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Feasibility and diagnostic accuracy of brief health literacy and numeracy screening instruments in an urban emergency department.

ABSTRACT: The objective was to evaluate the diagnostic accuracy of five health literacy screening instruments in emergency department (ED) patients: the Rapid Evaluation of Adult Literacy in Medicine-Revised (REALM-R), the Newest Vital Sign (NVS), Single Item Literacy Screens (SILS), health numeracy, and physician gestalt. A secondary objective was to evaluate the feasibility of these instruments as measured by administration time, time on task, and interruptions during test administration.This was a prospective observational cross-sectional study of a convenience sampling of adult patients presenting during March 2011 and February 2012 to one urban university-affiliated ED. Subjects were consenting non-critically ill, English-speaking patients over the age of 18 years without aphasia, dementia, mental retardation, or inability to communicate. The diagnostic test characteristics of the REALM-R, NVS, SILS, health numeracy, and physician gestalt were quantitatively assessed by using the short Test of Functional Health Literacy in Adults (S-TOFHLA). A score of 22 or less was the criterion standard for limited health literacy (LHL).A total of 435 participants were enrolled, with a mean (±SD) age of 45 (±15.7) years, and 18% had less than a high school education. As defined by an S-TOFHLA score of 22 or less, the prevalence of LHL was 23.9%. In contrast, the NVS, REALM-R, and physician gestalt identified 64.8, 48.5, and 35% of participants as LHL, respectively. A normal NVS screen was the most useful test to exclude LHL, with a negative likelihood ratio of 0.04 (95% confidence interval [CI] = 0.01 to 0.17). When abnormal, none of the screening instruments, including physician gestalt, significantly increased the posttest probability of LHL. The NVS and REALM-R require 3 and 5 minutes less time to administer than the S-TOFHLA. Administration of the REALM-R is associated with fewer test interruptions.One-quarter of these ED patients had marginal or inadequate health literacy. Among the brief screening instruments evaluated, a normal NVS result accurately reduced the probability of LHL, although it will identify two-thirds of ED patients as high risk for LHL. None of the brief screening instruments significantly increases the probability of LHL when abnormal.

SUBMITTER: Carpenter CR

PROVIDER: S-EPMC4042843 | biostudies-literature | 2014 Feb

REPOSITORIES: biostudies-literature

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Feasibility and diagnostic accuracy of brief health literacy and numeracy screening instruments in an urban emergency department.

Carpenter Christopher R CR Kaphingst Kimberly A KA Goodman Melody S MS Lin Margaret J MJ Melson Andrew T AT Griffey Richard T RT

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 20140201 2

<h4>Objectives</h4>The objective was to evaluate the diagnostic accuracy of five health literacy screening instruments in emergency department (ED) patients: the Rapid Evaluation of Adult Literacy in Medicine-Revised (REALM-R), the Newest Vital Sign (NVS), Single Item Literacy Screens (SILS), health numeracy, and physician gestalt. A secondary objective was to evaluate the feasibility of these instruments as measured by administration time, time on task, and interruptions during test administrat ...[more]

PMID: 24673669

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Project description:BackgroundViolent injury is the leading cause of death among urban youth. Emergency department (ED) visits represent an opportunity to deliver a brief intervention (BI) to reduce violence among youth seeking medical care in high-risk communities.ObjectiveThe objective was to determine the efficacy of a universally applied BI addressing violence behaviors among youth presenting to an urban ED.MethodsED youth (14 to 20 years old) seeking medical or injury-related care in a Level I ED (October 2011-March 2015) and screening positive for a home address within the intervention or comparison neighborhood of a larger youth violence project were enrolled in this quasi-experimental study. Based on home address, participants were assigned to receive either the 30-minute therapist-delivered BI (Project Sync) or a resource brochure (enhanced usual care [EUC] condition). The Project Sync BI combined motivational interviewing and cognitive skills training, including a review of participant goals, tailored feedback, decisional balance exercises, role-playing exercises, and linkage to community resources. Participants completed validated survey measures at baseline and a 2-month follow-up assessment. Main outcome measures included self-report of physical victimization, aggression, and self-efficacy to avoid fighting. Poisson and zero-inflated Poisson regression analyses analyzed the effects of the BI, compared to the EUC condition, on primary outcomes.ResultsA total of 409 eligible youth (82% participation) were enrolled and assigned to receive either the BI (n = 263) or the EUC condition (n = 146). Two-month follow-up was 91% (n = 373). There were no significant baseline differences between study conditions. Among the entire sample, mean (±SD) age was 17.7 (±1.9) years, 60% were female, 93% were African American, and 79% reported receipt of public assistance. Of participants, 9% presented for a violent injury, 9% reported recent firearm carriage, 20% reported recent alcohol use, and 39% reported recent marijuana use. Compared with the EUC group, participants in the therapist BI group showed self-reported reductions in frequency of violent aggression (therapist, -46.8%; EUC, -36.9%; incident rate ratio [IRR] = 0.87; 95% confidence interval [CI] = 0.76 to 0.99) and increased self-efficacy for avoiding fighting (therapist, +7.2%; EUC, -1.3%; IRR = 1.09; 95% CI = 1.02 to 1.15). No significant changes were noted for victimization.ConclusionsAmong youth seeking ED care in a high-risk community, a brief, universally applied BI shows promise in increased self-efficacy for avoiding fighting and a decrease in the frequency of violent aggression.

Project description:ObjectivesA recent study demonstrated the efficacy of the SafERteens intervention in reducing peer violence among adolescents presenting to the emergency department (ED). The objective of this study was to determine the efficacy of this ED-based brief intervention (BI) on dating violence 1 year following the ED visit among the subsample of adolescents in the original randomized controlled trial reporting past-year dating violence.MethodsPatients (aged 14 to 18 years) at an ED were eligible for inclusion if they had past-year violence and alcohol use. Participants were randomized to one of three conditions (BI delivered by a computer [CBI], BI delivered by a therapist and a computer (T+CBI), or control) and completed follow-ups at 3, 6, and 12 months. In addition to content on alcohol misuse and peer violence, adolescents reporting dating violence received a tailored module on dating violence. The outcome of interest was frequency of moderate and severe dating violence victimization and aggression (baseline and 3, 6, and 12 months after ED visit).ResultsAmong eligible adolescents, 55% (n = 397) reported dating violence and were included in these analyses. Compared to the control group (who received a resource brochure only), participants in the CBI showed reductions in moderate dating victimization at 3 months (inter-rater reliability [IRR] = 0.71; 95% confidence interval [CI] = 0.51 to 0.99; p < 0.05) and 6 months (IRR = 0.56; 95% CI = 0.38 to 0.83; p < 0.01). Models examining interaction effects were significant for the CBI on moderate dating victimization at 3 months (IRR = 0.81; 95% CI = 0.67 to 0.98; p < 0.05) and 6 months (IRR = 0.81; 95% CI = 0.66 to 0.99; p < 0.05). Significant interaction effects were found for the T+CBI on moderate dating violence victimization at 6 months (IRR = 0.81; 95% CI = 0.69 to 0.96; p < 0.01) and 12 months (IRR = 0.76; 95% CI = 0.63 to 0.90; p < 0.001) and severe dating violence victimization at 3 months (IRR = 0.76; 95% CI = 0.59 to 0.96; p < 0.05).ConclusionsED-based BIs tailored to address multiple risk behaviors (i.e., peer violence, alcohol use, and dating violence) show promise for reducing moderate and severe dating victimization for up to 1 year following an ED visit.

Project description:BackgroundThe ability to rule out or in a major adverse cardiac event (MACE) in patients with suspected acute coronary syndrome at emergency department (ED) presentation would be beneficial to patient care and the health care system. The clinical chemistry score (CCS) was evaluated in this context.MethodsThis diagnostic accuracy study evaluated 2 different ED cohorts with suspected acute coronary syndrome. For patients in cohort 1, who presented to the ED of 3 hospitals in Hamilton, Ontario, between May and August 2013, retrospective measurements were taken using the Ortho Clinical Diagnostics high-sensitivity cardiac troponin I (hs-cTnI) assay; for patients in cohort 2, who presented to the ED of the same 3 hospitals in Hamilton between November 2012 and February 2013, an ED cardiac presentation blood test panel was performed with the Abbott Diagnostics hs-cTnI assay. The sensitivity and specificity of the CCS (cut-offs of ? 1 and 5) and hs-cTnI alone (published cut-offs) were compared for MACE (composite of death, myocardial infarction, unstable angina, revascularization) at 30 days for both cohorts and at 90 days for cohort 2.ResultsThe incidence of MACE at 30 days was higher in cohort 1 (n = 1058) (19.4%, 95% confidence interval [CI] 16.8%-22.2%) than in cohort 2 (n = 5974) (14.6%, 95% CI 13.6%-15.6%). In cohort 1, a CCS of 1 or above yielded a sensitivity of 99.5% (95% CI 97.3%-99.9%). The sensitivity with an Ortho hs-cTnI cut-off of 1 ng/L or above was 91.2% (95% CI 86.5%-95.7%). The specificity of a CCS of 5 (97.8%, 95% CI 96.5%-98.7%) was higher than when the overall 99th-percentile cut-off for the Ortho hs-cTnI assay (> 11 ng/L; 90.1%, 95% CI 87.9%-92.0%) was used. A similar pattern was observed in cohort 2 at 30 days and persisted at 90 days with the Abbott hs-cTnI assay.InterpretationThe CCS derived with 2 different hs-cTnI assays and ED populations yielded higher sensitivity and specificity estimates for MACE than hs-cTnI alone. An intervention study is needed to evaluate the impact of the CCS at both the patient and hospital levels.Trial registrationClinicalTrials.gov, no. NCT01994577.

Project description:BackgroundSymptom checkers are clinical decision support apps for patients, used by tens of millions of people annually. They are designed to provide diagnostic and triage advice and assist users in seeking the appropriate level of care. Little evidence is available regarding their diagnostic and triage accuracy with direct use by patients for urgent conditions.ObjectiveThe aim of this study is to determine the diagnostic and triage accuracy and usability of a symptom checker in use by patients presenting to an emergency department (ED).MethodsWe recruited a convenience sample of English-speaking patients presenting for care in an urban ED. Each consenting patient used a leading symptom checker from Ada Health before the ED evaluation. Diagnostic accuracy was evaluated by comparing the symptom checker's diagnoses and those of 3 independent emergency physicians viewing the patient-entered symptom data, with the final diagnoses from the ED evaluation. The Ada diagnoses and triage were also critiqued by the independent physicians. The patients completed a usability survey based on the Technology Acceptance Model.ResultsA total of 40 (80%) of the 50 participants approached completed the symptom checker assessment and usability survey. Their mean age was 39.3 (SD 15.9; range 18-76) years, and they were 65% (26/40) female, 68% (27/40) White, 48% (19/40) Hispanic or Latino, and 13% (5/40) Black or African American. Some cases had missing data or a lack of a clear ED diagnosis; 75% (30/40) were included in the analysis of diagnosis, and 93% (37/40) for triage. The sensitivity for at least one of the final ED diagnoses by Ada (based on its top 5 diagnoses) was 70% (95% CI 54%-86%), close to the mean sensitivity for the 3 physicians (on their top 3 diagnoses) of 68.9%. The physicians rated the Ada triage decisions as 62% (23/37) fully agree and 24% (9/37) safe but too cautious. It was rated as unsafe and too risky in 22% (8/37) of cases by at least one physician, in 14% (5/37) of cases by at least two physicians, and in 5% (2/37) of cases by all 3 physicians. Usability was rated highly; participants agreed or strongly agreed with the 7 Technology Acceptance Model usability questions with a mean score of 84.6%, although "satisfaction" and "enjoyment" were rated low.ConclusionsThis study provides preliminary evidence that a symptom checker can provide acceptable usability and diagnostic accuracy for patients with various urgent conditions. A total of 14% (5/37) of symptom checker triage recommendations were deemed unsafe and too risky by at least two physicians based on the symptoms recorded, similar to the results of studies on telephone and nurse triage. Larger studies are needed of diagnosis and triage performance with direct patient use in different clinical environments.

Dataset Information

Feasibility and diagnostic accuracy of brief health literacy and numeracy screening instruments in an urban emergency department.

Publications

Feasibility and diagnostic accuracy of brief health literacy and numeracy screening instruments in an urban emergency department.

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