Low literacy is associated with increased risk of hospitalization and death among individuals with heart failure

Jia Rong Wu, George M. Holmes, Darren A. Dewalt, Aurelia Macabasco-O'Connell, Kirsten Bibbins-Domingo, Bernice Ruo, David W. Baker, Dean Schillinger, Morris Weinberger, Kimberly A. Broucksou, Brian Erman, Christine D. Jones, Crystal W. Cene, Michael Pignone

Research output: Contribution to journalArticlepeer-review

114 Scopus citations


BACKGROUND: Low literacy increases the risk for many adverse health outcomes, but the relationship between literacy and adverse outcomes in heart failure (HF) has not been well studied. METHODS: We studied a cohort of ambulatory patients with symptomatic HF (NYHA Class II-IV within the past 6 months) who were enrolled in a randomized controlled trial of self-care training recruited from internal medicine and cardiology clinics at four academic medical centers in the US. The primary outcome was combined all-cause hospitalization or death, with a secondary outcome of hospitalization for HF. Outcomes were assessed through blinded interviews and subsequent chart reviews, with adjudication of cause by a panel of masked assessors. Literacy was measured using the short Test of Functional Health Literacy in Adults. We used negative binomial regression to examine whether the incidence of the primary and secondary outcomes differed according to literacy. RESULTS: Of the 595 study participants, 37 % had low literacy. Mean age was 61, 31 % were NYHA class III/IV at baseline, 16 % were Latino, and 38 % were African-American. Those with low literacy were older, had a higher NYHA class, and were more likely to be Latino (all p < 0.001). Adjusting for site only, participants with low literacy had an incidence rate ratio (IRR) of 1.39 (95 % CI: 0.99, 1.94) for all-cause hospitalization or death and 1.36 (1.11, 1.66) for HF-related hospitalization. After adjusting for demographic, clinical, and self-management factors, the IRRs were 1.31 (1.06, 1.63) for all-cause hospitalization and death and 1.46 (1.20, 1.78) for HF-related hospitalization. CONCLUSIONS: Low literacy increased the risk of hospitalization for ambulatory patients with heart failure. Interventions designed to mitigate literacy-related disparities in outcomes are warranted.

Original languageEnglish
Pages (from-to)1174-1180
Number of pages7
JournalJournal of General Internal Medicine
Issue number9
StatePublished - Sep 2013

Bibliographical note

Funding Information:
Acknowledgments: The project described was supported by Award Number R01HL081257 from the National Heart, Lung, And Blood Institute and a supplement to that grant provided under the American Recovery and Reinvestment Act of 2009 (ARRA). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, And Blood Institute or the National Institutes of Health.


  • heart failure
  • literacy
  • outcomes

ASJC Scopus subject areas

  • Internal Medicine


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