To the Editor: We had several concerns and questions about the study by Dr Peterson and colleagues on the association of low health literacy with mortality in patients with heart failure,1 particularly their use of the health literacy screening tool, patient selection, and outcome interpretation.
To our knowledge, the 3 brief screening questions used to identify patients with low health literacy have not been validated for written self-administration; prior validation studies have occurred only in settings in which a research assistant read the items aloud to the patient.2,3 In addition, administering the questions in written format could have led to a selection bias against patients with low literacy skills because they would have had greater difficulty completing the survey. While some surveys were administered via telephone interview, the proportion was not reported.
McNaughton C, Collins S, Kripalani S. Health Literacy and Patients With Heart Failure. JAMA. 2011;306(5):489–491. doi:10.1001/jama.2011.1064
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