proxy for health literacy, as there is only a modest correlation between education and health literacy. There also are interactions between education and other demographic characteristics (e.g., ethnicity, age, primary language) on health literacy (Beers et al., 2003; Guerra and Shea, 2003). A recent study suggests that a single questionnaire item may have reasonable sensitivity and specificity in detecting inadequate health literacy and appears to perform well if the prevalence of inadequate health literacy in the population is high enough (Chew and Bradley, 2003). In order for a strategy of reducing health literacy-related disparities by measuring health literacy-related quality is to succeed, research to develop a rapid and reliable measure of health literacy is needed.

A second approach is to develop novel measures of quality that may be less disease-specific, yet have particular relevance to patients with limited health literacy across chronic conditions. To our knowledge, relatively little work has been done in this regard. For example, the National Center for Quality Assurance (NCQA) for managed care organizations has created standards regarding the readability of the patient appeal of denial of services form (NCQA, 2003). While arguably of importance, the approach of assessing quality by measuring document readability is obviously narrow in scope, and does not capture a more comprehensive view of the patient experience. Other possibilities include measuring patients’ reports of their experiences of communication (Schillinger et al., 2004), rates of discordance between patients’ and providers’ reports of medication regimens (Schillinger et al., 2003a), the extent to which home monitoring and support for chronic disease is available (Norris et al., 2002b), the range of learning options and media available to patients, the ease with which one can navigate a health system, or capturing the degree to which a health system has a family and community orientation (Starfield, 1998). In order for significant progress to be made, it is essential that research is done to develop appropriate quality indicators for health literacy-related performance.

CONCLUSIONS

Despite wide variation in literacy levels, our society places high literacy demands on its members. It is apparent that attempts to reduce health literacy-related disparities must revolve around either directly addressing the problem of basic literacy and/or creating a health-care system in which the gap between the literacy demands of the system and the literacy skills of the patients it serves is significantly narrowed. Modern chronic disease care requires that patients play an active role in their care, and that clinicians and the health systems in which they work take on the challenge of partnering with patients to promote successful outcomes. Meeting these goals is



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