Literacy and Race as Risk Factors for Low Rates of Advance Directives in Older Adults

Abstract

Background Advance directives are documented instructions by a patient to ensure their medical care preferences are fulfilled in the event they cannot communicate with clinicians or family members. Objectives The current study examined the relationship between literacy and other patient level factors on having an advance directive. Design Face-to-face structured interview. Setting Participants were recruited from either an academic general internal medicine clinic or one of four federally qualified health centers in Chicago. Participants 784 adults ages 55 to 74. Measurements Assessment of participant literacy, sociodemographic factors, and having an advance directive for medical care. Results Having an advanced directive was reported by 12.4% of subjects with low literacy, 26.6% of those with marginal literacy, and 49.5% of those with adequate literacy (p<0.001). In multivariable analyses, both literacy and race were independently associated with a lower likelihood of having an advance directive. Specifically, people with limited literacy and African Americans were less likely to have an advance directive (RR, 0.45; 95% CI, 0.22–0.95; RR, 0.64; 95% CI: 0.47–0.88, respectively). Exploratory analyses exhibited that there was not a significant interaction between the effect of literacy and race. Conclusion Limited literacy and African American race were significant risk factors to not having an advance directive in this cohort of older patients. Literacy and race likely represent two separate but important causal pathways that need to be understood to improve how the health care system ascertains and protects patients’ advanced care preferences.

Racial and Ethnic Differences in Advance Directive Possession: Role of Demographic Factors, Religious Affiliation, and Personal Health Values in a National Survey of Older Adults

“…In addition, some other alternative predictors of interest could not be examined, such as access to information on advance directives, 7,9,11 the quality of the patient-provider relationship, 1,4,24,25 and health literacy (as distinct from educational attainment). 26,27 In summary, low adoption of advance directives among black older Americans (as compared with white older Americans) is not explained by other demographic factors, religious characteristics, or personal health values. As a matter of policy, these findings support targeted efforts and reimbursement models to promote advance care planning among members of underserved groups, as an individual's religious beliefs and personal health values do not fully explain the racial difference in advance directive possession.…”

Racial Disparities in Extremity Soft-Tissue Sarcoma Outcomes

“…may all play a role in deterring them from seeking early care and ultimately affecting survival. [26][27][28] This is also compounded by previously acknowledged barriers in access to care in African Americans. 26,[29][30][31] Although income was accounted for in this study, other sociodemographic inequalities and geographical variation among African Americans and whites may also play a role in confounding the survival discrepancies seen.…”

Impact of a Care Directives Activity Tab in the Electronic Health Record on Documentation of Advance Care Planning

“…Limitations of our report include the potential impact of unmeasured factors on our findings. For instance, we did not adjust CDA use rates for factors known to have an impact on advance care planning, such as race and literacy, 13 although we have no reason to believe that patients with and without CDA use differed in ways that would have influenced our findings. Although the CDA is intended to improve both the documentation and retrieval of advance care planning preferences, this study addressed only the first.…”