Author information

• ¹Division of Gastroenterology and Hepatology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
• ²Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
• ³Nutrition Counseling and Services, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
• ⁴Renal-Electrolyte and Hypertension Division, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
• ⁵Division of General Internal Medicine and Geriatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
• ⁶Center for Applied Health Research on Aging, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA.
• ⁷Division of Transplant Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
• ⁸Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.

Abstract

The effect of low health literacy (HL) on outcomes in end-stage liver disease (ESLD) is largely unknown. The association of low HL on clinical outcomes was investigated in a prospective cohort of outpatients with ESLD undergoing liver transplant (LT) evaluation. From 2014-2017, 276 patients underwent LT evaluation with assessments of liver disease severity, medical and psychosocial comorbidities, physical frailty, and malnutrition. Literacy was measured with the Newest Vital Sign (NVS), a brief validated assessment. Multivariable models assessed relationships between HL and clinical outcomes adjusting for clinical and psychosocial variables. The median Model for End-stage Liver Disease-Sodium (MELD-Na) score of the study sample was 14 (IQR 10-18), 71 (25.7%) of candidates were frail, 117 (42.4%) had malnutrition, 151 (54.7%) had hepatic encephalopathy, 104 (37.7%) had low HL, and 83 (39.2%) had marginal or poor social support. Adjusting for education level, socioeconomic factors, and severity of illness, low HL was independently associated with physical frailty (adjusted odds ratio [aOR]: 3.59, 95% CI 1.50-8.59; p=0.004) and not being waitlisted (aOR 1.96, 95% CI: 1.03-3.75; p=0.04). Strong social support attenuated the relationship between low HL and not being waitlisted (aOR 1.58, 95% CI: 0.74-3.36; p=0.24). CONCLUSION: Low HL is common and a largely unrecognized risk factor for poor health outcomes among patients with ESLD. Patient-oriented infrastructure and support are needed at the health system level to ensure all patients can successfully navigate the complex process of LT evaluation and waitlisting.