Prevalence of and factors associated with limited health literacy in spine patients

The Association of Area Deprivation Index and Spine Surgery Outcomes: A Systematic and Narrative Review

BACKGROUND AND OBJECTIVES

With an aging population, the prevalence of spine pathology including degenerative spine disease continues to increase. These pathologies present a significant disease burden, often requiring long-term and expensive care. Recent literature has linked several socioeconomic determinants of health with outcomes after spine surgery. We sought to conduct a systematic review to determine the relationship between Area Deprivation Index (ADI), a measure of neighborhood-level socioeconomic status, and objective and patient-reported outcome (PRO) measures after spine surgery and to propose potential interventions.

METHODS

An Embase and Medline search was conducted from inception to April 1st, 2024, for relevant articles assessing ADI and spine surgery outcomes. The inclusion criteria were all North American observational studies available in English that reported on the association of ADI and adult cervical, lumbar, neoplastic, or deformity spine surgery outcomes.

RESULTS

Ten articles met the inclusion criteria resulting in a combined 56 925 patients who had undergone elective surgery for cervical, lumbar, spine metastases, and adult spine deformity pathologies. Two studies reported ADI to be associated with increased costs of care and postoperative lengths of stay after cervical spine surgery. Five studies found the association between high ADI with increased rates of respiratory failure, 90-day emergency room visits, longer lengths of stay, 90-day reoperation rates, and poor PROs after lumbar spine surgery. One study found an association with high ADI and increased 30-day and 90-day readmissions across all spine surgeries, and 1 study found no association between ADI and overall survival after surgery for spinal metastases.

CONCLUSION

Across available literature, high ADI seems to be associated with higher rates of postoperative readmissions and worse PROs. Further studies are needed to better understand the mechanisms underlying the effects of ADI on spine surgery outcomes and identify possible interventions to optimize outcomes.

Readability of the Most Commonly Used Patient-Reported Outcome Measures in Hand Surgery

PURPOSE

Patient-reported outcome measures (PROMs) assess surgical outcomes and patient perspectives on function, symptoms, and quality of life. The readability of patient-reported outcome measures is crucial for ensuring patients can understand and accurately complete them. The National Institutes of Health and American Medical Association recommend that patient materials be written at or below a sixth-grade reading level. We aimed to evaluate whether PROMs identified in the hand literature meet these recommended reading standards.

METHODS

We conducted a readability analysis of 22 PROMs referenced in the hand literature. Readability was assessed using the Flesch Reading Ease Score (FRES) and the Simple Measure of Gobbledygook (SMOG) Index. Scores were obtained using an online readability calculator. Patient-reported outcome measures meeting a FRES ≥ 80 or SMOG ˂ 7 were considered at a sixth-grade reading level or lower, per the National Institutes of Health and American Medical Association guidelines.

RESULTS

Across all PROMs, the average FRES was 66 ± 12, and the average SMOG Index was 8 ± 1, corresponding to approximately an eighth- to ninth-grade reading level. Three PROMs met the target readability thresholds: Patient-Reported Outcome Measurement Information System-Physical Function Upper Extremity, Patient Evaluation Measure, and the 6-item Carpal Tunnel Syndrome Symptom Scale. Several PROMs, including the Southampton Dupuytren's Scoring Scheme, Hand Assessment Tool, and Manual Ability Measure 16, demonstrated relatively low readability scores.

CONCLUSIONS

Most PROMs mentioned in the hand literature exceeded the recommended sixth-grade reading level, potentially affecting patient comprehension and data accuracy. Although improving readability may enhance patient understanding, altering PROM wording is not straightforward and may require extensive revalidation because changes risk affecting validity and reliability, underscoring the complexity of revising PROMs.

CLINICAL RELEVANCE

These findings highlight the importance of raising awareness about PROM readability issues. Recognizing these readability challenges may encourage researchers, developers, and journal editors to consider recommended guidelines when proposing, modifying, or evaluating these measures.

Sports Medicine Patient-Reported Outcomes Fail to Meet National Institutes of Health- and American Medical Association-Recommended Reading Levels

PURPOSE

To evaluate the readability of commonly used patient-reported outcome measures (PROMs) in the sports medicine literature to determine whether they meet the recommended reading levels set by the National Institutes of Health and the American Medical Association (AMA).

METHODS

A readability analysis was conducted on 26 PROMs commonly used in the sports medicine literature. The primary readability metrics used were the Flesch Reading Ease Score (FRES) and the Simple Measure of Gobbledygook (SMOG) Index. Readability scores were obtained using an online readability calculator and compared against National Institutes of Health and American Medical Association guidelines. An FRES of 80 or greater or an SMOG Index less than 7 was applied as a threshold for a sixth-grade reading level or lower.

RESULTS

The average FRES and SMOG Index for all PROMs were 65 ± 13 and 9 ± 1, respectively, indicating an eighth- to ninth-grade reading level. Four PROMs met the FRES and SMOG Index threshold for readability: 12-Item Short Form Survey, Pediatric Quality of Life Inventory, Numeric Pain Rating Scale, and Musculoskeletal Function Assessment. The Patient-Specific Functional Scale, Disablement in the Physically Active scale, Upper Extremity Functional Index, Low Back Outcome Score, and International Knee Documentation Committee questionnaire were among the least readable PROMs.

CONCLUSIONS

Most sports medicine PROMs are written above the recommended sixth-grade reading level.

CLINICAL RELEVANCE

Ensuring that sports medicine PROMs meet recommended readability standards may improve data accuracy and patient comprehension. By reducing literacy barriers, clinicians can obtain more reliable responses, better evaluate outcomes, and ultimately enhance patient care.

Development of Machine Learning Algorithms for Identifying Patients With Limited Health Literacy

RATIONALE

Limited health literacy (HL) leads to poor health outcomes, psychological stress, and misutilization of medical resources. Although interventions aimed at improving HL may be effective, identifying patients at risk of limited HL in the clinical workflow is challenging. With machine learning (ML) algorithms based on readily available data, healthcare professionals would be enabled to incorporate HL screening without the need for administering in-person HL screening tools.

AIMS AND OBJECTIVES

Develop ML algorithms to identify patients at risk for limited HL in spine patients.

METHODS

Between December 2021 and February 2023, consecutive English-speaking patients over the age of 18 and new to an urban academic outpatient spine clinic were approached for participation in a cross-sectional survey study. HL was assessed using the Newest Vital Sign and the scores were divided into limited (0-3) and adequate (4-6) HL. Additional patient characteristics were extracted through a sociodemographic survey and electronic health records. Subsequently, feature selection was performed by random forest algorithms with recursive feature selection and five ML models (stochastic gradient boosting, random forest, Bayes point machine, elastic-net penalized logistic regression, support vector machine) were developed to predict limited HL.

RESULTS

Seven hundred and fifty-three patients were included for model development, of whom 259 (34.4%) had limited HL. Variables identified for predicting limited HL were age, Area Deprivation Index-national, Social Vulnerability Index, insurance category, Body Mass Index, race, college education, and employment status. The Elastic-Net Penalized Logistic Regression algorithm achieved the best performance with a c-statistic of 0.766, calibration slope/intercept of 1.044/-0.037, and Brier score of 0.179.

CONCLUSION

Elastic-Net Penalized Logistic Regression had the best performance when compared with other ML algorithms with a c-statistic of 0.766, calibration slope/intercept of 1.044/-0.037, and a Brier score of 0.179. Over one-third of patients presenting to an outpatient spine center were found to have limited HL. While this algorithm is far from being used in clinical practice, ML algorithms offer a potential opportunity for identifying patients at risk for limited HL without administering in-person HL assessments. This could possibly enable screening and early intervention to mitigate the potential negative consequences of limited HL without taxing the existing clinical workflow.

Readability of foot and ankle patient-reported outcomes: Alignment with National institutes of health and american medical association standards

Patient-reported outcome measures are essential tools for assessing surgical interventions, capturing patient perspectives on functionality, symptoms, and quality of life. However, ensuring that these measures are easily understandable is crucial for accurate patient responses. The National Institutes of Health and American Medical Association recommend that patient materials be written at or below a sixth-grade reading level. This study evaluated the readability of 45 commonly used patient-reported outcome measures in foot and ankle surgery to determine alignment with these guidelines. A readability analysis was conducted using the Flesch Reading Ease Score and the Simple Measure of Gobbledygook Index, with a threshold of a Flesch Reading Ease Score of at least 80 or a Simple Measure of Gobbledygook Index below 7 indicating a sixth-grade or lower reading level. The average readability scores indicated an eighth to ninth-grade reading level, with only 31% of patient-reported outcome measures meeting the readability threshold. Among the least readable measures were the American Orthopaedic Foot and Ankle Society Clinical Rating Scales for various foot and ankle regions and the Ankle Osteoarthritis Scale. These findings suggest that most foot and ankle surgery patient-reported outcome measures are above the recommended readability level, potentially hindering patient comprehension and response accuracy. Improving the readability of patient-reported outcome measures, either by developing new tools or modifying existing ones, may enhance the accessibility and reliability of patient-reported data. LEVEL OF CLINICAL EVIDENCE: 4.

Disparities in Patient-reported Outcome Measure Completion Rates and Baseline Function in Newly Presenting Spine Patients

STUDY DESIGN

Retrospective review.

OBJECTIVE

The purpose of this study was to evaluate disparities in patient-reported outcome measures (PROM) completion rates and baseline function scores among newly presenting spine patients.

SUMMARY OF BACKGROUND DATA

Prior studies have demonstrated that minority patients and those of low socioeconomic status may present with worse physical and mental health on PROMs. As PROMs are increasingly used in clinical care, research, and health policy, accurate assessment of health status among populations relies on the successful completion of PROM instruments.

METHODS

A retrospective review of 10,803 consecutive new patients presenting to a single multidisciplinary spine clinic from June 2020 to September 2022 was performed. Univariate statistics were performed to compare demographics between patients who did and did not complete PROMs. Multivariable analysis was used to compare PROM instrument completion rates by race, ethnicity, and Social Vulnerability Index (SVI) and baseline scores among responders.

RESULTS

A total of 68.4% of patients completed PROMs at the first clinic visit. After adjusting for age, sex, body mass index, and diagnosis type, patients of non-White race (OR=0.661, 95% CI=0.599-0.729, P <0.001), Hispanic ethnicity (OR=0.569, 95% CI=0.448-0.721, P <0.001), and increased social vulnerability (OR=0.608, 95% CI=0.511-0.723, P <0.001) were less likely to complete PROMs. In the multivariable models, patients of non-White race reported lower levels of physical function (β=-6.5, 95% CI=-12.4 to -0.6, P =0.032) and higher levels of pain intensity (β=0.6, 95% CI=0.2-1.0, P =0.005). Hispanic ethnicity (β=1.5, 95% CI=0.5-2.5, P =0.004) and increased social vulnerability (β=1.1, 95% CI=0.4-1.8, P =0.002) were each associated with increased pain intensity.

CONCLUSIONS

Among newly presenting spine patients, those of non-White race, Hispanic ethnicity, and with increased social vulnerability were less likely to complete PROMs. As these subpopulations also reported worse physical function or pain intensity, additional strategies are needed to better capture patient-reported health status to avoid bias in clinical care, outcomes research, and health policy.

LEVEL OF EVIDENCE

4.

Racial Disparity in Length of Stay Following Implementation of a Bariatric Enhanced Recovery Program

INTRODUCTION

Enhanced Recovery Programs (ERPs) mitigate racial disparities in postoperative length of stay (LOS) for colorectal populations. It is unclear, however, if these effects exist in the bariatric surgery population. Therefore, this study aimed to evaluate the racial disparities in LOS before and after implementation of bariatric surgery ERP.

METHODS

A retrospective cohort study was performed using data from a single institution. Patients undergoing minimally invasive sleeve gastrectomy or Roux-en-Y gastric bypass from 2017 to 2019 (pre-ERP) or 2020-2022 (ERP) were included. Chi-square, Kruskal-Wallis, and analysis of variance were used to compare groups, and estimated LOS (eLOS) was assessed via multivariable regression.

RESULTS

Seven hundred sixty four patients were identified, including 363 pre-ERPs and 401 ERPs. Pre-ERP and ERP cohorts were similar in age (median 44.3 years versus 43.8 years, P = 0.80), race (53.4% Black versus 56.4% Black, P = 0.42), and preoperative body mass index (median 48.3 versus 49.4, P = 0.14). Overall median LOS following bariatric surgery decreased from 2 days pre-ERP to 1 day following ERP (P < 0.001). Average LOS for Black and White patients decreased by 0.5 and 0.48 days, respectively. However, overall eLOS remained greater for Black patients compared with White patients despite ERP implementation (eLOS 0.21 days, P = 0.01).

CONCLUSIONS

Implementation of a bariatric surgery ERP was associated with decreased LOS for both Black and White patients. However, Black patients did have slightly longer LOS than White patients in both pre-ERP and ERP eras. More work is needed to understand the driving mechanism(s) of these disparities to eliminate them.

Limited health literacy is common among vascular surgery patients

BACKGROUND

Health literacy is a crucial aspect of informed decision-making, and limited health literacy has been associated with worse health care outcomes. To date, health literacy has not been examined in vascular surgery patients. Therefore, we conducted a prospective observational study to determine the prevalence and factors associated with poor health literacy in vascular surgery patients.

METHODS

The Newest Vital Sign (Pfizer, New York, NY), a validated instrument, was used to appraise the health literacy of 150 patients who visited the outpatient vascular clinic at UF Health Shands Hospital between April 2022 and August 2022. Patients who scored a 4 (out of 6) or higher were classified as having adequate health literacy. Each study participant also completed a sociodemographic questionnaire.

RESULTS

In total, 82 out of the 150 (54%) patients we screened had limited health literacy. The prevalence of limited health literacy varied and was independently associated with increased age (odds ratio 1.06; 95% [1.02 to 1.10], P = .004), having not attended college (high school diploma versus college+ odds ratio 3.5; 95% [1.26 to 10.1], P = .018), and African American race (odds ratio 5.3; 95% [1.59 to 22.3], P = .012). A total of 83% of African American patients had limited health literacy, compared to 49% of Asian and White patients.

CONCLUSION

Most vascular surgery patients have limited health literacy. Increased age, fewer years of education, and African American race were associated with limited health literacy. Physicians caring for patients with lower health literacy should investigate and use communication strategies tailored to patients with limited health literacy.

Readability of Patient-Reported Outcomes in Spine Surgery and Implications for Health Literacy

STUDY DESIGN

Observational study.

OBJECTIVE

To evaluate the readability of commonly utilized patient-reported outcome measures (PROMs) in spine surgery.

SUMMARY OF BACKGROUND DATA

Although studies have evaluated patient education materials, discharge instructions, and informed consent forms in spine surgery, there is a dearth of literature on the readability of PROMs despite widespread health illiteracy. Without knowledge of PROM readability, it is unclear whether these measures are able to be understood by the average spine patient.

MATERIALS AND METHODS

We analyzed all commonly utilized nonvisual PROMs within the spinal literature and uploaded PROMs into an online readability calculator. The Flesch Reading Ease Score (FRES) and Simple Measure of Gobbledygook (SMOG) Index were collected. A FRES>79 or SMOG<7 was considered readable by the general population per American Medical Association and Centers for Disease Control guidelines. A stricter threshold recommended in health care (SMOG <6 or FRES>89) was then used to further review readability.

RESULTS

Seventy-seven PROMs were included. Based on FRES, the mean readability of all PROMs was 69.2 ± 17.2 (range, 10-96.4), indicating an average eighth to ninth-grade reading level. The mean readability score categorized by the SMOG Index was 8.12 ± 2.65 (range, 3.1-25.6), representing an eighth-grade reading level. Compared with the reading level of the general population, 49 (63.6%) PROMs are written above the United States literacy level, according to FRES. Using stricter definitions of readability, 8 PROMs were considered readable, including PROM Information System pain behavior (FRES: 96.4 and SMOG: 5.2), PROM Information System sleep disturbance (SMOG: 5.6), Neck Pain and Disability Scale (SMOG: 4.3), and Zung Depression Scale (SMOG: 3.1).

CONCLUSIONS

Most PROMs utilized in spine surgery require an average reading competency far above the average patient's comprehension. This may have a meaningful impact on understanding PROM instruments and may affect the accuracy of complete surveys and the rates of incompletion.

The Impact of Socioeconomic Status on the Presence of Advance Care Planning Documents in Patients With Acute Cervical Spinal Cord Injury

INTRODUCTION

Patients presenting with spinal cord injury (SCI) often times have notable deficits or polytrauma and may require urgent decision making for early management. However, their presentation may affect decision-making ability. Although advance care planning (ACP) may help guide spine surgeons as to patient preferences, the rate at which they are available and disparities in ACP completion are still not understood. The objective of this study was to evaluate disparities in the completion of ACP among patients with acute SCI.

METHODS

All patients presenting with cervical SCI to the emergency department at an urban, tertiary level I trauma center from 2010 to 2021 were identified from a prospective database of all consults evaluated by the spine service. Each patient's medical record was reviewed to assess for the presence of ACP documents such as living will, power of attorney, or advance directive. Community-level socioeconomic status was assessed using the Distressed Communities Index. Bivariable and multivariable analyses were performed.

RESULTS

We identified 424 patients: 104 (24.5%) of whom had ACP. Patients with ACP were older (64.8 versus 56.5 years, P = 0.001), more likely White (78.8% versus 71.9%, P = 0.057), and present with ASIA Impairment Scale grade A SCI (21.2% versus 12.8%, P = 0.054), although the latter two did not reach statistical significance. On multivariable logistic regression, patients residing in at-risk communities were significantly less likely to have ACP documents compared with those in prosperous communities (odds ratio [OR]: 0.29, P = 0.03). Although patients living in distressed communities were less likely to complete ACP compared with those in prosperous communities (OR 0.50, P = 0.066), this did not meet statistical significance. Female patients were also less likely to have ACP (OR: 0.43, P = 0.005).

CONCLUSION

Female patients and those from at-risk communities are markedly less likely to complete ACP. Attention to possible disparities during admission and ACP discussions may help ensure that patients of all backgrounds have treatment goals documented.

Racial Differences in Perioperative Complications, Readmissions, and Mortalities After Elective Spine Surgery in the United States: A Systematic Review Using AI-Assisted Bibliometric Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVES

To evaluate the impact of race on post-operative outcomes and complications following elective spine surgery in the United States.

METHODS

PUBMED, MEDLINE(R), ERIC, EMBASE, and SCOPUS were searched for studies documenting peri-operative events for White and African American (AA) patients following elective spine surgery. Pooled odds ratios were calculated for each 90-day outcome and meta-analyses were performed for 4 peri-operative events and 7 complication categories. Sub-analyses were performed for each outcome on single institution (SI) studies and works that included <100,000 patients.

RESULTS

53 studies (5,589,069 patients, 9.8% AA) were included. Eleven included >100,000 patients. AA patients had increased rates of 90-day readmission (OR 1.33, P = .0001), non-routine discharge (OR 1.71, P = .0001), and mortality (OR 1.66, P = .0003), but not re-operation (OR 1.16, P = .1354). AA patients were more likely to have wound-related complications (OR 1.47, P = .0001) or medical complications (OR 1.35, P = .0006), specifically cardiovascular (OR 1.33, P = .0126), deep vein thrombosis/pulmonary embolism (DVT/PE) (OR 2.22, P = .0188) and genitourinary events (OR 1.17, P = .0343). SI studies could only detect racial differences in re-admissions and non-routine discharges. Studies with <100,000 patients replicated the above findings but found no differences in cardiovascular complications. Disparities in mortality were only detected when all studies were included.

CONCLUSIONS

AA patients faced a greater risk of morbidity across several distinct categories of peri-operative events. SI studies can be underpowered to detect more granular complication types (genitourinary, DVT/PE). Rare events, such as mortality, require larger sample sizes to identify significant racial disparities.

Limited health literacy results in lower health-related quality of life in spine patients

BACKGROUND CONTEXT

Spinal conditions impact health-related quality of life (HRQoL). Patient education and counseling improve HRQoL, yet the effects may be limited for patients with inadequate health literacy (HL). Despite the established relationship between HRQoL and HL in other fields, research in the orthopedic spine population is lacking.

PURPOSE

To investigate if limited HL results in lower HRQoL and to evaluate factors are associated with HRQoL in patients seen at an outpatient orthopedic spine center.

STUDY DESIGN/SETTING

Prospective single-center cross-sectional study.

PATIENT SAMPLE

Patients 18 years of age or older seen at a tertiary urban academic hospital- based multi-surgeon outpatient spine center.

OUTCOME MEASURES

EQ-5D-5L health-related quality of life (HRQoL) questionnaire, and the Newest Vital Sign (NVS) HL assessment tool.

METHODS

Between October 2022 and February 2023, consecutive English-speaking patients over the age of 18 and new to the outpatient spine clinic were approached for participation in this cross-sectional survey study. Patients completed a sociodemographic survey, EQ-5D-5L HRQoL questionnaire, and Newest Vital Sign (NVS) HL assessment tool. The EQ-5D-5L yields two continuous outcomes: an index score ranging from below 0 to 1 and a visual analog scale (EQ-VAS) score ranging from 0 to 100. The NVS scores were divided into limited (0-3) and adequate (4-6) HL. Multivariate linear regression with purposeful selection of variables was performed to identify independent factors associated with HRQoL.

RESULTS

Out of 397 eligible patients, 348 (88%) agreed to participate and were included in statistical analysis. Limited HL was independently associated with lower EQ-5D-5L index scores (B=1.07 [95% CI 1.00-1.15], p=.049. Other factors associated with lower EQ-5D-5L index scores were being obese (BMI≥30), having housing concerns, and being an active smoker. Factors associated with lower EQ-VAS scores were being underweight (BMI<18.5), obese, having housing concerns, and higher updated Charlson comorbidity index (uCCI) scores. Being married was associated with higher EQ-VAS scores.

CONCLUSIONS

Limited HL is associated with lower EQ-5D-5L index scores in spine patients, indicating lower HRQoL. To effectively apply HL-related interventions in this population, a better understanding of the complex interactions between patient characteristics, social determinants of health, and HRQoL outcomes is required. Further research should focus on interventions to improve HRQoL in patients with limited HL and how to accurately identify these patients.

LEVEL OF EVIDENCE

Level II prognostic.

Health Literacy in Orthopaedics

Health literacy is a dynamic, multifaceted skill set that relies on patients, healthcare providers, and the healthcare system. In addition, health literacy assessment provides an avenue for evaluating patient understanding and offers insights into their health management capabilities. Inadequate health literacy results in poor patient outcomes and compromised care by considerably hindering successful communication and comprehension of relevant health information between the patient and the provider. In this narrative review, we explore why limited health literacy poses serious implications for orthopaedic patient health and safety, expectations, treatment outcomes, and healthcare costs. Furthermore, we elaborate on the complexity of health literacy, provide an overview of key concepts, and offer recommendations for clinical practice and research investigations.

Reliability of self-reported health literacy screening in spine patients

BACKGROUND CONTEXT

Limited health literacy has previously been associated with increased health care utilization, worse general health status and self-reported health, and increased mortality. Identifying and accommodating patients with limited health literacy may offer an avenue towards mitigating adverse health outcomes and reduce unnecessary health care expenditure. Due to the challenges associated with implementation of lengthy health literacy assessments, the Brief Health Literacy Screening Instrument was developed. However, to our knowledge, there are no reports on the accuracy of this screening questionnaire, with or without the inclusion of sociodemographic characteristics, when predicting limited health literacy in orthopaedic spine patients.

PURPOSE

To evaluate the reliability and predictive accuracy of self-reported health literacy screening questions with and without the inclusion of sociodemographic variables in orthopaedic spine patients.

STUDY DESIGN

Cross-sectional.

PATIENT SAMPLE

Patients seen at a tertiary urban academic hospital-based multi-surgeon spine center OUTCOME MEASURES: Brief Health Literacy Screening Instrument (BRIEF), and the Newest Vital Sign (NVS) health literacy assessment tool.

METHODS

Between December 2021 and February 2022, consecutive English-speaking patients over the age of 18 presenting as new patients to an urban, hospital-based outpatient spine clinic were approached for participation. A sociodemographic survey, the BRIEF, and the NVS Health Literacy Assessment Tool were administered verbally. Simple and multivariable logistic regression was utilized to assess the accuracy of each BRIEF question individually, and collectively, at predicting limited health literacy as defined by the NVS. Further regression analysis included sociodemographic variables (age, body mass index, race, ethnicity, highest educational degree, employment status, marital status, annual household income, insurance status, and self-reported health.

RESULTS

A total of 262 patients [mean age (years), 57 ± 17] were included in this study. One hundred thirty-four (51%) were male, 223 (85%) were White, and 151 (58%) were married. Patient BRIEF scores were as follows: 23 (9%) limited, 43 (16%) marginal, and 196 (75%) adequate. NVS scores identified 87 (33%) patients with possible limited health literacy. BRIEF items collectively demonstrated fair accuracy in the prediction of limited health literacy (area under the receiver operating characteristic curve, 0.76; 95% CI, 0.70-0.82). Individually, the fourth BRIEF item ("How confident are you in filling out medical forms by yourself?") was the best predictor of limited health literacy (area under the receiver operating characteristic curve, 0.67; 95% CI, 0.60-0.73). The predictive accuracy of the BRIEF items, both individually and collectively, increased with the inclusion of sociodemographic variables within the logistic regression. Specific characteristics independently associated with limited health literacy were self-identified Black race, retired or disabled employment status, single or divorced marital status, high school education or below, and self-reported "poor" health.

CONCLUSIONS

Limited health literacy has implications for patient outcomes and health care costs. Our results show that the BRIEF questionnaire is a low-cost screening tool that demonstrates fair predictability in determining limited health literacy within a population of spine patients. Self-reported health literacy assessments may be more feasible in daily practice and easier to implement into clinical workflow.