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Russell L. Rothman, MD, MPP; Darren A. DeWalt, MD, MPH; Robb Malone, PharmD, CDE; Betsy Bryant, PharmD, CDE; Ayumi Shintani, PhD, MPH; Britton Crigler, BS; Morris Weinberger, PhD; Michael Pignone, MD, MPH

JAMA. 2004;292:1711-1716.

Context  Low literacy is an important barrier for patients with diabetes, but interventions to address low literacy have not been well examined.

Objective  To examine the role of literacy on the effectiveness of a comprehensive disease management program for patients with diabetes.

Design, Setting, and Participants  Analysis of the influence of literacy on glycemic control and systolic blood pressure using data from a randomized controlled trial (conducted from February 2001 through April 2003) of a comprehensive diabetes management program. Participants were 217 patients aged 18 years or older with type 2 diabetes and poor glycemic control (glycosylated hemoglobin [HbA_1c] levels 8.0%) and presenting to a US academic general internal medicine practice.

Interventions  All communication to patients was individualized and delivered to enhance comprehension among patients with low literacy. Intervention patients received intensive disease management from a multidisciplinary team. Control patients received an initial management session and continued with usual care.

Main Outcome Measures  Achievement of goal HbA_1c levels and systolic blood pressure at 12-month follow-up for control and intervention patients stratified by literacy status.

Results  Complete 12-month data were available for 193 patients (89%). Among patients with low literacy, intervention patients were more likely than control patients to achieve goal HbA_1c levels (7.0%) (42% vs 15%, respectively; adjusted odds ratio [OR], 4.6; 95% confidence interval [CI], 1.3 to 17.2; P = .02). Patients with higher literacy had similar odds of achieving goal HbA_1c levels regardless of intervention status (24% vs 23%; adjusted OR, 1.0; 95% CI, 0.4 to 2.5; P = .98). Improvements in systolic blood pressure were similar by literacy status.

Conclusions  Literacy may be an important factor for predicting who will benefit from an intervention for diabetes management. A diabetes disease management program that addresses literacy may be particularly beneficial for patients with low literacy, and increasing access to such a program could help reduce health disparities.

Author Affiliations: Center for Health Services Research, Division of General Medicine, Department of Medicine (Drs Rothman and Shintani), Diabetes Research and Training Center (Drs Rothman and Shintani), and Department of Biostatistics (Dr Shintani), Vanderbilt University Medical Center, Nashville, Tenn; Departments of Medicine (Drs DeWalt, Malone, Bryant and Pignone and Mr Crigler) and Health Policy and Administration (Dr Weinberger), University of North Carolina, Chapel Hill; and Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC (Dr Weinberger).

Corresponding Author: Russell L. Rothman, MD, MPP, Center for Health Services Research, Vanderbilt University Medical Center, Suite 6000, Medical Center East, Nashville, TN 37232-8300 (russell.rothman{at}vanderbilt.edu).

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