Lipid Luminations: Assessing Health Literacy as a Modifiable Risk Factor for the Prevention of Peripheral Artery Disease Based on Recommendations from the World Heart Federation Cholesterol Roadmap

Disease prevention can lead to optimal promotion of health and improved quality of life. To achieve this goal, the concept must be emphasized by the clinician and adopted by the patient. Modifiable risk factors such as diet, exercise, smoking, etc. have long been recognized as causing or contributing to chronic illnesses including atherosclerotic disease. More recently the impact of health literacy has been recognized as a risk factor that can also impact a patient’s health journey. Addressing a patient’s ability to understand medical terminology, follow treatment regimens, and obtain access to care is crucial in the effort to prevent chronic illnesses. Short sighted efforts to simply treat the disease is not effective, more work must be done to remove barriers for the patient. In this article we will consider the effect health literacy has on patients living with atherosclerotic diseases and suggest it should be considered as a modifiable risk factor. 

The United States is well-known for spending more money per capita on healthcare in comparison to other countries. The amount spent on treating populations with chronic diseases, such as high risk cardiovascular disease, isn’t due to one singular risk factor or issue which proves challenging as the cost to treat this population can be burdensome to a hospital system.1 While clinical advancements and nuanced treatment options are available for chronic illnesses, the prevalence of said chronic disease burden in America remains high. Multiple reasons exist for this issue including:

  • lack of access to specialty care
  • socio-economic impediments 
  • regional availability of treatments
  • the impact of the social determinants of health, including health literacy 

Health literacy has been defined and generally accepted as “The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”. While it is widely accepted that health literacy is a social determinant of health (SDOH) limiting one’s ability to manage health-related issues, there is little research or education which currently exists to address this issue. The U.S. Department of Education conducted research in 2003 assessing adult health literacy in which they concluded only 12% of Americans were categorized as being health literacy proficient, with 36% of Americans having baseline or low health literacy.3 One's ability to understand medical terminology, follow treatment plans, and gain access to appropriate health care impact health literacy levels. 

Health literacy impacts the way an individual perceives illness and its effect over time on quality of life. This is true among those living with atherosclerotic diseases, such as peripheral arterial (PAD) or carotid artery disease. Little research has been conducted in the United States to determine how health literacy impacts the health of those living with atherosclerotic disease, yet it is not recognized as a major barrier to the prevention and treatment of disease, and thus achieving optimal health.

Population health initiatives and slow shifts to value-based care continue to highlight the importance of disease prevention and a greater emphasis on cardiovascular health, rather than combatting the costly downstream sequela of chronic illnesses. However, to be successful, population health tactics must center on whole-person care, education, prevention, and incorporating the patient into the shared-decision making process. This is especially true among underserved populations who are at the highest risk for the development of more severe stages of atherosclerotic disease.

If chronic disease management, in the context of achieving optimal cardiovascular health, is to be successful, patients must be able to ask the right questions, follow their prescriptive therapies, and truly understand the impact their health-related choices will have on the prevention of future negative outcomes related to their condition. This is also true as it relates to atherosclerotic diseases such as PAD and carotid disease. Both diseases continue to grow in prevalence in the United States despite costly efforts to treat these and other atherosclerotic cardiovascular diseases (ASCVD). Between 2013–2020 it is estimated that 18.7 million adults in the United States reported having a history of ASCVD.4 While some may have a genetic predisposition to high cholesterol which can lead to ASCVD, other risk factors such as diet, exercise, etc. are considered as modifiable risk factors. The sustained prevalence of ASCVD continues to highlight risk factors which could be modified to prevent the development or worsening of this and other chronic illnesses.

The World Heart Federation has addressed many impediments which exist on a global level that might cause increased risk of ASCVD. In their Cholesterol Roadmap the Federation acknowledges global issues such as knowledge or care gaps, health system roadblocks, and other issues related to successful prevention strategies.5 The Federation acknowledges more must be done to combat public health issues, including health literacy. While the report focuses on the effect low health literacy has on lower- to middle-income countries, many of these same barriers apply to certain regions of the United States (U.S.) highly impacted by the SDOH.

Underserved communities, particularly black communities, are disproportionately impacted by the SDOH and by atherosclerotic diseases, especially PAD. According to the American Heart Association (AHA) black populations are at higher risk of developing PAD.  When seeking medical care for PAD, black populations are presenting with greater severity of the disease and are more likely to have lower limb amputations as compared to their white counterparts.6 Health literacy disproportionately impacts black populations, with 57% experiencing limited health literacy.3 “Black Americans living with limited health literacy experience a higher burden of disease, poorer health outcomes, and reduced access to quality healthcare”.7

This presents an oxymoron of sorts for both clinicians treating patients with ASCVD and for policy makers. Traditionally clinicians are reimbursed for treating patients with ASCVD through fee-for-service pathways rather than capitated value-based reimbursement programs or disease specific bundled payments targeting diseases such as PAD. Notwithstanding there are quality metrics which have impacted reimbursement rates for certain diagnoses such as acute myocardial infarction (AMI) and stroke. These reporting measures include observed/expected mortality and readmission rates for AMI and stroke, but what of the other ASCVD which, if not well-managed, can lead to increases in morbidity and mortality? If the absence of health literacy is not recognized as a barrier to CVD prevention and optimization of health, and both treatment and education to this end are not implemented effectively, these challenges will continue to disproportionately impact the most vulnerable. The COVID-19 pandemic highlighted many deficiencies in our current healthcare system, bringing special attention to the SDOH. As a global community we learned that race and zip code might determine an individual’s likelihood of survival of a disease.8 If those most impacted by health literacy are also those most predisposed to severe versions of atherosclerotic diseases like PAD, then action must be taken. Health literacy should be seen as a modifiable risk factor and efforts taken to improve health literacy levels among vulnerable populations. Further research must be conducted to fully understand what types of actions should be taken to close the health literacy gap in America.

Ms. Price-McDonald has no financial relationships to disclose. 

References

  1. Valero-Elizondo J, Salami JA, Ogunmoroti O, et al. Favorable Cardiovascular Risk Profile Is Associated With Lower Healthcare Costs and Resource Utilization: The 2012 Medical Expenditure Panel Survey. Circ Cardiovasc Qual Outcomes. 2016;9(2):143-153. doi:10.1161/CIRCOUTCOMES.115.002616
  2. Ratzan SC, Parker RM. Introduction. In: National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Selden CR, Zorn M, Ratzan SC, Parker RM, Editors. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services. 2000.
  3. G.E. Kutner M, Y. Jin, C. Paulsen, The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006- 483), (2006). Accessed May 13, 2016 https://nces.ed.gov/pubs2006/ 2006483.pdf.
  4. Alanaeme CJ, Bittner V, Brown TM, et al. Estimated number and percentage of US adults with atherosclerotic cardiovascular disease recommended add-on lipid-lowering therapy by the 2018 AHA/ACC multi-society cholesterol guideline. Am Heart J Plus. 2022; 21:100201. doi:10.1016/j.ahjo.2022.100201
  5. Ray KK, Ference BA, Séverin T, et al. World Heart Federation Cholesterol Roadmap 2022. Glob Heart. 2022;17(1):75. Published 2022 Oct 14. doi:10.5334/gh.1154
  6. Allison M, Armstrong D, Goodney P, et al. Health Disparities in Peripheral Artery Disease: A Scientific Statement from the American Heart Association. Circulation. 2023; 148 (3): 286-296. doi: 10.1161/CIR.0000000000001153.
  7. Berkman Nd, Sheridan Sl, Donahue Ke, Halpern Dj, Crotty K. Low Health Literacy and Health Outcomes: An Updated Systematic Review. Ann Intern Med. 2011;155(2):97-107. doi: 10.7326/0003-4819-155-2-201107190-00005.
  8. Hanson AE, Hains DS, Schwaderer AL, Starr MC. Variation in COVID-19 Diagnosis by Zip Code and Race and Ethnicity in Indiana. Front Public Health. 2020;8:593861. Published 2020 Dec 11. doi:10.3389/fpubh.2020.593861

Article By:

Melissa Price-McDonald, MPH

DHSc Candidate

Thomas Jefferson University

College of Population Health

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