Associations of health literacy with dialysis adherence and health resource utilization in patients receiving maintenance hemodialysis

Am J Kidney Dis. 2013 Jul;62(1):73-80. doi: 10.1053/j.ajkd.2012.12.014. Epub 2013 Jan 24.


Background: Although limited health literacy is common in hemodialysis patients, its effects on clinical outcomes are not well understood.

Study design: Observational study.

Setting & participants: 260 maintenance hemodialysis patients enrolled in a randomized clinical trial of symptom management strategies from January 2009 through April 2011.

Predictor: Limited health literacy.

Outcomes: Dialysis adherence (missed and abbreviated treatments) and health resource utilization (emergency department visits and end-stage renal disease [ESRD]-related hospitalizations).

Measurements: We assessed health literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM) and used negative binomial regression to analyze the independent associations of limited health literacy with dialysis adherence and health resource utilization over 12-24 months.

Results: 41 of 260 (16%) patients showed limited health literacy (REALM score, ≤60). There were 1,152 missed treatments, 5,127 abbreviated treatments, 552 emergency department visits, and 463 ESRD-related hospitalizations. Limited health literacy was associated independently with an increased incidence of missed dialysis treatments (missed, 0.6% vs 0.3%; adjusted incidence rate ratio [IRR], 2.14; 95% CI, 1.10-4.17), emergency department visits (annual visits, 1.7 vs 1.0; adjusted IRR, 1.37; 95% CI, 1.01-1.86), and hospitalizations related to ESRD (annual hospitalizations, 0.9 vs 0.5; adjusted IRR, 1.55; 95% CI, 1.03-2.34).

Limitations: Generalizability and potential for residual confounding.

Conclusions: Patients receiving maintenance hemodialysis who have limited health literacy are more likely to miss dialysis treatments, use emergency care, and be hospitalized related to their kidney disease. These findings have important clinical practice and cost implications.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Cohort Studies
  • Female
  • Follow-Up Studies
  • Health Literacy*
  • Health Resources / statistics & numerical data*
  • Humans
  • Male
  • Middle Aged
  • Patient Compliance*
  • Prospective Studies
  • Renal Dialysis / statistics & numerical data*