HEALTH LITERACY IN TREATMENT ASSIGNMENT AND MEDICATION ADHERENCE: APPLICATION TO STABLE ANGINA PECTORIS

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  • March 21, 2019
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  • Savitz, Samuel
    • Affiliation: Gillings School of Global Public Health, Department of Health Policy and Management
Abstract
  • Health literacy is a major determinant of health outcomes, spending, and hospital admissions. However, gaps in the literature remain on the relationship between health literacy and health behaviors. The objective of this dissertation was to assess the relationship between health literacy and key health behaviors for patients with stable angina pectoris. The dissertation had three aims: 1) evaluate the relationship between health literacy and treatment assignment: medication only, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG) surgery; 2) assess patient and clinician behavior during treatment planning conversations; and 3) evaluate the relationship between health literacy and adherence to anti-anginal medications for stable angina. We used a 20 percent Medicare claims sample from 2007-2013 to evaluate the first and third aims. Health literacy was assessed using an area-based measure. Multinomial logistic regression was used to evaluate the relationship between health literacy and treatment assignment. Probit regression, inverse probability of treatment weighting, and two-stage residual inclusion were used to assess the relationship between health literacy and medication adherence. For the second aim, we used recorded patient-clinician encounters and questionnaire data from the PCI Choice Trial. In this data source, health literacy was assessed using a validated screening question. Patients living in low health literacy areas had significantly higher utilization of medication only (3.3 percentage points) and lower utilization of CABG (-3.0 percentage points) compared to patients in high health literacy areas. This finding may be related to health literacy being a predictor of worse access to care. Low literacy was associated with greater decisional conflict among patients and may be a barrier in communication. The clinician and the setting in which the conversation took place may also be important determinants of communication quality. Low health literacy may act as barrier to patient-clinician communication. Living in low health literacy areas was also associated with significantly lower medication adherence when using the quartile specification of health literacy (-2.8 percentage points), but not the dichotomous specification. There was also strong evidence for selection into treatment assignment. The small magnitude of these findings do not support the use of health literacy to inform interventions to improve medication adherence.
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Advisor
  • Jones, William
  • Stearns, Sally
  • Trogdon, Justin
  • Bailey, Stacy
  • Dusetzina, Stacie
Degree
  • Doctor of Philosophy
Degree granting institution
  • University of North Carolina at Chapel Hill Graduate School
Graduation year
  • 2018
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Date uploaded
  • June 13, 2018

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