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Health Literacy Burden Is Associated With Access to Liver Transplantation

Bababekov, Yanik J., MD, MPH1; Hung, Ya-Ching, MD, MPH1; Rickert, Charles G., MD1; Njoku, Faith C., BA2; Cao, Bonnie, BA3; Adler, Joel T., MD, MPH4; Brega, Angela G., PhD5; Pomposelli, James J., MD6; Chang, David C., PhD, MPH, MBA1; Yeh, Heidi, MD1

doi: 10.1097/TP.0000000000002536
Original Clinical Science—Liver
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Background. Getting listed for liver transplantation is a complex process. Institutional health literacy may influence the ability of patients with limited educational attainment (EA) to list. As an easily accessible indicator of institutional health literacy, we measured the understandability of liver transplant center education websites and assessed whether there was any association with the percentage of low EA patients on their waitlists.

Methods. Patients on the waitlist for liver transplantation 2007–2016 were identified in Scientific Registry of Transplant Recipients. Understandability of patient education websites was assessed using the Clear Communication Index (CCI). The Centers for Disease Control and Prevention has set itself a goal CCI of 90 as being easy to understand. Low EA was defined as less than a high school education. We adjusted for center case-mix, Donor Service Area characteristics, and EA of the general population.

Results. Patients (84 774) were listed across 112 liver transplant centers. The median percent of waitlisted patients at each center with low EA was 11.0% (IQR, 6.6–16.8). CCI ranged from 53 to 88 and correlated with the proportion of low EA patients on the waitlist. However, CCI was not associated with the percentage of low EA in the general population. For every 1-point improvement in CCI, low EA patients increase by 0.2% (P < 0.05), translating to a 3.6% increase, or additional 3000 patients, if all centers improved their websites to CCI of 90.

Conclusions. Educational websites that are easier to understand are associated with increased access to liver transplantation for patients with low EA. Lowering the health literacy burden by transplant centers may improve access to the liver transplant waitlist.

1Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

2University of California, Irvine Medical School, Irvine, CA.

3University of Rochester Medical School, Rochester, NY.

4Department of Surgery, University of Wisconsin Hospital and Clinics, University of Wisconsin School of Medicine and Public Health, Madison, WI.

5Department of Community and Behavioral Health, University of Colorado Hospital, Aurora, CO.

6Department of Surgery, University of Colorado Hospital, Aurora, CO.

Received 3 May 2018. Revision received 17 September 2018.

Accepted 25 September 2018.

Y.J.B. and Y.-C.H. contributed equally to this manuscript.

The authors declare no conflicts of interest.

Y.J.B. is supported by the Marshall K. Bartlett Surgical Research Fellowship from the Department of Surgery, Massachusetts General Hospital, Harvard Medical School.

Y.J.B. participated in research design, writing of the paper, performance of the research, and data analysis. Y.-C.H. participated in research design, writing of the paper, performance of the research, and data analysis. C.G.R. participated in writing of the paper and data analysis. F.C.N. participated in performance of the research and data analysis. B.C. participated in performance of the research and data analysis. J.T.A. participated in writing of the paper and data analysis. A.G.B. participated in writing of the paper and data analysis. J.J.P. participated in writing of the paper and data analysis. D.C.C. participated in research design, writing of the paper, performance of the research, and data analysis. H.Y. participated in research design, writing of the paper, performance of the research, and data analysis.

Correspondence: Yanik J. Bababekov, MD, MPH, Department of Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. (ybababekov@partners.org).

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