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Feasibility and Diagnostic Accuracy of Brief Health Literacy and Numeracy Screening Instruments in an Urban Emergency Department
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  • Description:

    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-TOHFLA). A score of 22 or less was the criterion standard for limited health literacy (LHL).


    Four hundred thirty-five participants were enrolled, with mean age of 45 years (SD ±15.7 years) and 18% had less than a high school education. As defined by an S-TOHFLA 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% CI = 0.01 to 0.17). When abnormal, none of the screening instruments, including physician gestalt, significantly increased the post-test probability of LHL. The NVS and REALM-R require 3 and 5 minutes less time to administer than the S-TOHFLA. Administration of the REALM-R is associated with less test interruptions.


    One-quarter of these ED patients had marginal or inadequate health literacy. Among the brief screening instruments evaluated, a normal Newest Vital Sign result accurately reduced the probability of limited health literacy, although it will identify two-thirds of ED patients as high-risk for limited health literacy. None of the brief screening instruments significantly increases the probability of limited health literacy when abnormal.

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    1KM1CA156708-01/CA/NCI NIH HHS/United States
    3U54CA153460-03S1/CA/NCI NIH HHS/United States
    KL2 RR024994/RR/NCRR NIH HHS/United States
    KL2 TR000450/TR/NCATS NIH HHS/United States
    KM1 CA156708/CA/NCI NIH HHS/United States
    KM1CA156708/CA/NCI NIH HHS/United States
    P30 DK092950/DK/NIDDK NIH HHS/United States
    P50 CA95815/CA/NCI NIH HHS/United States
    R01 CA168608/CA/NCI NIH HHS/United States
    R21 HS020309/HS/AHRQ HHS/United States
    TL1 RR024995/RR/NCRR NIH HHS/United States
    TL1 RR024995/RR/NCRR NIH HHS/United States
    TL1 TR000449/TR/NCATS NIH HHS/United States
    U58 DP0003435/DP/NCCDPHP CDC HHS/United States
    UL1 RR024992/RR/NCRR NIH HHS/United States
    UL1 TR000448/TR/NCATS NIH HHS/United States
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