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

So now we're gonna go on to the papers from the AFCRS. Our final two papers and the first one is by again Connie Chow and it's limited health literacy is associated with reduced adherence to ERP components. Connie, can you present your first your second paper here? Thank you, GlobalC MD for the opportunity to present the research that I presented at this year's American Society of Colon and Real Surgeons conference. Uh, my research focused on health literacy and its association with adherence to the components of enhanced recovery, as well as postoperative outcomes. I have no disclosures. 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. Importantly, 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. Importantly, patients with lower health literacy are also less likely to follow treatment plans. In fact, our group has previously shown that limited health literacy, as denoted by the red bubbles and the figure on the right. I associated with increased complications compared to patients without limited health literacy or higher health literacy, as shown by the bubbles in blue. The size of the bubbles correlate with postoperative complications, and you can see that they are greater for patients who have limited health literacy. Many studies have shown that increased adherence to components of enhanced recovery is associated with improved postoperative outcomes. However, the mechanism between health literacy and outcomes remains to be understood. Therefore, the objective of our study was to determine the association of health literacy with enhanced recovery adherence and postoperative outcomes. This is a retrospective cohort study from December 2018 to November 2021 of only elective inpatient colorectal surgeries tracked by our institutional ACS Nisquip database. We extracted seven ERP adherence variables from the NISQquip database and cross-reference this with our health literacy database, which is tracked in clinic where we measure patients' brief health literacy scores. Um, notably, our patients on average are about 56 years old and in general reflected the demographics of our state, about 70% white, a quarter black, majority female. Our mean BMI was about 30%, um, a majority of patients are non-diabetic, and about 15, 17% have a history of smoking within the past year. We have similar rates of insurance with private insurers and Medicare and a mean ASA of about 3. Most of the surgeries did not include the placement of an ostomy. Cases were on average about 3.5 hours. Most of the cases were for benign indications as well as cancer, uh, operations, and most of the cases were done laparoscopically. Uh, patients were on average adherent to about 6 or 7 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. When correlating patient and procedure level factors with adherence to overall ERP components, only two factors were associated with increased ERP adherence increased health literacy and a diagnosis of cancer, possibly because these patients are consistently navigating the healthcare system. As you can see in this figure, there is a direct linear correlation between increased health literacy score and increased percent adherence to the seven components of ERP that were tracked. You can see on the right a forest plot that shows a multivariable, uh, uh, regression, uh, associating factors with length of stay. On the left is a summary, where we can see black race, case duration, ost replacement, and the diagnosis of IBD are associated with increased length of stay. While the only protective factor. Factor was uh ERP adherence. Case duration makes sense. The longer the case, the more likely it's complicated, which increases length of stay. Ostomy placement, you have to wait for the ostomy to open up, and a diagnosis of IBD makes sense as well as these patients are in a chronic inflammatory state and have a difficult time healing. Black race is concerning, as enhanced recovery has previously been shown to, uh, close the gap in disparities in length of stay for our patients, and now that it's widening again warrants investigation. But it is very notable here that the only protective factor for decreased length of stay was adherence to the different components of enhanced recovery. Therefore, we found that higher health literacy is independently associated with greater ERP adherence, which is the only factor associated with shorter length of stay. Therefore, we posit that increased health literacy leads to increased adherence to ERP and decreased length of stay. We can target different interventions to improve patient health literacy and navigation of the healthcare system to improve their adherence to the components of ERP and therefore improve their outcomes. Thank you so much for your time. Thank you very much, Connie. Uh, Doctor Rosen, you wanna start by asking questions? Well, first of all, I want to make a comment, Connie. I mean, two presentations, best of the best in each society. Congratulations. We have a spot for you at the Cleveland Clinic. Let us know what you want. Don't take it so fast, Connie. That, that's phenomenal. Uh, if you want to fix, we'll make that happen. I have it recorded, Connie. We just recorded this, so you've got it. You got it. We'll take it. That's all I need. Uh, I'll kick out in any specialty you want. We'll, we'll take it. Um, so, so, you know, my, my question again, I mean, that's really great and, and, and phenomenal work. My question is more of a general question that, uh, I often find in reviewing a lot of papers about healthcare disparities and, and, and, and all the topics that you brought up. Is at the end, we identify these factors and I'm always left with, OK, so like, what am I supposed to do? Like, like what if I want to make this better, and, and I'll, I'll challenge you back for just a second because this is a little bit in, in your other talk as well. And that has to be a solution within our healthcare system where we are incredibly strained for resources. And it can't be, let's get 17 people to do this, that and the other, because I'm sure you guys just like us, I can barely have an MA put a patient in a room in clinic right now, much less go over, you know, an overwhelming amount of things. So in the world that we live in with all the constraints, what's the solution? Right. So I think that's a great question, and that's actually something that I, I feel like I question my mentees on frequently. You know, whenever they show me something, I'm like, so then what do we do about it? Like, what's the takeaway message and how do you change surgical practice? Cause ideally, that's the goal of all the research that we're doing is to change and improve surgical practice. Um, I will say for this study, a lot of times people, again, just like the telemedicine study, my goal is not to make all Uh, outpatient visits over telemedicine. My goal here also isn't to change patients' health literacy. I'm not a politician. I'm not a school principal. I'm not gonna be able to change people's education level or their health literacy level. Our goal is to meet patients where they're at. And so a lot of times if patients aren't receiving counseling, On the different components of enhanced recovery, they might sort of be at the whims of whatever's happening in the healthcare system, which can often change, especially now in the face of a lot of travel nurses who aren't getting the routine training that our former maybe GI surgery floor nurses had. We enhanced recovery at UAB has been a big deal for the last decade or so, and initially we had, you know, great uptake in teaching among the nurses, and it was very successful, and I think part of the reason why there were Uh, a closing gap in disparities in care between black and white patients. Um, but because now the nurses are not as well trained in enhanced recovery because they just don't know our system as well, because a lot of them are not from here, they travel to all these different institutions, unfortunately, a lot of this is going to rely on the patient autonomy and patient agency, and I think a lot of that relies on preoperative education and while they're in the hospital, education for the nurses as well, even if they are travel nurses to sort of Give them a rundown of what they need to do, um, but for our patients to be able to advocate for themselves. For example, if they're not being asked to walk the next day, reminding them how important it is that they're walking the next day, eating the day of, um, that they're getting their Foley up the next day, because, you know, and we've all sort of had experiences with that, especially as junior trainees, when maybe we don't know something and the patient's like, oh, aren't I supposed to get steroids or something post-op? And you're like, oh, yes, you definitely are. Let me talk to my attending about that. And when patients speak up about things that physicians have talked to them about in the pre-op setting, I think really helps them advocate for their medical care without, you know, being confrontational in any way, but certainly having an idea of what they're supposed to expect. Um, and I think that's the best part about an enhanced recovery is standardized care. Everybody gets the same thing and by equipping our patients with the knowledge and agency and advocacy, they can hopefully help, you know, with the implementation process because things are just so different now that it's, we don't want some patients benefiting from enhanced recovery and others not, if that makes sense. Yep, great answer. OK, uh. I just like this, uh, Connie, that was wonderful.