Associations between health literacy and healthcare utilization in patients with coexisting diabetes and end stage renal disease

Aims: Health literacy is concerned with the patient's ability to obtain, process, and act on appropriate health information, and has been linked to patients' self-management ability. In particular, self-management of end-stage renal disease with comorbid diabetes (DM ESRD) places considerable burden on patients, given increased and sometimes conflicting demands, placing patients at increased risk of hospitalization. This study aimed to explore the associations between health literacy and healthcare utilization in DM ESRD patients. Methods: Depression and Health Literacy was assessed in a prospective outpatient cohort of patients with DM ESRD on the Hospital Anxiety and Depression Scale (HADS) and the Health Literacy Questionnaire (HLQ). Primary outcomes were all-cause admission (number of events; days of hospitalization) and mortality over 15 to 24 months. Negative binomial or Cox regressions were used to model risk factors for hospitalization and mortality respectively. Results: Of 221 participants [median age 59 years, 39.4% women, 54.8% Chinese], 95 (43.0%) screened positive for depression. Risk for depression was higher for Chinese patients (OR 2.499. 95%CI 1.436 -4.349, P = .001) compared to non-Chinese respondents. Depression, older age. Chinese Ethnicity. Non-married status, lower education were all associated with lower scores in most health literacy domains. Lower hospitalisation rates were independently associated with home-ownership (1RR=0.639) and higher Actively Managing Health HLQ scores (1RR=0.674). Cumulative hospitalisation days were independently associated with serum albumin (IRR=0.914). HbA1c (IRR=1.190), Charson Comorbidity Index (IRR= 1.171) and depression (IRR= 1.061). Mortality was also significantly associated with Actively Managing Health (Hazard Ratio=0.382) after controlling for other risk factors. Conclusion: These findings suggest that strategies for improving health outcomes and reducing hospitalization and mortality risk in multi-morbid patients may benefit from adopting a stronger focus on critical and communicative domains of Health Literacy as part of patient education, and addressing emotional distress.