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Improving Patient Care: Jane E. Sisk, Paul L. Hebert, Carol R. Horowitz, Mary Ann McLaughlin, Jason J. Wang, and Mark R. Chassin Effects of Nurse Management on the Quality of Heart Failure Care in Minority Communities: A Randomized Trial Ann Intern Med 2006; 145: 273-283 [Abstract] [Full text] [PDF]

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IN RESPONSE

Jane E Sisk, Paul L. Hebert, Ph.D.   (22 November 2006)

Literacy and Heart Failure Self-Care

Michael P Pignone, Darren A. DeWalt   (5 September 2006)

IN RESPONSE 22 November 2006
Jane E Sisk, Ph.D. Mount Sinai School of Medicine and National Center for Health Statistics, U.S. Centers for Disease C, Paul L. Hebert, Ph.D. Send rapid response to journal: Re: IN RESPONSE jsisk{at}cdc.gov Jane E Sisk, et al.	We appreciated the thoughtful comments of Dr. Pigone and Mr. DeWalt. In our trial we measured patients’ health literacy, however, not general literacy.(1) In preliminary analyses, we found no evidence that low health literacy was correlated with the effectiveness of nurse management in terms of either of our primary outcomes of physical functioning or all- cause hospitalization. Specifically, we measured physical function using the Short Form 12 Physical Component Score (SF12 PCS), which we administered at baseline and every three months through the end of the intervention at 12 months. We estimated a linear regression of the change in SF12 PCS on treatment assignment (nurse versus usual care), an indicator for inadequate health literacy, and the interaction between inadequate literacy and treatment assignment. Although the coefficient on treatment assignment was significant indicating a positive effect of nurse management, the coefficient on the interaction term between nurse management and inadequate literacy (p>0.2) provided little evidence that the nurse intervention was more effective for patients with inadequate health literacy at baseline. Alternative specifications of this modeling--including models with additional control variables for socio-demographic factors, and longitudinal models that made use of intervening data points at 3, 6, and 9 months--yielded similar null findings regarding health literacy. Regarding all-cause hospitalizations, we estimated Poisson regression models with total hospitalizations over the 12-month study as a function of treatment assignment, inadequate literacy at baseline, and the interaction of these two variables. The coefficient on the interaction term was not significant (p>0.2). These null findings regarding health literacy are particularly vexing because they tend to discount a potential reason why our intervention succeeded where similar interventions have not. Continued research on why disease management works in some populations but not others is clearly needed, and is a focus of our continuing efforts. Paul L Hebert, Ph.D. Mount Sinai School of Medicine New York, NY 10025 Jane E. Sisk, Ph.D. Mount Sinai School of Medicine and National Centers for Health Statistics, U.S. Centers for Disease Control and Prevention Hyattsville, MD 20817 References: 1. Sisk JE, Hebert PL, Horowitz CR, McLaughlin MA, Wang JJ, Chassin MR. Effects of nurse management on the quality of heart failure care in minority communities. Ann Intern Med. 2006.145:273-283. Conflict of Interest: None declared
Literacy and Heart Failure Self-Care 5 September 2006
Michael P Pignone, MD, MPH University of North Carolina, Darren A. DeWalt Send rapid response to journal: Re: Literacy and Heart Failure Self-Care pignone{at}med.unc.edu Michael P Pignone, et al.	Dear Editor, Sisk and colleagues found that a nurse-led intervention reduced hospital admissions for patients with systolic heart failure recruited from ambulatory clinics in Harlem, New York. (1)We recently reported similar findings with a self-management program in a population of ambulatory patients with heart failure (both systolic and diastolic dysfunction) recruited from an academic internal medicine practice in North Carolina.(2) Incidence of hospitalizations was reduced by 47%. Our population included a high proportion of patients with low educational attainment (an average of 9.5 years of schooling), and high rates of inadequate literacy (41%). In our study, patients with low literacy appeared to derive similar or greater benefit from the intervention than patients with adequate literacy, although our sample size was too small to test formally for an interaction. Sisk and colleagues reported that 29.8% of participants had inadequate literacy.(1) It would be interesting to know if they found a similar reduction in the risk of hospitalization among those with inadequate literacy, compared to their patients with adequate literacy. References 1. Sisk JE, Hebert PL, Horowitz CR, McLaughlin MA, Wang JJ, Chassin MR. Effects of nurse management on the quality of heart failure care in minority communities: a randomized trial. Ann Intern Med. 2006 Aug 15;145(4):273-83. 2. DeWalt DA, Malone RM, Bryant ME, Kosnar MC, Corr KE, Rothman RL, Sueta CA, Pignone MP. A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170]. BMC Health Serv Res. 2006 Mar 13;6:30. Conflict of Interest: Drs. Pignone and DeWalt have received funding from Pfizer, Inc for literacy-related research.