honoraria/other from the American College of Physicians, Bayer, Bristol‐Myers Squibb, Daiichi Sankyo, and Janssen Pharmaceuticals.
Keywords
- health literacy
- medical decision making
- medication adherence
- social determinants of health
ASJC Scopus subject areas
- Health Policy
- Public Health, Environmental and Occupational Health