Dynamic Treatment Regimes

In recent years, treatment and intervention scientists increasingly realize that individual heterogeneity in disorder severity, background characteristics and co-occurring problems translates into heterogeneity in response to various aspects of any treatment program. Accordingly, research in this area is shifting from the traditional “one-size-fits-all ” treatment to dynamic treatment regimes, which allow greater individualization in programming over time. A dynamic treatment regime is a sequence of decision rules that specify how the dosage and/or type of treatment should be adjusted through time in response to an individual’s changing needs, aiming to optimize the effectiveness of the program. In the chapter we review the Sequential Multiple Assignment Randomized Trials (SMART), which is an experimental design useful for the development of dynamic treatment regimes. We compare the SMART approach with other experimental approaches and discuss data analyses methods for constructing a high quality dynamic treatment regime as well as other secondary analyses. 1

Literacy and Health Outcomes: A Systematic Review of the Literature

OBJECTIVE: To review the relationship between literacy and health outcomes. DATA SOURCES: We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Educational Resources Information Center (ERIC), Public Affairs Information Service (PAIS), Industrial and Labor Relations Review (ILLR), PsychInfo, and Ageline from 1980 to 2003. STUDY SELECTION: We included observational studies that reported original data, measured literacy with any valid instrument, and measured one or more health outcomes. Two abstractors reviewed each study for inclusion and resolved disagreements by discussion. DATA EXTRACTION: One reviewer abstracted data from each article into an evidence table; the second reviewer checked each entry. The whole study team reconciled disagreements about information in evidence tables. Both data extractors independently completed an 11-item quality scale for each article; scores were averaged to give a final measure of article quality. DATA SYNTHESIS: We reviewed 3,015 titles and abstracts and pulled 684 articles for full review; 73 articles met inclusion criteria and, of those, 44 addressed the questions of this report. Patients with low literacy had poorer health outcomes, including knowledge, intermediate disease markers, measures of morbidity, general health status, and use of health resources. Patients with low literacy were generally 1.5 to 3 times more likely to experience a given poor outcome. The average quality of the articles was fair to good. Most studies were cross-sectional in design; many failed to address adequately confounding and the use of multiple comparisons. CONCLUSIONS: Low literacy is associated with several adverse health outcomes. Future research, using more rigorous methods, will better define these relationships and guide developers of new interventions

The Prevalence of Limited Health Literacy

OBJECTIVE: To systematically review U.S. studies examining the prevalence of limited health literacy and to synthesize these findings by evaluating demographic associations in pooled analyses. DESIGN: We searched the literature for the period 1963 through January 2004 and identified 2,132 references related to a set of specified search terms. Of the 134 articles and published abstracts retrieved, 85 met inclusion criteria, which were 1) conducted in the United States with ≥25 adults, 2) addressed a hypothesis related to health care, 3) identified a measurement instrument, and 4) presented primary data. The authors extracted data to compare studies by population, methods, and results. MAIN RESULTS: The 85 studies reviewed include data on 31,129 subjects, and report a prevalence of low health literacy between 0% and 68%. Pooled analyses of these data reveal that the weighted prevalence of low health literacy was 26% (95% confidence interval [CI], 22% to 29%) and of marginal health literacy was 20% (95% CI, 16% to 23%). Most studies used either the Rapid Estimate of Adult Literacy in Medicine (REALM) or versions of the Test of Functional Health Literacy in Adults (TOFHLA). The prevalence of low health literacy was not associated with gender (P =.38) or measurement instrument (P =.23) but was associated with level of education (P =.02), ethnicity (P =.0003), and age (P =.004). CONCLUSIONS: A pooled analysis of published reports on health literacy cannot provide a nationally representative prevalence estimate. This systematic review exhibits that limited health literacy, as depicted in the medical literature, is prevalent and is consistently associated with education, ethnicity, and age. It is essential to simplify health services and improve health education. Such changes have the potential to improve the health of Americans and address the health disparities that exist today