HL role in low-value care

HL represents the extent to which patients are able to understand and act on health information.1 With rates ranging from 12% in the USA to 53% in European countries over the last 20 years, inadequate HL is an international and persistent problem.2–4 Limited HL is associated with poor health outcomes including difficulty with decision-making and resource misuse.5 6 Physicians may not recognise poor HL and/or overestimate a patient’s HL. Choosing Wisely is internationally recognised since 2012 for centring the patient–provider conversation on avoidance of unnecessary care—though these tools may not have been designed to capture the real-life challenges related to HL. The use of standardised tools, like question prompts or shared decision-making (SDM) videos that Choosing Wisely developed, helps patients become more engaged in their healthcare decisions. While valuable, these tools assume a common level of HL and exacerbate the risks of a one-size-fits-all approach. HL is not a binary state but exists on a continuum. The diversity that encompasses the concept of HL is illustrated by the absence of agreement on the best HL tool for screening or a threshold for defining proficiency.7 8 Therefore, educational resources need to be both flexible and adaptable, meeting patients where they are, rather than where we assume they should be.

In this issue of BMJ Quality & Safety, Muscat et al 9 shed light on the complex role of HL on decision-making. The authors reveal how lower HL can drive patients towards low-value care choices and lead to less engagement in decision-making. They analysed the data from a Choosing Wisely single-blinded randomised trial with four arms, where 1439 Australian adults recruited online were presented with a hypothetical low back pain scenario where the doctor recommends a scan to help figure out what is causing the pain. Patients were then randomised to (1) questions probing utility, risk and costs of the scan, (2) an SDM video that prepares patients to ask questions, (3) both interventions or (4) no intervention. The study authors used the Newest Vital Sign (NVS) to assess for HL; an objective, quick method which involves giving patients a nutrition label from an ice cream container to measure comprehension, numeracy skills and abstract reasoning. While the study found no difference in question-asking and decision-making outcomes between individuals with low and higher HL, limited HL was associated with less positive attitudes towards SDM, asking fewer questions and following lower value treatment plans.

This study provides valuable insights into how HL can affect patient engagement in healthcare decision-making. First, the authors demonstrate how self-reported HL can be quite different, and complimentary, from objective measurements. Almost 46% of individuals with limited HL based on the NVS screen, an objective measure, reported being ‘extremely’ confident in filling out medical forms, which is a subjective measure. This is because HL can be influenced by past experiences and confidence levels. A patient with a low NVS score and low confidence may need more intensive support, such as simplified instructions and additional help with paperwork. Using a combined approach can help providers create personalised interventions.

Decisional conflict and HL

Decisional conflict is defined as ‘a state of uncertainty about the course of action to take’ and represents a fundamental outcome for the assessment of quality decision-making as does decision self-efficacy and decisional regret.10 Clinical features of decisional conflict include hesitation, delay in decision-making and inability to choose.11 Decisional conflict is much more likely to be present when faced with life or death or difficult decisions, or when it is for someone else. Individuals with high levels of HL are also less likely to face decisional conflict.12 Assessing for decisional conflict is important as it allows for identification of effective patient and clinician interactions and decision aid tools. Understanding decisional conflict as an intermediary step necessary for SDM among individuals with low HL is critical. As Muscat et al allude to, it is very possible participants did not feel high degrees of decisional conflict. Both HL screening and SDM aids should then consider critical HL skills13 as being the most important for making informed decisions when faced with decisional conflict.

HL as a social determinant

It is also important to consider the equity implications of the study’s findings. The study by Muscat et al underscores that HL is not just a personal trait but a product of broader social determinants. Individuals with limited HL can be from communities experiencing inequities, where systemic factors like socioeconomic status, language barriers and lack of access to quality education exacerbate low HL. As such, promoting interventions which target HL is not just about improving healthcare outcomes, but also about advancing equity. Systematic HL screening can, however, introduce an element of stigma towards patients who often already face additional barriers to accessing care.14

Strategies to enhance quality and effective decision-making

The importance of an established therapeutic relationship is pivotal within proposed SDM frameworks. To support SDM, clinicians also need to critically appraise the evidence of the proposed intervention and deliver information in a way that patients can fully understand and act on.15 16 In the presence of decisional conflict, the use of decision aid tools or other decision support tools can enable patients and families to make informed and individualised decisions within the model of SDM. Choosing Wisely interventions which had multiple components, and which targeted clinicians as well, were most likely to show impact in reducing low-value-based care.17 Decision aids represent a tool that can be used within the framework of SDM to support patients in making informed decisions.18 Decision aids, when developed rigorously and validated with appropriate readability, can allow to lower decisional conflict, improve patients’ knowledge and involvement in decision-making and much more.19 Interestingly, the integration of decision aid tools within the clinical setting is most often assessed by measuring decisional conflict via the use of the validated and widely used Decisional Conflict Scale. Examples of decision aid tool formats can be as intricate as videos and online interactive platforms or as simple as a paper pamphlet. Overall, there is no unique preferred decision aid if it contributes to improving quality decision-making and is universal (allowing lower HL patients to also benefit from it).

When unable to screen individuals for limited HL, applying universal measures of support for patients can promote favourable outcomes.20 Universal measures of support entail providing care to all assuming limited HL from patients and then adapting as needed. Suggested measures can be simple and easy to introduce to clinical practice. More specifically, they include using the teach-back method, encouraging questions, use of plain language, providing visual support, confirming understanding, repeating and summarising. Future interventions aimed at improving SDM away from low-value care should then consider their impact on decisional conflict and its important association with HL. Integration of decision aids associated with Choosing Wisely can then be implemented more judiciously and perhaps with more effectiveness.