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Original Investigation
January 13, 2003

Closing the Loop: Physician Communication With Diabetic Patients Who Have Low Health Literacy

Author Affiliations

From the Primary Care Research Center (Drs Schillinger, Grumbach, and Bindman, Mss Wang, Daher, and Leong-Grotz, and Messrs Wilson and Castro), the Department of Medicine (Drs Schillinger and Bindman), and the Department of Family and Community Medicine (Dr Grumbach), University of California, San Francisco; San Francisco General Hospital, San Francisco, Calif (Drs Schillinger, Grumbach, and Bindman, Mss Wang, Daher, and Leong-Grotz, and Messrs Wilson and Castro); VA Palo Alto Health Care System, Palo Alto, Calif (Dr Piette); and Department of Health Research and Social Policy, Stanford University School of Medicine, Stanford, Calif (Dr Piette). Dr Piette is now with the Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System, and the University of Michigan Medical School, Ann Arbor.

Arch Intern Med. 2003;163(1):83-90. doi:10.1001/archinte.163.1.83

Background  Patients recall or comprehend as little as half of what physicians convey during an outpatient encounter. To enhance recall, comprehension, and adherence, it is recommended that physicians elicit patients' comprehension of new concepts and tailor subsequent information, particularly for patients with low functional health literacy. It is not known how frequently physicians apply this interactive educational strategy, or whether it is associated with improved health outcomes.

Methods  We used direct observation to measure the extent to which primary care physicians working in a public hospital assess patient recall and comprehension of new concepts during outpatient encounters, using audiotapes of visits between 38 physicians and 74 English-speaking patients with diabetes mellitus and low functional health literacy. We then examined whether there was an association between physicians' application of this interactive communication strategy and patients' glycemic control using information from clinical and administrative databases.

Results  Physicians assessed recall and comprehension of any new concept in 12 (20%) of 61 visits and for 15 (12%) of 124 new concepts. Patients whose physicians assessed recall or comprehension were more likely to have hemoglobin A1c levels below the mean (≤8.6%) vs patients whose physicians did not (odds ratio, 8.96; 95% confidence interval, 1.1-74.9) (P = .02). After multivariate logistic regression, the 2 variables independently associated with good glycemic control were higher health literacy levels (odds ratio, 3.97; 95% confidence interval, 1.09-14.47) (P = .04) and physicians' application of the interactive communication strategy (odds ratio, 15.15; 95% confidence interval, 2.07-110.78) (P<.01).

Conclusions  Primary care physicians caring for patients with diabetes mellitus and low functional health literacy rarely assessed patient recall or comprehension of new concepts. Overlooking this step in communication reflects a missed opportunity that may have important clinical implications.