Ob-Gyns Stress Importance of Clear Patient-Provider Communication

Health literacy directly impacts patient outcomes

Washington, DC—Nearly one half of the people in the United States have difficulty understanding health information while there is a growing body of evidence demonstrating that health literacy has a direct impact on patient outcomes. For instance, adults with low health literacy are at increased risk of hospitalizations; they encounter more barriers to getting necessary health care services; and they are less likely to understand their doctor's medical advice which can lead to poor outcomes, including death.

Today, in a revised Committee Opinion from its committees on Patient Safety and Quality Improvement and Health Care for Underserved Women, the American College of Obstetricians and Gynecologists (ACOG) stresses the importance for all individuals in the health care system to recognize and address the problem of limited health literacy. In “Health Literacy to Promote Patient Safety,” ACOG encourages health care providers to keep messages simple, avoid medical jargon and tailor health care instructions to each individual.

Health literacy is defined as the degree to which individuals have the capacity to obtain, process and understand basic health information and services in order make appropriate health decisions. It includes the components of writing and reading, listening and speaking, and using and understanding numbers.

“Everyone in the health care field has the responsibility to make sure our patients fully understand their health conditions, treatment options and the importance of taking medications exactly as directed. Assuming a patient understands because she nods her head is not enough,” stated Whitney B. You, MD, MPH, a lead author of the Committee Opinion. “By using familiar, culturally sensitive language and avoiding medical jargon, we can help ensure our patients understand our directions. Asking our patients to repeat back to us what they understand is a helpful way we can be certain they comprehend our recommendations.”

Multiple factors at either end of the patient-provider relationship affect a patient’s understanding of health information. They include cultural factors, a physician’s health knowledge and communication skills, the demands of the situation, the environment in which the health information is being conveyed and time constraints. Other factors include a patient’s ability to communicate effectively with the health care team, to manage and commit to her own health care needs, and to comprehend complex concepts such as probability and risk.

To that end, it is extremely important for all health professionals, particularly obstetrician-gynecologists, to provide patients with clear, understandable, and actionable science-based health information. ACOG supports the guidelines issued by the U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion and includes resources for health care providers in the newly issued Committee Opinion.

In the Committee Opinion, ACOG outlines a number of specific, concrete ways for physicians and other health care providers to help communicate clearly with patients, including:

• Tailor speaking and listening skills to individual patients;
• Use medically trained language interpreters when necessary;
• Ask patients to restate what they've been told in their own words to gauge their understanding;
• Use written materials with a limited number of simple messages;
• Use visual aids for key points; and
• Use familiar language and avoid medical jargon.

Committee Opinion #676, “Health Literacy to Promote Patient Safety,” is published in the October 2016 issue of Obstetrics & Gynecology.

Other recommendations issued in the October Obstetrics & Gynecology:

Committee Opinion #675, Management of Vulvar Intraepithelial Neoplasia

Vulvar intraepithelial neoplasia (VIN) is an increasingly common problem, particularly among women in their 40s. Although spontaneous regression has been reported, VIN should be considered a premalignant condition. Immunization with the quadrivalent or 9-valent human papillomavirus vaccine, which is effective against human papillomavirus genotypes 6, 11, 16, and 18, and 6, 11, 16, 18, 31, 33, 45, 52, and 58, respectively, has been shown to decrease the risk of vulvar high-grade squamous intraepithelial lesion (HSIL) (VIN usual type) and should be recommended for girls aged 11–12 years with catch-up through age 26 years if not vaccinated in the target age. There are no screening strategies for the prevention of vulvar cancer through early detection of vulvar HSIL (VIN usual type). Detection is limited to visual assessment with confirmation by histopathology when needed. Treatment is recommended for all women with vulvar HSIL (VIN usual type). Because of the potential for occult invasion, wide local excision should be performed if cancer is suspected, even if biopsies show vulvar HSIL. When occult invasion is not a concern, vulvar HSIL (VIN usual type) can be treated with excision, laser ablation, or topical imiquimod (off-label use). Given the relatively slow rate of progression, women with a complete response to therapy and no new lesions at follow-up visits scheduled 6 months and 12 months after initial treatment should be monitored by visual inspection of the vulva annually thereafter.

Committee Opinion #677, Antenatal Corticosteroid Therapy for Fetal Maturation
Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes. A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation, including for those with ruptured membranes and multiple gestations. It also may be considered for pregnant women starting at 23 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, based on a family’s decision regarding resuscitation, irrespective of membrane rupture status and regardless of fetal number. Administration of betamethasone may be considered in pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation at imminent risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids. A single repeat course of antenatal corticosteroids should be considered in women who are less than 34 0/7 weeks of gestation who have an imminent risk of preterm delivery within the next 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. Continued surveillance of long-term outcomes after in utero corticosteroid exposure should be supported. Quality improvement strategies to optimize appropriate and timely antenatal corticosteroid administration are encouraged.

Practice Bulletin #167, Gynecologic Care for Women and Adolescents With Human Immunodeficiency Virus
In the United States in 2013, there were an estimated 226,000 women and adolescents living with human immunodeficiency virus (HIV) infection. Women with HIV are living longer, healthier lives, so the need for routine and problem-focused gynecologic care has increased. The purpose of this document is to educate clinicians about basic health screening and care, family planning, prepregnancy care, and managing common gynecologic problems for women and adolescents who are infected with HIV. For information on screening guidelines, refer to the American College of Obstetricians and Gynecologists’ Committee Opinion No. 596, Routine Human Immunodeficiency Virus Screening.

Practice Bulletin #168, Cervical Cancer Screening and Prevention

The incidence of cervical cancer in the United States has decreased more than 50% in the past 30 years because of widespread screening. In 1975, the rate was 14.8 per 100,000 women. By 2011, it decreased to 6.7 per 100,000 women. Mortality from the disease has undergone a similar decrease from 5.55 per 100,000 women in 1975 to 2.3 per 100,000 women in 2011. The American Cancer Society (ACS) estimated that there would be 12,900 new cases of cervical cancer in the United States in 2015, with 4,100 deaths from the disease. Cervical cancer is much more common worldwide, particularly in countries without screening programs, with an estimated 527,624 new cases of the disease and 265,672 resultant deaths each year. When cervical cancer screening programs have been introduced into communities, marked reductions in cervical cancer incidence have followed. New technologies for cervical cancer screening continue to evolve, as do recommendations for managing the results. In addition, there are different risk–benefit considerations for women at different ages, as reflected in age specific screening recommendations. In 2011, the ACS, the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) updated their joint guidelines for cervical cancer screening, as did the U.S. Preventive Services Task Force (USPSTF). Subsequently, in 2015, ASCCP and the Society of Gynecologic Oncology (SGO) issued interim guidance for the use of a human papillomavirus (HPV) test for primary screening for cervical cancer that was approved in 2014 by the U.S. Food and Drug Administration (FDA). The purpose of this document is to provide a review of the best available evidence regarding the prevention and early detection of cervical cancer.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 57,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org