BACKGROUNDWe sought to examine the relationship between literacy and heart failure-related quality of life (HFQOL), and to explore whether literacy-related differences in knowledge, self-efficacy and/or self-care behavior explained the relationship.METHODSWe recruited patients with symptomatic heart failure (HF) from four academic medical centers. Patients completed the short version of the Test of Functional Health Literacy in Adults (TOFHLA) and questions on HF-related knowledge, HF-related self-efficacy, and self-care behaviors. We assessed HFQOL with the Heart Failure Symptom Scale (HFSS) (range 0–100), with higher scores denoting better quality of life. We used bivariate (t-tests and chi-square) and multivariate linear regression analyses to estimate the associations between literacy and HF knowledge, self-efficacy, self-care behaviors, and HFQOL, controlling for demographic characteristics. Structural equation modeling was conducted to assess whether general HF knowledge, salt knowledge, self-care behaviors, and self-efficacy mediated the relationship between literacy and HFQOL.RESULTSWe enrolled 605 patients with mean age of 60.7 years; 52% were male; 38% were African-American and 16% Latino; 26% had less than a high school education; and 67% had annual incomes under $25,000. Overall, 37% had low literacy (marginal or inadequate on TOFHLA). Patients with adequate literacy had higher general HF knowledge than those with low literacy (mean 6.6 vs. 5.5, adjusted difference 0.63, p < 0.01), higher self-efficacy (5.0 vs. 4.1 ,adjusted difference 0.99, p < 0.01), and higher prevalence of key self-care behaviors (p < 0.001). Those with adequate literacy had better HFQOL scores compared to those with low literacy (63.9 vs. 55.4, adjusted difference 7.20, p < 0.01), but differences in knowledge, self-efficacy, and self-care did not mediate this difference in HFQOL.CONCLUSIONLow literacy was associated with worse HFQOL and lower HF-related knowledge, self-efficacy, and self-care behaviors, but differences in knowledge, self-efficacy and self-care did not explain the relationship between low literacy and worse HFQOL.

Background Self-care training can reduce hospitalization for heart failure (HF), and more intensive intervention may benefit more vulnerable patients, including those with low literacy. Methods and Results A 1-year, multisite, randomized controlled comparative effectiveness trial with 605 patients with HF. Those randomized to single session received a 40-minute in-person, literacy-sensitive training; the multisession group received the same initial training and then ongoing telephone-based support. The primary outcome was combined incidence of all-cause hospitalization or death; secondary outcomes included HF-related hospitalization and HF-related quality of life (HFQOL) with pre-specified stratification by literacy. Overall, the incidence of all-cause hospitalization and death did not differ between intervention groups (incidence rate ratio (IRR)=1.01 (95% Confidence Interval (CI): 0.83, 1.22). The effect of multisession training compared with single session training differed by literacy group: among low literacy, multisession yielded lower incidence of all-cause hospitalization and death: IRR=0.75 (0.45,1.25); and among higher literacy, multisession yielded higher incidence: IRR=1.22 (0.99,1.50) (interaction p=0.048). For HF-related hospitalization: among low literacy, multisession yielded lower incidence: IRR=0.53 (95% CI: 0.25,1.12); and among higher literacy, multisession yielded higher incidence: IRR=1.32 (95% CI: 0.92,1.88) (interaction p=0.005). HFQOL improved more for patients receiving multisession compared with single session at 1 and 6 months, but the difference at 12 months was smaller. Effects on HFQOL did not differ by literacy. Conclusions Overall, an intensive multisession intervention did not change clinical outcomes compared with a single session intervention. People with low literacy appear to benefit more from multisession than people with higher literacy. Clinical Trial Registration Information ClinicalTrials.gov; Identifier: NCT00378950.

Objective. To examine the effect of rural hospital closures on the local economy. Data Sources. U.S. Census Bureau, OSCAR, Medicare Cost Reports, and surveys of individuals knowledgeable about local hospital closures. Study Design. Economic data at the county level for 1990-2000 were combined with information on hospital closures. The study sample was restricted to rural counties experiencing a closure during the sample period. Longitudinal regression methods were used to estimate the effect of hospital closure on per-capita income, unemployment rate, and other community economic measures. Models included both leading and lagged closure terms allowing a preclosure economic downturn as well as time for the closure to be fully realized by the community. Data Collection. Information on closures was collected by contacting every state hospital association, reconciling information gathered with that contained in the American Hospital Association file and OIG reports. Principal Findings. Results indicate that the closure of the sole hospital in the community reduces per-capita income by $703 ( po0.05) or 4 percent ( po0.05) and increases the unemployment rate by 1.6 percentage points ( po0.01). Closures in communities with alternative sources of hospital care had no long-term economic impact, although income decreased for 2 years following the closure. Conclusions. The local economic effects of a hospital closure should be considered when regulations that affect hospitals' financial well-being are designed or changed.

Background The optimal strategy for promoting self-care for heart failure (HF) is unclear. Methods and Results We conducted a randomized trial to determine whether a “teach to goal” (TTG) educational and behavioral support program provided incremental benefits to a brief (one hour) educational intervention (BEI) for knowledge, self-care behaviors, and HF-related quality of life (HFQOL). The TTG program taught use of adjusted-dose diuretics and then reinforced learning goals and behaviors with 5-8 telephone counseling sessions over one month. Participants’ (N=605) mean age was 61 years; 37% had marginal or inadequate literacy; 69% had ejection fraction < 0.45; and 31% had class III or IV symptoms. The TTG group had greater improvements in general and salt knowledge (p < 0.001) and greater increases in self-care behaviors (from mean 4.8 to 7.6 for TTG vs. 5.2 to 6.7 for BEI; p<0.001). HFQOL improved from 58.5 to 64.6 for the TTG group but did not change for the BEI group (64.7 to 63.9; p < 0.001 for the difference in change scores). Improvements were similar regardless of participants’ literacy level. Conclusions Telephone reinforcement of learning goals and self-care behaviors improved knowledge, health behaviors, and HF-related QOL compared to a single education session.

We analyzed a statewide survey of individuals with chronic back and neck pain to determine whether prevalence and care use varied by patient race or ethnicity. We conducted a telephone survey of a random sample of 5,357 North Carolina households in 2006. Adults with chronic (>3 months duration or >24 episodes of pain per year), impairing back or neck pain were identified and were asked to complete a survey about their health and care utilization. 837 respondents (620 white, 183 black, 34 Latino) reported chronic back or neck pain. Whites and blacks had similar rates of chronic back pain. Back pain prevalence was lower in Latinos (10.4% [9.3–11.6] vs 6.3% [3.8–8.8] ), likely due to their younger age; and the prevalence of chronic, disabling neck pain was lower in blacks (2.5% [1.9–3.1] vs 1.1% [0.04–1.9]). Blacks had higher pain scores in the previous 3 months (5.2 vs 5.9 p<0.05), and higher Roland disability scores (0–23 point scale): 14.2 vs 16.8, p<0.05. Care seeking was similar among races (83% white, 85% black, 72% Latino). Use of opioids was also similar between races, at 49% for whites, 52% for blacks, and trended lower at 35% for Latinos. We found few racial/ethnic differences in care-seeking, treatment use, and use of narcotics for the treatment of chronic back and neck pain.

Objectives To determine the extent to which demographic and geographic disparities exist in the use of post-acute rehabilitation care (PARC) for joint replacement. Methods Cross-sectional analysis of two years (2005–2006) of population-based hospital discharge data from 392 hospitals in four states (AZ, FL, NJ, WI). 164,875 individuals 45 years and older admitted to the hospital for a hip or knee joint replacement and who survived their inpatient stay were identified. Three dichotomous dependent variables were examined: 1) discharge to home vs. institution (i.e., skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF)); 2) discharge to home with vs. without home health (HH); and 3) discharge to a SNF vs. IRF. Multilevel logistic regression analyses were conducted to identify demographic and geographic disparities in PARC use, controlling for illness severity/comorbidities, hospital characteristics, and PARC supply. Interactions among race, socioeconomic, and geographic variables were explored. Results Considering PARC as a continuum from more to less intensive care in regard to hours of rehabilitation/day (e.g., IRF→SNF→HH→no HH), the uninsured received less intensive care in all three models. Individuals on Medicaid and those of lower SES received less intensive care in the HH/no HH and SNF/IRF models. Individuals living in rural areas received less intensive care in the institution/home and HH/no HH models. The effect of race was modified by insurance and by state. In most instances minorities received less intensive care. PARC use varied by hospital. Conclusions Efforts to further understand the reasons behind these disparities and their effect on outcomes are needed.

Objective-To use population-based, hospital discharge data to determine the extent to which demographic and geographic disparities exist in the use of PARC following stroke.Design-Cross-sectional analysis of two years (2005)(2006) of population-based, hospital discharge data.Setting-All short-term acute care hospitals in four demographically and geographically diverse states (AZ, FL, NJ, WI).Participants-Individuals 45 years and older (mean age of 72.6 years) admitted to the hospital with a primary diagnosis of stroke, who survived their inpatient stay and who were not transferred to a hospice or other short-term, acute care facility (N=187,188). The sample was 52.4 percent female, 79.5 percent White, 11.4 percent Black, and 9.1 percent Hispanic. Interventions-Not applicable.Main Outcome Measures-1) Discharge to an institution versus home. 2) For those discharged home, discharge home with or without home health (HH). 3) For those discharged toOnly electronic reprints will be available from authors. an institution, discharge to an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF). Multilevel logistic regression analyses were conducted to identify demographic and geographic disparities in PARC use, controlling for illness severity/comorbidities, hospital characteristics, and PARC supply.Results-Blacks, females, older individuals, and those with lower incomes were more likely to be discharged to an institution; Hispanic individuals and the uninsured were less likely. Racial minorities, females, older individuals, and those with lower incomes were more likely to receive HH; uninsured individuals and rural residents were less likely. Blacks, females, older individuals, the uninsured, and those with lower incomes were more likely to use SNF vs IRF care. PARC use varied significantly by state and by hospital.Conclusions-Several demographic and geographic disparities in PARC use were identified.

Background Heart failure (HF) self-care interventions can improve outcomes, but less than optimal adherence may limit their effectiveness. We evaluated if adherence to weight monitoring and diuretic self-adjustment was associated with HF-related ED visits or hospitalizations. Methods and Results We performed a case-control analysis nested in a HF self-care randomized trial. Participants received HF self-care training including weight monitoring and diuretic self-adjustment, which they were to record in a diary. We defined cases as HF-related ED visits or hospitalizations and the 7 preceding days; controls were defined as 7-day periods free of ED visits and hospitalizations. We used logistic regression to compare weight monitoring and diuretic self-adjustment adherence in cases and controls, adjusted for demographic and clinical covariates. Among 303 participants, we identified 81 HF-related ED visits or hospitalizations (cases) in 54 patients over one year of follow-up. Weight monitoring adherence (OR 0.42, 95% CI 0.23, 0.76) and diuretic self-adjustment adherence (OR 0.44, 95% CI 0.19, 0.98) were both associated with lower adjusted odds of HF-related ED visits or hospitalizations. Conclusions Adherence to weight monitoring and diuretic self-adjustment was associated with lower odds of HF-related ED visits or hospitalizations. Adherence to these activities may reduce HF-related morbidity.