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AAOS Now

Published 3/25/2022
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Brandon May

Poor Health Literacy Linked to Depression in Orthopaedic Trauma Patients

In a study performed at Emory University, orthopaedic trauma patients were noted to be more likely to have poor health literacy. A lack of optimal health literacy in that population was also associated with a higher risk of depression and limited access to transportation to medical visits, work, and other day-to-day locations.

The findings of the study will be presented by Jesse Seilern und Aspang, MD, an orthopaedic surgeon and researcher from Emory University in Atlanta.

“While we showed an association between poor health literacy and depression, as well as lack of transportation access, this question remains a ‘chicken or egg’ situation,” Dr. Aspang said. For instance, Dr. Aspang wondered whether improving health communication, delivery of educational materials to patients, and care coordination could mitigate the risk for depression for the orthopaedic population.

“Would treating depression or post-traumatic stress disorder enable patients to more easily navigate the complexities of post-trauma care?” Dr. Aspang told AAOS Now. “Or do we simply need to identify at-risk patients for both conditions and deliver personalized holistic post-trauma care that addresses each?”

According to Dr. Aspang and colleagues, previous research findings have demonstrated associations among orthopaedic trauma patients’ level of health literacy, surgical outcomes, and patient satisfaction. However, as the researchers explained in their poster presentation, little is known regarding associations between poor health literacy in this population and patterns of morbidity and access to care.

“We asked this question specifically because we are constantly seeking to identify ways of improving the holistic care of trauma patients,” Dr. Aspang explained.

In this prospective analysis, Dr. Aspang and researchers evaluated a total of 184 consecutive patients who were admitted to an American College of Surgeons–verified level 1 trauma center between January 2019 and December 2020. Approximately 40 percent of the population was female, and the mean age of the overall cohort was 42 ± 17 years.

Patients in the study received and completed a comprehensive survey regarding social determinants of health. The investigators also used three screening questions to assess patients’ levels of health literacy:

  1. How often do you have someone help you read hospital materials?
  2. How often do you have problems learning about your medical condition because of difficulty understanding written information?
  3. How confident are you filling out medical forms by yourself?

The five possible response options for the health literacy assessment were:

a) a little of the time
c) some of the time
d) most of the time
e) all of the time

Patients were classified as having poor health literacy if they answered c, d, or e to the first two questions and a, b, or c to the third question. The investigators also obtained and analyzed trauma registry information for the recruited patients.

Based on the health literacy assessment, 17 percent of patients were classified has having poor health literacy. Variables that did not demonstrate an association with health literacy included age, sex, race, education, housing status, comorbidities, in-hospital complications, and hospital utilization (P >0.05).

However, variables that were significantly associated with poor health literacy included an increased probability for major depression based on responses to the Patient Health Questionnaire two-item scale (PHQ-2) (odds ratio [OR] = 10.58, P <0.001), a lack of medical-related transportation (or="5.26,">P = 0.002) or work-/life-related transportation (OR = 4.58, P = 0.007), and a misdemeanor or felony criminal history (OR = 2.95, P = 0.033).

The investigators noted that patients who scored ≥3 on the PHQ-2 were nearly 2.5 times more likely to have poor health literacy than those who scored lower on the assessment item (OR = 2.359, P <0.001).>

Limitations of the study included the relatively small sample size, the inclusion of patients from a single center, and the predominance of male patients in the final sample.

Based on the findings, the researchers explained that the identified association between poor health literacy “with major depression, lack of transportation, and a criminal record is novel evidence, indicating a multifactorial cause, and calls for heightened awareness in this vulnerable at-risk population, which could facilitate clinical care pathway optimization, in addition to improving surgical outcomes.”

“Our biggest opportunity with the results of this study is taking the next step in developing and testing risk-mitigating interventions,” Dr. Aspang concluded.

The study will be on display as Poster P0958 on Friday in Academy Hall, from 7 a.m. to 5 p.m.

Dr. Aspang’s coauthors of “Poor Health Literacy in the Orthopaedic Trauma Population Is Linked to Increased Risk for Major Depression: a Prospective Analysis at an Urban Level 1 Trauma Center” are Madeline Wetterhall, BS; Roberto Hernandez-Irizarry, MD, MSc; and Mara Lynne Schenker, MD, FAAOS.

Brandon May is a freelance writer for AAOS Now.