Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN; Center for Effective Health Communication, Vanderbilt University Medical Center, Nashville, TN.
Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN.
Mayo Clin Proc. 2018 Dec;93(12):1728-1738. doi: 10.1016/j.mayocp.2018.07.024. Epub 2018 Nov 7.
To test theorized patient-level mediators in the causal pathway between health literacy (HL) and 1-year mortality in adults with cardiovascular disease (CVD).
A total of 3000 adults treated at Vanderbilt University Hospital from October 11, 2011, through December 18, 2015, for acute coronary syndrome or acute decompensated heart failure (ADHF) participated in the Vanderbilt Inpatient Cohort Study. Participants completed a bedside-administered survey and consented to health record review and longitudinal follow-up. Multivariable mediation models examined the direct and indirect effects of HL (a latent variable with 4 indicators) with 1-year mortality after discharge (dichotomous). Hypothesized mediators included social support, health competence, health behavior, comorbidity index, type of CVD diagnosis, and previous-year hospitalizations.
Of the 2977 patients discharged from the hospital (60% male; mean age, 61 years; 83% non-Hispanic white, 37% admitted for ADHF), 17% to 23% had inadequate HL depending on the measure, and 10% (n=304) died within 1 year. The total effect of lower HL on 1-year mortality (adjusted odds ratio [AOR]=1.31; 95% CI, 1.01-1.69) was decomposed into an indirect effect (AOR=1.50; 95% CI, 1.35-1.67) via the mediators and a nonsignificant direct effect (AOR=0.87; 95% CI, 0.66-1.14). Each SD decrease in HL was associated with an absolute 3.2 percentage point increase in the probability of 1-year mortality via mediators admitted for ADHF, comorbidities, health behavior, health competence, and previous-year hospitalizations (listed by contribution to indirect effect).
Patient-level factors link low HL and mortality. Health competence and health behavior are modifiable mediators that could be targeted by interventions post hospitalization for CVD.
在健康素养（HL）与心血管疾病（CVD）成人 1 年死亡率之间的因果路径中，检验理论上的患者水平中介因素。
2011 年 10 月 11 日至 2015 年 12 月 18 日期间，共有 3000 名在范德比尔特大学医院接受急性冠状动脉综合征或急性失代偿性心力衰竭（ADHF）治疗的成年人参加了范德比尔特住院队列研究。参与者完成了床边管理的调查，并同意进行健康记录审查和纵向随访。多变量中介模型检查了 HL（具有 4 个指标的潜在变量）与出院后 1 年死亡率（二分类）之间的直接和间接影响。假设的中介因素包括社会支持、健康能力、健康行为、合并症指数、CVD 诊断类型和前一年的住院治疗。
在出院的 2977 名患者中（60%为男性；平均年龄为 61 岁；83%为非西班牙裔白人，37%因 ADHF 入院），根据测量方法，17%至 23%的患者 HL 不足，10%（n=304）在 1 年内死亡。较低 HL 对 1 年死亡率的总影响（调整后的优势比[OR]为 1.31；95%置信区间，1.01-1.69）被分解为通过中介因素的间接影响（OR=1.50；95%置信区间，1.35-1.67）和无显著意义的直接影响（OR=0.87；95%置信区间，0.66-1.14）。HL 每降低 1 个标准差，通过中介因素（因 ADHF 入院、合并症、健康行为、健康能力和前一年住院治疗而入院的因素）导致 1 年死亡率的概率增加 3.2 个百分点（按间接影响的贡献列出）。
患者水平因素将低 HL 与死亡率联系起来。健康能力和健康行为是可调节的中介因素，可作为 CVD 出院后干预的目标。
