Best of the Best Gen Surg - Limited Health Literacy is Associated with Reduced Adherence to ERP Components. - Dr. Shao

Health literacy is defined as the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.

Health literacy is modifiable and health literacy-based interventions have been shown to improve outcomes and patient experience.

Patients with lower health literacy are more likely to have higher health care costs, higher rates of hospital and emergency room visits, and higher mortality rates.

Patients with lower health literacy are less likely to follow treatment plans.

The presenter's group previously showed that limited health literacy is associated with increased complications compared to patients with higher health literacy.

Many studies have shown that increased adherence to components of enhanced recovery is associated with improved postoperative outcomes.

This was a retrospective cohort study from December 2018 to November 2021 of elective inpatient colorectal surgeries tracked by the institutional ACS NSQIP database.

Seven ERP adherence variables were extracted from the NSQIP database and cross-referenced with the institution's health literacy database, which tracks patients' brief health literacy scores measured in clinic.

Study patients were on average about 56 years old, about 70% white, a quarter black, majority female, with mean BMI about 30, majority non-diabetic, and about 15-17% with history of smoking within the past year.

Study patients had similar rates of private insurance and Medicare, mean ASA of about 3, most surgeries did not include ostomy placement, cases averaged about 3.5 hours, most were for benign indications and cancer, and most were done laparoscopically.

Patients were on average adherent to about 6 or 7 ERP components.

For postoperative outcomes, 12% had a surgical site infection within 30 days of surgery, average length of stay was about 5.5 days, and about 10% of patients were readmitted within 30 days.

Only two factors were associated with increased ERP adherence: increased health literacy and a diagnosis of cancer.

There is a direct linear correlation between increased health literacy score and increased percent adherence to the seven ERP components tracked.

Multivariable regression showed that black race, case duration, ostomy placement, and diagnosis of IBD are associated with increased length of stay.

The only protective factor for decreased length of stay was ERP adherence.

Enhanced recovery has previously been shown to close the gap in disparities in length of stay, and the finding that black race is now associated with increased length of stay warrants investigation.

Higher health literacy is independently associated with greater ERP adherence, which is the only factor associated with shorter length of stay.

The presenter posits that increased health literacy leads to increased adherence to ERP and decreased length of stay.

Enhanced recovery at UAB has been a major initiative for the last decade, with initially great uptake in teaching among nurses and successful outcomes including closing gaps in disparities between black and white patients.

Travel nurses are not receiving the routine training that former GI surgery floor nurses had, and are not as well trained in enhanced recovery because they don't know the institutional system as well.

The presenter proposes that preoperative education and in-hospital education for nurses, combined with patient autonomy and agency to advocate for themselves regarding ERP components, may improve adherence.