Patients with Limited Health Literacy Have Worse Preoperative Function, Pain Control and Experience Prolonged Hospitalizations Following Shoulder Arthroplasty

These authors observe that patients with limited health literacy may have difficulty understanding and acting upon medical information, placing them at risk for potential misuse of health services and adverse outcomes. The purposes of our study were to determine the prevalence of limited health literacy in patients undergoing inpatient shoulder arthroplasty, its association with the degree of preoperative symptom intensity and magnitude of limitations, and its effects on perioperative outcomes including postoperative length of stay (LOS), total inpatient costs, and inpatient opioid consumption.

They retrospectively identified 230 patients having elective inpatient reverse or anatomic shoulder arthroplasty having preoperative assessment of health literacy using the 4 questions of the Brief Health Literacy Screening Tool (see this link):

How often do you have someone help you read hospital materials?

How often do you have problems learning about your medical condition because of difficulty understanding written information?

How often do you have a problem understanding what is told to you about your medical condition?

How confident are you filling out medical forms by yourself?

58 (25.2%) of these patients were classified as having limited health literacy. Prior to surgery, these patients had significantly higher rates of opioid use, more self-reported allergies, worse American Shoulder and Elbow Surgeons scores, visual analog scale pain scores, forward elevation and external rotation but did not significantly differ in terms of any additional demographic or clinical characteristics. Patients with limited health literacy had significantly longer lengths-of-stay but did not differ in terms of total hospitalization costs or total inpatient opioid consumption. In multivariable analysis, limited health literacy was independently predictive of significantly longer length of stay.

These patients also demonstrated trends towards worse overall health and higher levels of socioeconomic deprivation.

Comment: Health literacy ranges widely among patients. Fully understanding the indications, alternatives, risks, rehabilitation, commitment and social support for shoulder arthroplasty requires a high degree of sophistication and study.

The rate of limited health literacy as assessed by these four questions was high (25%), higher than one might expect. Looking at the phrasing of the four questions it is possible that they may be misunderstood in and of themselves. Thus the measured rate of limited health literacy may be even greater than noted here.

Limited health literacy may affect the patient's decision to proceed with surgery. One one hand not understanding the potential benefit of arthroplasty may result in delay of treatment until the patient's arthritis had advanced to a more severe stage with more severe symptoms. On the other hand not understanding the commitment, risks and alternatives of shoulder arthroplasty may result in proceeding with arthroplasty prematurely or without adequate preparation.

So as surgeons we have an obligation to all patients to provide an understanding of what they need to know. To that end, preoperative discussions should involve a family member or friend if there is any concern about the patient's ability to achieve this understanding. Because retention of what is said in the office is limited, written handouts and open access for followup questions is important. If the surgeon is concerned that the patient may not be fully understanding of and prepared for an arthroplasty, a second preoperative visit is helpful in assuring that all the ingredients for a successful outcome are in place. At such a second visit patients can be asked to provide their understanding of the procedure, the risks and the aftercare.

Shoulder arthroplasty is an elective procedure: there is no rush in getting the patient to the operating room before they are informed and prepared.

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