SCIENTIFIC ARTICLE
Health Literacy and Time Spent With a Hand Surgeon Mariano E. Menendez, MD,* Raymond C. Parrish II, BS,* David Ring, MD, PhD*
Purpose To characterize the relationship between health literacy and duration of new hand surgery office visits. Methods Using a stopwatch from outside the room, we measured the duration of the visit (minutes of face-to-face contact between attending surgeon and patient) for 224 new patients presenting to 1 of 5 orthopedic hand surgeons (D.R.). Directly after the visit, patients were asked to complete the Newest Vital Sign (NVS) health literacy test, a sociodemographic survey, and 3 Patient-Reported Outcomes Measurement Information Systemebased questionnaires: Pain Interference, Upper Extremity Function, and Depression. The Newest Vital Sign scores were divided into limited (0e3) and adequate (4e6) health literacy. Medical records were reviewed to collect data on diagnosis, visit type, management, and whether patients were first seen by a resident/fellow. Multiple linear regression modeling was used to characterize the association between health literacy and duration of visit while controlling for the effect of other patient and visit characteristics. Results The unadjusted mean visit duration was 1.9 minutes shorter in patients with limited health literacy (9.4 minutes) than in patients with adequate health literacy (11.3 minutes), and this difference persisted after adjustment for a broad range of patient and visit characteristics. Greater magnitude of disability was associated with longer visits, as were second-opinion appointments, a diagnosis of nonspecific arm pain or compression neuropathy, and appointments in which operative management was chosen. Visits in which a resident/fellow saw the patient first were shorter than visits without resident/fellow assistance. Conclusions The finding that limited health literacy correlated with shorter visits may suggest that patients who may stand to benefit the most from detailed health education and counseling received less. (J Hand Surg Am. 2016;-(-):-e-. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Prognostic II. Key words Health literacy, visit duration, hand surgery, patient-centered care.
From the *Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Received for publication September 28, 2015; accepted in revised form December 20, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David Ring, MD, PhD, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St., Yawkey Center, Suite 2100, Boston, MA 02114; e-mail: [email protected]. 0363-5023/16/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.12.031
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visits is a key to practice efficiency and is often viewed as one aspect of patient-centeredness.1e4 Longer visits do not necessarily lead to greater patient satisfaction,5,6 but they can allow for more shared decision making, counseling, and education.7e12 However, long encounters disrupt practice workflow and often reflect ineffective interactions that can be cognitively and emotionally demanding for physicians and their office personnel.13 IME MANAGEMENT IN OUTPATIENT OFFICE
Ó 2016 ASSH
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Health literacy—the ability to obtain, process, and understand information and services to make health decisions—is increasingly recognized as a contributor to health disparities and ineffective patient care.14 Patients with limited health literacy have less access to preventive health services,15 suboptimal disease control,16,17 and greater risk of hospitalizations, emergency department visits, and death.18e22 Some of these health disparities may arise as a result of insufficient patient understanding, which might be improved by a longer visit with the physician. But little is known about the association between health literacy and the length of office visits. To bridge the gap between perception and reality in order to make informed decisions and be as healthy as possible, a patient needs to understand the issues and get past her or his first impressions. Limited health literacy may be an important barrier to both understanding and flexible thinking. It remains unclear whether patients with limited health literacy have longer or shorter outpatient office visits with a hand surgeon. One might expect these visits to be longer. There might be a greater number of questions and a greater need to explain things carefully to be fully understood. Conversely, patients with limited health literacy might not feel empowered to speak up or ask questions. They might be selfconscious, embarrassed, or deferential. In addition, it might be more difficult for the physician to establish a satisfying and mutually respectful relationship with a patient with low health literacy. Physicians may find themselves having less to say and unconsciously preferring a shorter visit. We undertook this study to examine the relationship between health literacy and duration of hand surgery office visits. We tested the primary null hypothesis that there was no difference in visit duration between patients with limited and adequate health literacy. In addition, we sought to identify other patient and visit characteristics affecting visit length.
were asked to complete a series of questionnaires aimed at monitoring quality of care. They were unaware of the specific study aims and were not told the outcome measures in the consent process. A research fellow (M.E.M) not involved in clinical care measured the duration of the visit (minutes of face-to-face contact between attending surgeon and patient) using a stopwatch from outside the room. Although the physicians were aware of the existence of the initial studies, they were unaware of which patients were being enrolled into them, and neither the patients nor the surgeons knew they were being timed. Directly after the visit, patients were asked to complete a sociodemographic survey (eg, age, gender, race/ethnicity, insurance status, work status, marital status), the Newest Vital Sign (NVS) health literacy test,23 and 3 Patient-Reported Outcomes Measurement Information System (PROMIS)ebased computerized adaptive testing questionnaires: Pain Interference,24 Upper Extremity Function,25 and Depression.26 The NVS test measures health literacy and numeracy and is based on a nutrition label from an ice cream container, with design identical to the nutrition label present on all packaged food in the United States.27,28 The NVS was originally validated against the Test of Functional Health Literacy in Adults29 in primary care patients in the Southwestern United States.23 The test was administered orally and in person. Patients were given the nutrition label and were asked 6 questions about it (Appendix A; available on the Journal’s Web site at www.jhandsurg.org), with 1 point being awarded for each correct response. We divided the resulting NVS scores into limited (0e3) and adequate (4e6) health literacy, using the same threshold as in the original NVS study and a recent study in hand surgery.23,30 An NVS score of less than 4 has a sensitivity of 100% and a specificity of 64% for predicting limited health literacy (Test of Functional Health Literacy in Adults score, < 75).23 The PROMIS Pain Interference evaluates the degree to which pain hinders physical, mental, and social activities.24,30 Higher scores indicate less effective coping strategies. The PROMIS Upper Extremity Function questionnaire quantifies the extent of disability with physical activities that involve use of the arm and hand such as writing, tying shoelaces, and holding a plate of food.25 Lower scores represent higher levels of upper extremity disability. The PROMIS Depression questionnaire assesses depressive symptoms (eg, guilt, sadness, worthlessness),26,31 and higher scores indicate greater symptoms of depression. For the PROMIS Pain Interference and Depression questionnaires, a score of 50 represents the
MATERIALS AND METHODS Design and definitions After institutional review board approval, we conducted a secondary analysis of 224 patients from 2 prospective cohort studies regarding patient satisfaction in the hand surgery office setting.5 Patients were eligible if they were at least 18 years old, native Englishespeaking, and visiting the offices of 1 of 5 orthopedic hand surgeons (D.R.) for the first time. Enrollment took place between December 2014 and July 2015. Oral informed consent for the initial studies was obtained from each patient prior to enrollment. After their visit, patients J Hand Surg Am.
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mean for the U.S. general population, and every 10 points represents an SD. The mean score for the more recent PROMIS Upper Extremity Function questionnaire has not been calibrated on a national sample. We reviewed medical records to collect data on specific diagnosis, visit type (first vs second opinion), and management, classified as surgical, nonsurgical (eg, orthosis, corticosteroid injection, hand therapy), diagnostic testing (eg, computed tomography, magnetic resonance imaging, ultrasound, electromyography), or counseling/observation. We also recorded whether or not a resident or fellow saw the patient before the attending surgeon did. All questionnaires were completed using a laptop computer, except for the NVS test, which was administered orally in accordance with its guidelines.23
Compared with patients with adequate health literacy, those with limited health literacy were more likely to be older, female, nonwhite, publicly insured, and not working (Appendix B; available on the Journal’s Web site at www.jhandsurg.org). RESULTS The unadjusted mean visit duration was 1.9 minutes shorter in patients with limited health literacy than in patients with adequate health literacy (P ¼ .03; Appendix C; available on the Journal’s Web site at www.jhandsurg.org). This difference in visit duration persisted (1.9 minutes; P ¼ .047) after adjustment for patient and visit characteristics (Appendix D; available on the Journal’s Web site at www.jhandsurg.org). Other factors independently affecting visit duration were upper extremity disability, visit type, diagnosis (Fig. 1), management, and resident/fellow assistance. Greater magnitude of disability was associated with longer visits (1.0-minute increase per 10-unit decrease in PROMIS Upper Extremity Function scores; P ¼ .02), as were second-opinion visits (6.9-minute increase compared with first opinions; P < .001), a diagnosis of nonspecific arm pain (7.8-minute increase compared with amputation/crash/laceration; P < .001) or compression neuropathy (4.1-minute increase compared with amputation/crash/laceration; P ¼ .03), and appointments in which operative management was chosen (2.8-minute increase compared with counseling/observation; P ¼ .03). Visits in which a resident/fellow saw the patient first were 4.3 minutes shorter than visits without resident/fellow assistance (P < .001; Appendix D; available on the Journal’s Web site at www.jhandsurg.org).
Statistical analysis To evaluate the association between each explanatory variable and visit duration, we used Pearson correlation coefficients for continuous variables, independent samples t tests for dichotomous variables, and analysis of variance for categorical variables. Multiple linear regression modeling was performed to examine the relationship between health literacy and duration of visit while controlling for the effect of other patient and visit characteristics. All covariates were entered into the model simultaneously without further selection. Results were presented in minutes as regression coefficients (b) with 95% confidence intervals. To better understand the percentage of variation in visit duration explained by each of these variables and by the model as a whole, we also reported the partial R2 and the total R2. Statistical significance was set at P less than .05.
DISCUSSION We observed that hand surgery office visits were nearly 20% shorter for patients with limited health literacy. Shorter visits may suggest that these patients have simpler problems that are more efficiently addressed or that they prefer being less involved in decision making, although that seems unlikely. Conversely, the visit might be shorter if patients with limited health literacy ask fewer questions, were less comfortable voicing their concerns, and felt less involved in decision making. It may be that physicians felt less connected and less comfortable with patients who were different from them, particularly if there were cultural and language differences in addition to the limited health literacy. Physicians have unconscious biases that may contribute to health disparities.32,33 A recent survey among 248 trauma
Patient characteristics The 224 patients composing our study population included 114 (51%) men and 110 women with a mean (SD) age of 50 years (SD, 17 years). Most patients were white (82%), employed (72%), and married (55%). Sixty-nine percent of patients had private insurance, 28% had government-funded insurance (Medicare, 20%; Medicaid, 8%), and 3% had workers’ compensation. The mean (SD) duration of the visit was 11 minutes (SD, 6.4 minutes), and 5% of patients were seeking a second opinion. Nearly half of patients were first seen by a resident or fellow (47%) and managed nonsurgically (43%). The most common diagnoses were upper extremity fractures (19%), compression neuropathy (12%), and sprains, dislocations, or mallet fingers (12%). Approximately 1 in 3 patients had limited health literacy (31%). J Hand Surg Am.
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FIGURE 1: Duration of visit by diagnosis.
surgeons showed that, whereas 79% of respondents explicitly stated that they had no race preferences and 55% that they had no social class preferences, 74% and 91% demonstrated unconscious preferences for white and upper-class patients, respectively.32 A study of audiotaped primary care visits found that providers were more verbally dominant, less empathic, and less patient-centered in their approach with nonwhite patients, in whom health literacy was relatively low.34 More recent studies and ours found no racial differences in outpatient visit duration.35 Our results suggest that race and other sociodemographic factors are subsumed under the more powerful influence of health literacy on variation in visit duration. Larger confirmatory studies are merited. In a highly specialized and technical field such as hand surgery, where active participation in care depends upon at least a basic understanding of human anatomy and most treatments are preference-sensitive, one might perhaps expect office visits by patients with limited health literacy to be longer—not shorter. A recent study showed that orthopedic trauma outpatients with limited health literacy were less likely to know which bone they fractured, the expected recovery time, and the name of the medications they were prescribed for deep venous thrombosis prophylaxis.36 To improve patient-centered communication and involvement in care, hand surgeons—and physicians in general—might consider engaging more in active listening by paraphrasing the patients’ statements; using charts, graphs, and analogies for difficult-tounderstand concepts; and scripting and practicing clear explanations for common conditions, pausing J Hand Surg Am.
between sentences for questions and inquiring about quizzical looks (eg, “Does that fit what you were thinking?”). Asking, “What are your questions?” instead of, “Do you have any questions?” may eliminate embarrassment and give patients the message that questions are expected. It may also be that, instead of longer visits, what might help are tools such as videos or Web sites that can facilitate incremental improvements in health literacy as part of the treatment and recovery strategy. As soon as limited health literacy is identified as a potential barrier to a successful and satisfying visit to a doctor, we might take an alternative approach using enhancements to the traditional faceto-face transfer of knowledge. These enhancements should account for the shortcomings of the expert-topatient information transfer and incorporate the advantages of decision-support tools designed to educate patients and help them determine their preferences (eg, decision aids).37 The observation that second-opinion visits were considerably longer than first-opinion visits may reflect the fact that second opinions are often sought when the initial opinion was unsatisfying, unexpected, or difficult to understand.38 Again, desire for a second or third opinion might also raise the opportunity for decision support that addresses the patient at his or her level of health literacy, within his or her cultural context, and appropriate to his or her values and preferences. There was no significant difference in the incidence of second-opinion visits between patients with adequate (5%) and limited (7%) health literacy (P ¼ .40). Long visits within a busy office schedule may unintentionally prompt r
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considered only first-time office visits in order to minimize bias associated with heterogeneity of physician-patient familiarity. With that being said, the relationship between health literacy and visit duration may change for follow-up and postoperative visits. Fifth, although we did not measure office time with the resident/fellow, we at least controlled for the effect of resident/fellow assistance on visit duration in multivariable regression analysis. Given that there is no prior evidence of a correlation between the time spent with a resident/fellow and health literacy, this variable may not act as a confounding factor in the association between health literacy and time spent with a hand surgeon. Moreover, there was no significant difference in the rate of visits with resident/ fellow assistance between patients with adequate (47%) and limited (49%) health literacy (P ¼ .70). Sixth, we excluded noneEnglish-speaking patients, because some of the questionnaires used in the original studies were not validated for patients speaking other languages. Given that language and cultural barriers often coexist with limited health literacy and may synergistically hinder physician-patient communication, the observed health literacy differences in visit duration might have been even more pronounced had we enrolled more culturally and linguistically diverse patients. Seventh, although we controlled for several sources of variation in visit duration, other unmeasured patient-level factors (eg, previsit expectations, desired level of involvement in decision making, presence of a companion, preferences in visit duration) may affect encounter length. Finally, because of the limited number of surgeons in the study, we were unable to determine physician characteristics affecting visit duration.
physicians to spend less time with the next patient in order to catch up with the schedule. This may be a problem when the patient in question has limited health literacy. Using decision-support tools might help both the patient and the physician doing the difficult work of crossing health literacy and misconception barriers in a less cognitively and emotionally draining manner. Similarly, our finding that patients with greater disability and nonspecific arm pain have longer visits may correspond with the observation that patients with greater magnitude of disability and pain complaints without a clear physical cause are more likely to find a hand surgeon’s advice unexpected and counterintuitive.39 It is possible that patients who are injured might be more adaptive and resilient than patients seeking advice for discretionary quality of life conditions, many of which are part of the normal aging process for which a substantial percentage of patients do not seek care.40e43 The finding that surgical management was associated with longer visits might be due to the fact that extra time is spent obtaining surgical consent and explaining risks/benefits of the procedure, which could in turn lead to patients asking more questions. When a resident/fellow saw the patient first, visits were considerably shorter. Having residents/ fellows—and maybe physician extenders—can be an effective approach to optimize physician productivity and practice efficiency, particularly in face of recent evidence that resident/fellow assistance does not detract from the patient experience.5 Our analysis should be interpreted cautiously in light of its shortcomings. First, although we measured actual visit duration rather than relying on physician estimates like most previous related studies using the National Ambulatory Medical Care Survey,12,44e46 we did not audio-record visits and were unable to explore differences in time allocation and quality of care. We also did not directly assess surgeonperceived visit complexity using a standardized questionnaire such as the Difficult Doctor Patient Relationship Questionnaire.47 Second, although we included patients presenting to different hand surgeons, this study was performed at a single urban academic center serving predominantly white patients in the Northeastern United States, and the results may not generalize to other settings, populations, and regions. Third, our findings might have been different had we enrolled patients presenting with a single condition or a group of similar conditions and with a standardized previsit work-up. However, inclusion of patients with the usual spectrum of illnesses in our office could also be seen as a strength. Fourth, we J Hand Surg Am.
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28. Komenaka IK, Nodora JN, Machado L, et al. Health literacy assessment and patient satisfaction in surgical practice. Surgery. 2014;155(3):374e383. 29. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10(10):537e541. 30. Menendez ME, Mudgal CS, Jupiter JB, Ring D. Health literacy in hand surgery patients: a cross-sectional survey. J Hand Surg Am. 2015;40(4):798e804.e792. 31. Menendez ME, Bot AG, Hageman MG, Neuhaus V, Mudgal CS, Ring D. Computerized adaptive testing of psychological factors: relation to upper-extremity disability. J Bone Joint Surg Am. 2013;95(20):e149. 32. Haider AH, Schneider EB, Sriram N, et al. Unconscious race and class bias: its association with decision making by trauma and acute care surgeons. J Trauma Acute Care Surg. 2014;77(3):409e416. 33. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231e1238. 34. Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health. 2004;94(12):2084e2090. 35. Olfson M, Cherry DK, Lewis-Fernandez R. Racial differences in visit duration of outpatient psychiatric visits. Arch Gen Psychiatry. 2009;66(2):214e221. 36. Kadakia RJ, Tsahakis JM, Issar NM, et al. Health literacy in an orthopedic trauma patient population: a cross-sectional survey of patient comprehension. J Orthop Trauma. 2013;27(8):467e471. 37. Stacey D, Legare F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;1:CD001431. 38. Sutherland LR, Verhoef MJ. Patients who seek a second opinion: are they different from the typical referral? J Clin Gastroenterol. 1989;11(3):308e313. 39. Strooker JA, Nota SP, Hageman MG, Ring DC. Patients with greater symptom intensity and more disability are more likely to be surprised by a hand surgeon’s advice. Clin Orthop Relat Res. 2015;473(4): 1478e1483. 40. Becker SJ, Briet JP, Hageman MG, Ring D. Death, taxes, and trapeziometacarpal arthrosis. Clin Orthop Relat Res. 2013;471(12): 3738e3744. 41. Becker SJ, Makarawung DJ, Spit SA, King JD, Ring D. Disability in patients with trapeziometacarpal joint arthrosis: incidental versus presenting diagnosis. J Hand Surg Am. 2014;39(10):2009e2015.e2008. 42. Chan JJ, Teunis T, Ring D. Prevalence of triangular fibrocartilage complex abnormalities regardless of symptoms rise with age: systematic review and pooled analysis. Clin Orthop Relat Res. 2014;472(12):3987e3994. 43. Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014;23(12):1913e1921. 44. Blumenthal D, Causino N, Chang YC, et al. The duration of ambulatory visits to physicians. J Fam Pract. 1999;48(4):264e271. 45. Hu P, Reuben DB. Effects of managed care on the length of time that elderly patients spend with physicians during ambulatory visits: National Ambulatory Medical Care Survey. Med Care. 2002;40(7): 606e613. 46. Mechanic D, McAlpine DD, Rosenthal M. Are patients’ office visits with physicians getting shorter? N Engl J Med. 2001;344(3): 198e204. 47. Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159(10):1069e1075.
7. Geraghty EM, Franks P, Kravitz RL. Primary care visit length, quality, and satisfaction for standardized patients with depression. J Gen Intern Med. 2007;22(12):1641e1647. 8. Gross DA, Zyzanski SJ, Borawski EA, Cebul RD, Stange KC. Patient satisfaction with time spent with their physician. J Fam Pract. 1998;47(2):133e137. 9. Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JE Jr. Characteristics of physicians with participatory decision-making styles. Ann Intern Med. 1996;124(5):497e504. 10. Nowalk MP, Bardella IJ, Zimmerman RK, Shen S. The physician’s office: can it influence adult immunization rates? Am J Manag Care. 2004;10(1):13e19. 11. Streja DA, Rabkin SW. Factors associated with implementation of preventive care measures in patients with diabetes mellitus. Arch Intern Med. 1999;159(3):294e302. 12. Chen LM, Farwell WR, Jha AK. Primary care visit duration and quality: does good care take longer? Arch Intern Med. 2009;169(20): 1866e1872. 13. Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Intern Med. 2001;134(9 Pt 2): 897e904. 14. Hasnain-Wynia R, Wolf MS. Promoting health care equity: is health literacy a missing link? Health Serv Res. 2010;45(4):897e903. 15. Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care. 2002;40(5):395e404. 16. McNaughton CD, Jacobson TA, Kripalani S. Low literacy is associated with uncontrolled blood pressure in primary care patients with hypertension and heart disease. Patient Educ Couns. 2014;96(2):165e170. 17. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288(4):475e482. 18. Herndon JB, Chaney M, Carden D. Health literacy and emergency department outcomes: a systematic review. Ann Emerg Med. 2011;57(4):334e345. 19. Marcantonio ER, McKean S, Goldfinger M, Kleefield S, Yurkofsky M, Brennan TA. Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan. Am J Med. 1999;107(1):13e17. 20. Mitchell SE, Sadikova E, Jack BW, Paasche-Orlow MK. Health literacy and 30-day postdischarge hospital utilization. J Health Commun. 2012;17(Suppl 3):325e338. 21. Morrison AK, Chanmugathas R, Schapira MM, Gorelick MH, Hoffmann RG, Brousseau DC. Caregiver low health literacy and nonurgent use of the pediatric emergency department for febrile illness. Acad Pediatr. 2014;14(5):505e509. 22. Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med. 2007;167(14):1503e1509. 23. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3(6):514e522. 24. Amtmann D, Cook KF, Jensen MP, et al. Development of a PROMIS item bank to measure pain interference. Pain. 2010;150(1):173e182. 25. Hays RD, Spritzer KL, Amtmann D, et al. Upper-extremity and mobility subdomains from the Patient-Reported Outcomes Measurement Information System (PROMIS) adult physical functioning item bank. Arch Phys Med Rehabil. 2013;94(11):2291e2296. 26. Pilkonis PA, Choi SW, Reise SP, et al. Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS(R)): depression, anxiety, and anger. Assessment. 2011;18(3):263e283. 27. Hassan K, Heptulla RA. Glycemic control in pediatric type 1 diabetes: role of caregiver literacy. Pediatrics. 2010;125(5): e1104ee1108.
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APPENDIX A. Newest Vital Sign: Questions in English 1. If you eat the entire container, how many calories will you eat? 2. If you are allowed to eat 60 g of carbohydrates as a snack, how much ice cream could you have? 3. Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g of saturated fat each day, which includes 1
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serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day? 4. If you usually eat 2,500 cal in a day, what percentage of your daily value of calories will you be eating if you eat 1 serving? 5. Is it safe for you to eat this ice cream? 6. (Ask only if the patient responds “no” to question 5): Why not?
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APPENDIX B.
Characteristics of the Study Population (n [ 24) Health Literacy Parameter
Total, n (%) Age (y), mean SD (range)
Limited (NVS Score 3)
All Patients 224 (100)
69 (31)
50 17 (20e88)
56 16 (21e88)
Adequate (NVS Score 4e6)
P
155 (69) 47 16 (20e83)
< .001
Sex, n (%) Female
110 (49)
42 (61)
68 (44)
Male
114 (51)
27 (39)
87 (56)
184 (82)
49 (71)
135 (87)
40 (18)
20 (29)
20 (13)
Medicare
45 (20)
21 (30)
24 (16)
Medicaid
18 (8)
14 (20)
4 (3)
154 (69)
33 (48)
121 (78)
7 (3)
1 (1)
6 (4)
161 (72)
34 (49)
127 (82)
.019
Race/ethnicity, n (%) White Nonwhite
.004
Insurance status, n (%)
Private Workers’ compensation
< .001
Working status, n (%) Working Unemployed
8 (4)
6 (9)
2 (1)
Disabled
28 (13)
15 (22)
13 (8)
Retired
27 (12)
14 (20)
13 (8)
< .001
Marital status, n (%) Single
71 (32)
17 (25)
54 (35)
124 (55)
38 (55)
86 (56)
Separated or divorced
17 (8)
9 (13)
8 (5)
Widowed
12 (5)
5 (7)
7 (5)
Sprain, dislocation, or mallet finger
26 (12)
5 (7)
21 (14)
Hand, wrist, or elbow fracture
42 (19)
6 (9)
36 (23)
Amputation, crush, or laceration
18 (8)
5 (7)
13 (8)
Carpal tunnel or cubital tunnel syndrome
26 (12)
9 (13)
17 (11)
Osteoarthrosis
16 (7)
7 (10)
9 (6)
Trigger finger
23 (10)
11 (16)
12 (8)
Ganglion cyst
13 (6)
5 (7)
8 (5)
Nonspecific arm pain
18 (8)
4 (6)
14 (9)
Lateral epicondylitis
7 (3)
5 (7)
2 (1)
All other diagnoses
35 (16)
12 (17)
23 (15)
212 (95)
64 (93)
148 (96)
12 (5)
5 (7)
7 (5)
Surgical
34 (15)
12 (17)
22 (14)
Nonsurgical
97 (43)
32 (46)
65 (42)
Diagnostic testing
38 (17)
8 (12)
30 (19)
Counseling/observation
55 (25)
17 (25)
38 (25)
Married
.11
Diagnosis, n (%)
.032
Appointment type, n (%) First opinion Second opinion
.40
Management, n (%)
.53
(Continued)
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APPENDIX B.
Characteristics of the Study Population (n [ 24) (Continued) Health Literacy Parameter
Limited (NVS Score 3)
All Patients
Adequate (NVS Score 4e6)
P
Resident/fellow involvement* No
118 (53)
35 (51)
83 (54)
Yes
106 (47)
34 (49)
72 (47)
0.70
PROMIS instruments, mean SD (range) Pain Interference
57 8.2 (32e76)
58 9.1 (32e73)
Upper Extremity Function
39 9.9 (16e62)
36 9.8 (16e56)
40 9.7 (21e62)
.008
Depression
47 8.9 (34e73)
49 10 (34e73)
46 8.3 (34e67)
.053
*Whether or not a resident or fellow saw the patient before the attending surgeon.
J Hand Surg Am.
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.46
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APPENDIX C.
APPENDIX C.
Bivariate Analysis
Parameter
Duration of Visit (min), Mean SD
Parameter
P
Limited
9.4 5.6 11.3 6.7
Surgical
.03
Nonsurgical
Sex Female
10.9 6.8
Male
10.5 6.1
.67
White
10.8 6.5
Nonwhite
10.1 6.3 9.9 5.4
Medicaid
10.2 5.8
Private
11.0 6.8
.54
Counseling/observation
10.0 .6
No
13.1 6.9
Yes
8.1 4.7
Age .71
Pain Interference
Working status
Disabled
9.8 5.6
Retired
9.1 4.9 10.4 6.8
Married
11.0 6.8 9.1 5.7
Hand, wrist, or elbow fracture
10.9 6.1
Amputation, crush, or laceration
10.6 5.1
Carpal tunnel or cubital tunnel syndrome
13.6 9.2
Osteoarthrosis
9.7 4.6
Trigger finger
10.0 4.7
Ganglion cyst
7.5 4.1
Nonspecific arm pain
15.0 7.7
Lateral epicondylitis
11.6 7.2
All other diagnoses
9.3 5.8 10.3 6.1
Second opinion
17.7 8.4
.35
.002
Depression
e0.01
.85
.17
0.47
.01
.01 (Continued)
J Hand Surg Am.
e0.1
.003
Appointment type First opinion
P
0.2
Diagnosis Sprain, dislocation, or mallet finger
Correlation (r)
e0.2
Marital status Single
Health Literacy and Time Spent With a Hand Surgeon Mariano E. Menendez, MD,* Raymond C. Parrish II, BS,* David Ring, MD, PhD*
Purpose To characterize the relationship between health literacy and duration of new hand surgery office visits. Methods Using a stopwatch from outside the room, we measured the duration of the visit (minutes of face-to-face contact between attending surgeon and patient) for 224 new patients presenting to 1 of 5 orthopedic hand surgeons (D.R.). Directly after the visit, patients were asked to complete the Newest Vital Sign (NVS) health literacy test, a sociodemographic survey, and 3 Patient-Reported Outcomes Measurement Information Systemebased questionnaires: Pain Interference, Upper Extremity Function, and Depression. The Newest Vital Sign scores were divided into limited (0e3) and adequate (4e6) health literacy. Medical records were reviewed to collect data on diagnosis, visit type, management, and whether patients were first seen by a resident/fellow. Multiple linear regression modeling was used to characterize the association between health literacy and duration of visit while controlling for the effect of other patient and visit characteristics. Results The unadjusted mean visit duration was 1.9 minutes shorter in patients with limited health literacy (9.4 minutes) than in patients with adequate health literacy (11.3 minutes), and this difference persisted after adjustment for a broad range of patient and visit characteristics. Greater magnitude of disability was associated with longer visits, as were second-opinion appointments, a diagnosis of nonspecific arm pain or compression neuropathy, and appointments in which operative management was chosen. Visits in which a resident/fellow saw the patient first were shorter than visits without resident/fellow assistance. Conclusions The finding that limited health literacy correlated with shorter visits may suggest that patients who may stand to benefit the most from detailed health education and counseling received less. (J Hand Surg Am. 2016;-(-):-e-. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Prognostic II. Key words Health literacy, visit duration, hand surgery, patient-centered care.
From the *Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Received for publication September 28, 2015; accepted in revised form December 20, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: David Ring, MD, PhD, Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit St., Yawkey Center, Suite 2100, Boston, MA 02114; e-mail: [email protected]. 0363-5023/16/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.12.031
T
visits is a key to practice efficiency and is often viewed as one aspect of patient-centeredness.1e4 Longer visits do not necessarily lead to greater patient satisfaction,5,6 but they can allow for more shared decision making, counseling, and education.7e12 However, long encounters disrupt practice workflow and often reflect ineffective interactions that can be cognitively and emotionally demanding for physicians and their office personnel.13 IME MANAGEMENT IN OUTPATIENT OFFICE
Ó 2016 ASSH
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Health literacy—the ability to obtain, process, and understand information and services to make health decisions—is increasingly recognized as a contributor to health disparities and ineffective patient care.14 Patients with limited health literacy have less access to preventive health services,15 suboptimal disease control,16,17 and greater risk of hospitalizations, emergency department visits, and death.18e22 Some of these health disparities may arise as a result of insufficient patient understanding, which might be improved by a longer visit with the physician. But little is known about the association between health literacy and the length of office visits. To bridge the gap between perception and reality in order to make informed decisions and be as healthy as possible, a patient needs to understand the issues and get past her or his first impressions. Limited health literacy may be an important barrier to both understanding and flexible thinking. It remains unclear whether patients with limited health literacy have longer or shorter outpatient office visits with a hand surgeon. One might expect these visits to be longer. There might be a greater number of questions and a greater need to explain things carefully to be fully understood. Conversely, patients with limited health literacy might not feel empowered to speak up or ask questions. They might be selfconscious, embarrassed, or deferential. In addition, it might be more difficult for the physician to establish a satisfying and mutually respectful relationship with a patient with low health literacy. Physicians may find themselves having less to say and unconsciously preferring a shorter visit. We undertook this study to examine the relationship between health literacy and duration of hand surgery office visits. We tested the primary null hypothesis that there was no difference in visit duration between patients with limited and adequate health literacy. In addition, we sought to identify other patient and visit characteristics affecting visit length.
were asked to complete a series of questionnaires aimed at monitoring quality of care. They were unaware of the specific study aims and were not told the outcome measures in the consent process. A research fellow (M.E.M) not involved in clinical care measured the duration of the visit (minutes of face-to-face contact between attending surgeon and patient) using a stopwatch from outside the room. Although the physicians were aware of the existence of the initial studies, they were unaware of which patients were being enrolled into them, and neither the patients nor the surgeons knew they were being timed. Directly after the visit, patients were asked to complete a sociodemographic survey (eg, age, gender, race/ethnicity, insurance status, work status, marital status), the Newest Vital Sign (NVS) health literacy test,23 and 3 Patient-Reported Outcomes Measurement Information System (PROMIS)ebased computerized adaptive testing questionnaires: Pain Interference,24 Upper Extremity Function,25 and Depression.26 The NVS test measures health literacy and numeracy and is based on a nutrition label from an ice cream container, with design identical to the nutrition label present on all packaged food in the United States.27,28 The NVS was originally validated against the Test of Functional Health Literacy in Adults29 in primary care patients in the Southwestern United States.23 The test was administered orally and in person. Patients were given the nutrition label and were asked 6 questions about it (Appendix A; available on the Journal’s Web site at www.jhandsurg.org), with 1 point being awarded for each correct response. We divided the resulting NVS scores into limited (0e3) and adequate (4e6) health literacy, using the same threshold as in the original NVS study and a recent study in hand surgery.23,30 An NVS score of less than 4 has a sensitivity of 100% and a specificity of 64% for predicting limited health literacy (Test of Functional Health Literacy in Adults score, < 75).23 The PROMIS Pain Interference evaluates the degree to which pain hinders physical, mental, and social activities.24,30 Higher scores indicate less effective coping strategies. The PROMIS Upper Extremity Function questionnaire quantifies the extent of disability with physical activities that involve use of the arm and hand such as writing, tying shoelaces, and holding a plate of food.25 Lower scores represent higher levels of upper extremity disability. The PROMIS Depression questionnaire assesses depressive symptoms (eg, guilt, sadness, worthlessness),26,31 and higher scores indicate greater symptoms of depression. For the PROMIS Pain Interference and Depression questionnaires, a score of 50 represents the
MATERIALS AND METHODS Design and definitions After institutional review board approval, we conducted a secondary analysis of 224 patients from 2 prospective cohort studies regarding patient satisfaction in the hand surgery office setting.5 Patients were eligible if they were at least 18 years old, native Englishespeaking, and visiting the offices of 1 of 5 orthopedic hand surgeons (D.R.) for the first time. Enrollment took place between December 2014 and July 2015. Oral informed consent for the initial studies was obtained from each patient prior to enrollment. After their visit, patients J Hand Surg Am.
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mean for the U.S. general population, and every 10 points represents an SD. The mean score for the more recent PROMIS Upper Extremity Function questionnaire has not been calibrated on a national sample. We reviewed medical records to collect data on specific diagnosis, visit type (first vs second opinion), and management, classified as surgical, nonsurgical (eg, orthosis, corticosteroid injection, hand therapy), diagnostic testing (eg, computed tomography, magnetic resonance imaging, ultrasound, electromyography), or counseling/observation. We also recorded whether or not a resident or fellow saw the patient before the attending surgeon did. All questionnaires were completed using a laptop computer, except for the NVS test, which was administered orally in accordance with its guidelines.23
Compared with patients with adequate health literacy, those with limited health literacy were more likely to be older, female, nonwhite, publicly insured, and not working (Appendix B; available on the Journal’s Web site at www.jhandsurg.org). RESULTS The unadjusted mean visit duration was 1.9 minutes shorter in patients with limited health literacy than in patients with adequate health literacy (P ¼ .03; Appendix C; available on the Journal’s Web site at www.jhandsurg.org). This difference in visit duration persisted (1.9 minutes; P ¼ .047) after adjustment for patient and visit characteristics (Appendix D; available on the Journal’s Web site at www.jhandsurg.org). Other factors independently affecting visit duration were upper extremity disability, visit type, diagnosis (Fig. 1), management, and resident/fellow assistance. Greater magnitude of disability was associated with longer visits (1.0-minute increase per 10-unit decrease in PROMIS Upper Extremity Function scores; P ¼ .02), as were second-opinion visits (6.9-minute increase compared with first opinions; P < .001), a diagnosis of nonspecific arm pain (7.8-minute increase compared with amputation/crash/laceration; P < .001) or compression neuropathy (4.1-minute increase compared with amputation/crash/laceration; P ¼ .03), and appointments in which operative management was chosen (2.8-minute increase compared with counseling/observation; P ¼ .03). Visits in which a resident/fellow saw the patient first were 4.3 minutes shorter than visits without resident/fellow assistance (P < .001; Appendix D; available on the Journal’s Web site at www.jhandsurg.org).
Statistical analysis To evaluate the association between each explanatory variable and visit duration, we used Pearson correlation coefficients for continuous variables, independent samples t tests for dichotomous variables, and analysis of variance for categorical variables. Multiple linear regression modeling was performed to examine the relationship between health literacy and duration of visit while controlling for the effect of other patient and visit characteristics. All covariates were entered into the model simultaneously without further selection. Results were presented in minutes as regression coefficients (b) with 95% confidence intervals. To better understand the percentage of variation in visit duration explained by each of these variables and by the model as a whole, we also reported the partial R2 and the total R2. Statistical significance was set at P less than .05.
DISCUSSION We observed that hand surgery office visits were nearly 20% shorter for patients with limited health literacy. Shorter visits may suggest that these patients have simpler problems that are more efficiently addressed or that they prefer being less involved in decision making, although that seems unlikely. Conversely, the visit might be shorter if patients with limited health literacy ask fewer questions, were less comfortable voicing their concerns, and felt less involved in decision making. It may be that physicians felt less connected and less comfortable with patients who were different from them, particularly if there were cultural and language differences in addition to the limited health literacy. Physicians have unconscious biases that may contribute to health disparities.32,33 A recent survey among 248 trauma
Patient characteristics The 224 patients composing our study population included 114 (51%) men and 110 women with a mean (SD) age of 50 years (SD, 17 years). Most patients were white (82%), employed (72%), and married (55%). Sixty-nine percent of patients had private insurance, 28% had government-funded insurance (Medicare, 20%; Medicaid, 8%), and 3% had workers’ compensation. The mean (SD) duration of the visit was 11 minutes (SD, 6.4 minutes), and 5% of patients were seeking a second opinion. Nearly half of patients were first seen by a resident or fellow (47%) and managed nonsurgically (43%). The most common diagnoses were upper extremity fractures (19%), compression neuropathy (12%), and sprains, dislocations, or mallet fingers (12%). Approximately 1 in 3 patients had limited health literacy (31%). J Hand Surg Am.
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FIGURE 1: Duration of visit by diagnosis.
surgeons showed that, whereas 79% of respondents explicitly stated that they had no race preferences and 55% that they had no social class preferences, 74% and 91% demonstrated unconscious preferences for white and upper-class patients, respectively.32 A study of audiotaped primary care visits found that providers were more verbally dominant, less empathic, and less patient-centered in their approach with nonwhite patients, in whom health literacy was relatively low.34 More recent studies and ours found no racial differences in outpatient visit duration.35 Our results suggest that race and other sociodemographic factors are subsumed under the more powerful influence of health literacy on variation in visit duration. Larger confirmatory studies are merited. In a highly specialized and technical field such as hand surgery, where active participation in care depends upon at least a basic understanding of human anatomy and most treatments are preference-sensitive, one might perhaps expect office visits by patients with limited health literacy to be longer—not shorter. A recent study showed that orthopedic trauma outpatients with limited health literacy were less likely to know which bone they fractured, the expected recovery time, and the name of the medications they were prescribed for deep venous thrombosis prophylaxis.36 To improve patient-centered communication and involvement in care, hand surgeons—and physicians in general—might consider engaging more in active listening by paraphrasing the patients’ statements; using charts, graphs, and analogies for difficult-tounderstand concepts; and scripting and practicing clear explanations for common conditions, pausing J Hand Surg Am.
between sentences for questions and inquiring about quizzical looks (eg, “Does that fit what you were thinking?”). Asking, “What are your questions?” instead of, “Do you have any questions?” may eliminate embarrassment and give patients the message that questions are expected. It may also be that, instead of longer visits, what might help are tools such as videos or Web sites that can facilitate incremental improvements in health literacy as part of the treatment and recovery strategy. As soon as limited health literacy is identified as a potential barrier to a successful and satisfying visit to a doctor, we might take an alternative approach using enhancements to the traditional faceto-face transfer of knowledge. These enhancements should account for the shortcomings of the expert-topatient information transfer and incorporate the advantages of decision-support tools designed to educate patients and help them determine their preferences (eg, decision aids).37 The observation that second-opinion visits were considerably longer than first-opinion visits may reflect the fact that second opinions are often sought when the initial opinion was unsatisfying, unexpected, or difficult to understand.38 Again, desire for a second or third opinion might also raise the opportunity for decision support that addresses the patient at his or her level of health literacy, within his or her cultural context, and appropriate to his or her values and preferences. There was no significant difference in the incidence of second-opinion visits between patients with adequate (5%) and limited (7%) health literacy (P ¼ .40). Long visits within a busy office schedule may unintentionally prompt r
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considered only first-time office visits in order to minimize bias associated with heterogeneity of physician-patient familiarity. With that being said, the relationship between health literacy and visit duration may change for follow-up and postoperative visits. Fifth, although we did not measure office time with the resident/fellow, we at least controlled for the effect of resident/fellow assistance on visit duration in multivariable regression analysis. Given that there is no prior evidence of a correlation between the time spent with a resident/fellow and health literacy, this variable may not act as a confounding factor in the association between health literacy and time spent with a hand surgeon. Moreover, there was no significant difference in the rate of visits with resident/ fellow assistance between patients with adequate (47%) and limited (49%) health literacy (P ¼ .70). Sixth, we excluded noneEnglish-speaking patients, because some of the questionnaires used in the original studies were not validated for patients speaking other languages. Given that language and cultural barriers often coexist with limited health literacy and may synergistically hinder physician-patient communication, the observed health literacy differences in visit duration might have been even more pronounced had we enrolled more culturally and linguistically diverse patients. Seventh, although we controlled for several sources of variation in visit duration, other unmeasured patient-level factors (eg, previsit expectations, desired level of involvement in decision making, presence of a companion, preferences in visit duration) may affect encounter length. Finally, because of the limited number of surgeons in the study, we were unable to determine physician characteristics affecting visit duration.
physicians to spend less time with the next patient in order to catch up with the schedule. This may be a problem when the patient in question has limited health literacy. Using decision-support tools might help both the patient and the physician doing the difficult work of crossing health literacy and misconception barriers in a less cognitively and emotionally draining manner. Similarly, our finding that patients with greater disability and nonspecific arm pain have longer visits may correspond with the observation that patients with greater magnitude of disability and pain complaints without a clear physical cause are more likely to find a hand surgeon’s advice unexpected and counterintuitive.39 It is possible that patients who are injured might be more adaptive and resilient than patients seeking advice for discretionary quality of life conditions, many of which are part of the normal aging process for which a substantial percentage of patients do not seek care.40e43 The finding that surgical management was associated with longer visits might be due to the fact that extra time is spent obtaining surgical consent and explaining risks/benefits of the procedure, which could in turn lead to patients asking more questions. When a resident/fellow saw the patient first, visits were considerably shorter. Having residents/ fellows—and maybe physician extenders—can be an effective approach to optimize physician productivity and practice efficiency, particularly in face of recent evidence that resident/fellow assistance does not detract from the patient experience.5 Our analysis should be interpreted cautiously in light of its shortcomings. First, although we measured actual visit duration rather than relying on physician estimates like most previous related studies using the National Ambulatory Medical Care Survey,12,44e46 we did not audio-record visits and were unable to explore differences in time allocation and quality of care. We also did not directly assess surgeonperceived visit complexity using a standardized questionnaire such as the Difficult Doctor Patient Relationship Questionnaire.47 Second, although we included patients presenting to different hand surgeons, this study was performed at a single urban academic center serving predominantly white patients in the Northeastern United States, and the results may not generalize to other settings, populations, and regions. Third, our findings might have been different had we enrolled patients presenting with a single condition or a group of similar conditions and with a standardized previsit work-up. However, inclusion of patients with the usual spectrum of illnesses in our office could also be seen as a strength. Fourth, we J Hand Surg Am.
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REFERENCES 1. Guy GP Jr, Richardson LC. Visit duration for outpatient physician office visits among patients with cancer. J Oncol Pract. 2012;8(3 Suppl):2se8s. 2. Howie JG, Porter AM, Heaney DJ, Hopton JL. Long to short consultation ratio: a proxy measure of quality of care for general practice. Br J Gen Pract. 1991;41(343):48e54. 3. Lin CT, Albertson GA, Schilling LM, et al. Is patients’ perception of time spent with the physician a determinant of ambulatory patient satisfaction? Arch Intern Med. 2001;161(11):1437e1442. 4. Ishikawa H, Hashimoto H, Roter DL, Yamazaki Y, Takayama T, Yano E. Patient contribution to the medical dialogue and perceived patient-centeredness. An observational study in Japanese geriatric consultations. J Gen Intern Med. 2005;20(10):906e910. 5. Menendez ME, Chen NC, Mudgal CS, Jupiter JB, Ring D. Physician empathy as a driver of hand surgery patient satisfaction. J Hand Surg Am. 2015;40(9):1860e1865.e1862. 6. Teunis T, Thornton ER, Jayakumar P, Ring D. Time seeing a hand surgeon is not associated with patient satisfaction. Clin Orthop Relat Res. 2015;473(7):2362e2368.
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28. Komenaka IK, Nodora JN, Machado L, et al. Health literacy assessment and patient satisfaction in surgical practice. Surgery. 2014;155(3):374e383. 29. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med. 1995;10(10):537e541. 30. Menendez ME, Mudgal CS, Jupiter JB, Ring D. Health literacy in hand surgery patients: a cross-sectional survey. J Hand Surg Am. 2015;40(4):798e804.e792. 31. Menendez ME, Bot AG, Hageman MG, Neuhaus V, Mudgal CS, Ring D. Computerized adaptive testing of psychological factors: relation to upper-extremity disability. J Bone Joint Surg Am. 2013;95(20):e149. 32. Haider AH, Schneider EB, Sriram N, et al. Unconscious race and class bias: its association with decision making by trauma and acute care surgeons. J Trauma Acute Care Surg. 2014;77(3):409e416. 33. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231e1238. 34. Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health. 2004;94(12):2084e2090. 35. Olfson M, Cherry DK, Lewis-Fernandez R. Racial differences in visit duration of outpatient psychiatric visits. Arch Gen Psychiatry. 2009;66(2):214e221. 36. Kadakia RJ, Tsahakis JM, Issar NM, et al. Health literacy in an orthopedic trauma patient population: a cross-sectional survey of patient comprehension. J Orthop Trauma. 2013;27(8):467e471. 37. Stacey D, Legare F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2014;1:CD001431. 38. Sutherland LR, Verhoef MJ. Patients who seek a second opinion: are they different from the typical referral? J Clin Gastroenterol. 1989;11(3):308e313. 39. Strooker JA, Nota SP, Hageman MG, Ring DC. Patients with greater symptom intensity and more disability are more likely to be surprised by a hand surgeon’s advice. Clin Orthop Relat Res. 2015;473(4): 1478e1483. 40. Becker SJ, Briet JP, Hageman MG, Ring D. Death, taxes, and trapeziometacarpal arthrosis. Clin Orthop Relat Res. 2013;471(12): 3738e3744. 41. Becker SJ, Makarawung DJ, Spit SA, King JD, Ring D. Disability in patients with trapeziometacarpal joint arthrosis: incidental versus presenting diagnosis. J Hand Surg Am. 2014;39(10):2009e2015.e2008. 42. Chan JJ, Teunis T, Ring D. Prevalence of triangular fibrocartilage complex abnormalities regardless of symptoms rise with age: systematic review and pooled analysis. Clin Orthop Relat Res. 2014;472(12):3987e3994. 43. Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. 2014;23(12):1913e1921. 44. Blumenthal D, Causino N, Chang YC, et al. The duration of ambulatory visits to physicians. J Fam Pract. 1999;48(4):264e271. 45. Hu P, Reuben DB. Effects of managed care on the length of time that elderly patients spend with physicians during ambulatory visits: National Ambulatory Medical Care Survey. Med Care. 2002;40(7): 606e613. 46. Mechanic D, McAlpine DD, Rosenthal M. Are patients’ office visits with physicians getting shorter? N Engl J Med. 2001;344(3): 198e204. 47. Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. 1999;159(10):1069e1075.
7. Geraghty EM, Franks P, Kravitz RL. Primary care visit length, quality, and satisfaction for standardized patients with depression. J Gen Intern Med. 2007;22(12):1641e1647. 8. Gross DA, Zyzanski SJ, Borawski EA, Cebul RD, Stange KC. Patient satisfaction with time spent with their physician. J Fam Pract. 1998;47(2):133e137. 9. Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JE Jr. Characteristics of physicians with participatory decision-making styles. Ann Intern Med. 1996;124(5):497e504. 10. Nowalk MP, Bardella IJ, Zimmerman RK, Shen S. The physician’s office: can it influence adult immunization rates? Am J Manag Care. 2004;10(1):13e19. 11. Streja DA, Rabkin SW. Factors associated with implementation of preventive care measures in patients with diabetes mellitus. Arch Intern Med. 1999;159(3):294e302. 12. Chen LM, Farwell WR, Jha AK. Primary care visit duration and quality: does good care take longer? Arch Intern Med. 2009;169(20): 1866e1872. 13. Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Intern Med. 2001;134(9 Pt 2): 897e904. 14. Hasnain-Wynia R, Wolf MS. Promoting health care equity: is health literacy a missing link? Health Serv Res. 2010;45(4):897e903. 15. Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventive health care use among Medicare enrollees in a managed care organization. Med Care. 2002;40(5):395e404. 16. McNaughton CD, Jacobson TA, Kripalani S. Low literacy is associated with uncontrolled blood pressure in primary care patients with hypertension and heart disease. Patient Educ Couns. 2014;96(2):165e170. 17. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288(4):475e482. 18. Herndon JB, Chaney M, Carden D. Health literacy and emergency department outcomes: a systematic review. Ann Emerg Med. 2011;57(4):334e345. 19. Marcantonio ER, McKean S, Goldfinger M, Kleefield S, Yurkofsky M, Brennan TA. Factors associated with unplanned hospital readmission among patients 65 years of age and older in a Medicare managed care plan. Am J Med. 1999;107(1):13e17. 20. Mitchell SE, Sadikova E, Jack BW, Paasche-Orlow MK. Health literacy and 30-day postdischarge hospital utilization. J Health Commun. 2012;17(Suppl 3):325e338. 21. Morrison AK, Chanmugathas R, Schapira MM, Gorelick MH, Hoffmann RG, Brousseau DC. Caregiver low health literacy and nonurgent use of the pediatric emergency department for febrile illness. Acad Pediatr. 2014;14(5):505e509. 22. Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med. 2007;167(14):1503e1509. 23. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3(6):514e522. 24. Amtmann D, Cook KF, Jensen MP, et al. Development of a PROMIS item bank to measure pain interference. Pain. 2010;150(1):173e182. 25. Hays RD, Spritzer KL, Amtmann D, et al. Upper-extremity and mobility subdomains from the Patient-Reported Outcomes Measurement Information System (PROMIS) adult physical functioning item bank. Arch Phys Med Rehabil. 2013;94(11):2291e2296. 26. Pilkonis PA, Choi SW, Reise SP, et al. Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS(R)): depression, anxiety, and anger. Assessment. 2011;18(3):263e283. 27. Hassan K, Heptulla RA. Glycemic control in pediatric type 1 diabetes: role of caregiver literacy. Pediatrics. 2010;125(5): e1104ee1108.
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APPENDIX A. Newest Vital Sign: Questions in English 1. If you eat the entire container, how many calories will you eat? 2. If you are allowed to eat 60 g of carbohydrates as a snack, how much ice cream could you have? 3. Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g of saturated fat each day, which includes 1
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serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day? 4. If you usually eat 2,500 cal in a day, what percentage of your daily value of calories will you be eating if you eat 1 serving? 5. Is it safe for you to eat this ice cream? 6. (Ask only if the patient responds “no” to question 5): Why not?
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APPENDIX B.
Characteristics of the Study Population (n [ 24) Health Literacy Parameter
Total, n (%) Age (y), mean SD (range)
Limited (NVS Score 3)
All Patients 224 (100)
69 (31)
50 17 (20e88)
56 16 (21e88)
Adequate (NVS Score 4e6)
P
155 (69) 47 16 (20e83)
< .001
Sex, n (%) Female
110 (49)
42 (61)
68 (44)
Male
114 (51)
27 (39)
87 (56)
184 (82)
49 (71)
135 (87)
40 (18)
20 (29)
20 (13)
Medicare
45 (20)
21 (30)
24 (16)
Medicaid
18 (8)
14 (20)
4 (3)
154 (69)
33 (48)
121 (78)
7 (3)
1 (1)
6 (4)
161 (72)
34 (49)
127 (82)
.019
Race/ethnicity, n (%) White Nonwhite
.004
Insurance status, n (%)
Private Workers’ compensation
< .001
Working status, n (%) Working Unemployed
8 (4)
6 (9)
2 (1)
Disabled
28 (13)
15 (22)
13 (8)
Retired
27 (12)
14 (20)
13 (8)
< .001
Marital status, n (%) Single
71 (32)
17 (25)
54 (35)
124 (55)
38 (55)
86 (56)
Separated or divorced
17 (8)
9 (13)
8 (5)
Widowed
12 (5)
5 (7)
7 (5)
Sprain, dislocation, or mallet finger
26 (12)
5 (7)
21 (14)
Hand, wrist, or elbow fracture
42 (19)
6 (9)
36 (23)
Amputation, crush, or laceration
18 (8)
5 (7)
13 (8)
Carpal tunnel or cubital tunnel syndrome
26 (12)
9 (13)
17 (11)
Osteoarthrosis
16 (7)
7 (10)
9 (6)
Trigger finger
23 (10)
11 (16)
12 (8)
Ganglion cyst
13 (6)
5 (7)
8 (5)
Nonspecific arm pain
18 (8)
4 (6)
14 (9)
Lateral epicondylitis
7 (3)
5 (7)
2 (1)
All other diagnoses
35 (16)
12 (17)
23 (15)
212 (95)
64 (93)
148 (96)
12 (5)
5 (7)
7 (5)
Surgical
34 (15)
12 (17)
22 (14)
Nonsurgical
97 (43)
32 (46)
65 (42)
Diagnostic testing
38 (17)
8 (12)
30 (19)
Counseling/observation
55 (25)
17 (25)
38 (25)
Married
.11
Diagnosis, n (%)
.032
Appointment type, n (%) First opinion Second opinion
.40
Management, n (%)
.53
(Continued)
J Hand Surg Am.
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Vol. -, - 2016
6.e3
HEALTH LITERACY AND VISIT DURATION
APPENDIX B.
Characteristics of the Study Population (n [ 24) (Continued) Health Literacy Parameter
Limited (NVS Score 3)
All Patients
Adequate (NVS Score 4e6)
P
Resident/fellow involvement* No
118 (53)
35 (51)
83 (54)
Yes
106 (47)
34 (49)
72 (47)
0.70
PROMIS instruments, mean SD (range) Pain Interference
57 8.2 (32e76)
58 9.1 (32e73)
Upper Extremity Function
39 9.9 (16e62)
36 9.8 (16e56)
40 9.7 (21e62)
.008
Depression
47 8.9 (34e73)
49 10 (34e73)
46 8.3 (34e67)
.053
*Whether or not a resident or fellow saw the patient before the attending surgeon.
J Hand Surg Am.
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57 7.8 (39e76)
.46
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HEALTH LITERACY AND VISIT DURATION
APPENDIX C.
APPENDIX C.
Bivariate Analysis
Parameter
Duration of Visit (min), Mean SD
Parameter
P
Limited
9.4 5.6 11.3 6.7
Surgical
.03
Nonsurgical
Sex Female
10.9 6.8
Male
10.5 6.1
.67
White
10.8 6.5
Nonwhite
10.1 6.3 9.9 5.4
Medicaid
10.2 5.8
Private
11.0 6.8
.54
Counseling/observation
10.0 .6
No
13.1 6.9
Yes
8.1 4.7
Age .71
Pain Interference
Working status
Disabled
9.8 5.6
Retired
9.1 4.9 10.4 6.8
Married
11.0 6.8 9.1 5.7
Hand, wrist, or elbow fracture
10.9 6.1
Amputation, crush, or laceration
10.6 5.1
Carpal tunnel or cubital tunnel syndrome
13.6 9.2
Osteoarthrosis
9.7 4.6
Trigger finger
10.0 4.7
Ganglion cyst
7.5 4.1
Nonspecific arm pain
15.0 7.7
Lateral epicondylitis
11.6 7.2
All other diagnoses
9.3 5.8 10.3 6.1
Second opinion
17.7 8.4
.35
.002
Depression
e0.01
.85
.17
0.47
.01
.01 (Continued)
J Hand Surg Am.
e0.1
.003
Appointment type First opinion
P
0.2
Diagnosis Sprain, dislocation, or mallet finger
Correlation (r)
e0.2
Marital status Single
