<%BANNER%>

Role of Health Literacy in Total Knee Arthroplasty in Older Adults with Knee Osteoarthritis

Permanent Link: http://ufdc.ufl.edu/UFE0022677/00001

Material Information

Title: Role of Health Literacy in Total Knee Arthroplasty in Older Adults with Knee Osteoarthritis
Physical Description: 1 online resource (39 p.)
Language: english
Creator: Bautista, Miho
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: adult, aging, arthritis, arthroplasty, health, knee, literacy, old, older, osteoarthritis, replacement, surgery, utilization
Clinical Investigation (IDP) -- Dissertations, Academic -- UF
Genre: Medical Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Health literacy is an important determinant of healthcare utilization. This is thought to be related to inability for an individual with limited health literacy to advocate for his/her healthcare needs. We sought to determine whether health literacy is associated with the use of total knee arthroplasty (TKA)-an effective procedure to palliate an important cause of disability in older adults-osteoarthritis of the knee. Our specific aim was to investigate the association of health literacy with the utilization of TKA among older adults with knee OA. We hypothesize that older adults with limited health literacy have a decreased utilization of TKA for treatment of knee OA. The study included 889 black and white community-dwelling men and women aged 70-79 years participating in the Health, Aging and Body Composition Study (Health ABC Study)-a 10-year longitudinal cohort study. Participants were recruited in either Memphis, TN, or Pittsburgh, PA. They were all high functioning at baseline without dementia, functional difficulties, or life-limiting cancer. Participants took health literacy (HL) assessment during their clinical visits in year 3, using the Rapid Estimate of Adult Literacy of Medicine (REALM). They were excluded from the study if they had prior history of TKA or having no knee pain, aches or stiffness in either knee for most days of the week in the past 30 days. The REALM score was dichotomized into limited HL (=REALM score 0-60) and adequate HL (= REALM score 61-66). The incidence of the first TKA surgery was assessed from year 3 through year 9 of the Health ABC Study. Descriptive statistics, chi-square test, Wilcoxon rank test and logistic regression were used to analyze the relationship of HL with TKA. Overall, participants (n=889) were 40% male, 48% lived in Memphis, 49% had annual household income less than $25,000, 37% reported their health status to be very good or excellent, 56% Caucasians, 24% had less than high school equivalency, 97% reported having a usual source of healthcare, and advice, 24% had limited health literacy(HL). Their mean age was 73.5+/-2.9 years (Mean+/-SD) and body mass index of 28.5+/-5.1 kg/m2. The overall incidence of TKA was 6.7%. The incidence of TKA varied significantly by HL: 8.1% among persons with adequate HL; and 1.9% among persons with limited HL (p=0.0014). We removed body mass index, annual household income, health status, age, depression and usual source of healthcare and advice from the logistic regression model because they had no significant relationship with TKA (p=0.1). Cognitive function was also removed from the model because it was highly collinear with HL and TKA, and had a suppressive effect on the relationship of HL with TKA. The significant association of HL with TKA persisted after adjusting for knee pain, race, education and clinical site (p=0.03). In this cohort of well-functioning older adults, limited health literacy was associated with a decreased utilization of TKA. Future interventions to prevent disability in older adults may be more successful if the role of health literacy is better understood.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Miho Bautista.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: Garvan, Cynthia W.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-08-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022677:00001

Permanent Link: http://ufdc.ufl.edu/UFE0022677/00001

Material Information

Title: Role of Health Literacy in Total Knee Arthroplasty in Older Adults with Knee Osteoarthritis
Physical Description: 1 online resource (39 p.)
Language: english
Creator: Bautista, Miho
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: adult, aging, arthritis, arthroplasty, health, knee, literacy, old, older, osteoarthritis, replacement, surgery, utilization
Clinical Investigation (IDP) -- Dissertations, Academic -- UF
Genre: Medical Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Health literacy is an important determinant of healthcare utilization. This is thought to be related to inability for an individual with limited health literacy to advocate for his/her healthcare needs. We sought to determine whether health literacy is associated with the use of total knee arthroplasty (TKA)-an effective procedure to palliate an important cause of disability in older adults-osteoarthritis of the knee. Our specific aim was to investigate the association of health literacy with the utilization of TKA among older adults with knee OA. We hypothesize that older adults with limited health literacy have a decreased utilization of TKA for treatment of knee OA. The study included 889 black and white community-dwelling men and women aged 70-79 years participating in the Health, Aging and Body Composition Study (Health ABC Study)-a 10-year longitudinal cohort study. Participants were recruited in either Memphis, TN, or Pittsburgh, PA. They were all high functioning at baseline without dementia, functional difficulties, or life-limiting cancer. Participants took health literacy (HL) assessment during their clinical visits in year 3, using the Rapid Estimate of Adult Literacy of Medicine (REALM). They were excluded from the study if they had prior history of TKA or having no knee pain, aches or stiffness in either knee for most days of the week in the past 30 days. The REALM score was dichotomized into limited HL (=REALM score 0-60) and adequate HL (= REALM score 61-66). The incidence of the first TKA surgery was assessed from year 3 through year 9 of the Health ABC Study. Descriptive statistics, chi-square test, Wilcoxon rank test and logistic regression were used to analyze the relationship of HL with TKA. Overall, participants (n=889) were 40% male, 48% lived in Memphis, 49% had annual household income less than $25,000, 37% reported their health status to be very good or excellent, 56% Caucasians, 24% had less than high school equivalency, 97% reported having a usual source of healthcare, and advice, 24% had limited health literacy(HL). Their mean age was 73.5+/-2.9 years (Mean+/-SD) and body mass index of 28.5+/-5.1 kg/m2. The overall incidence of TKA was 6.7%. The incidence of TKA varied significantly by HL: 8.1% among persons with adequate HL; and 1.9% among persons with limited HL (p=0.0014). We removed body mass index, annual household income, health status, age, depression and usual source of healthcare and advice from the logistic regression model because they had no significant relationship with TKA (p=0.1). Cognitive function was also removed from the model because it was highly collinear with HL and TKA, and had a suppressive effect on the relationship of HL with TKA. The significant association of HL with TKA persisted after adjusting for knee pain, race, education and clinical site (p=0.03). In this cohort of well-functioning older adults, limited health literacy was associated with a decreased utilization of TKA. Future interventions to prevent disability in older adults may be more successful if the role of health literacy is better understood.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Miho Bautista.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: Garvan, Cynthia W.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-08-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022677:00001


This item has the following downloads:


Full Text






ROLE OF HEALTH LITERACY IN TOTAL KNEE ARTHROPLASTY
IN OLDER ADULTS WITH KNEE OSTEOARTHRITIS


















By

MIHO KOJIMA BAUTISTA


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE

UNIVERSITY OF FLORIDA

2008
































O 2008 Miho Kojima Bautista

































To my husband, Dad, Mom, and my brother










ACKNOWLEDGMENTS


I express my most sincere appreciation to my supervisory committee chair, Cynthia

Garvan, Ph.D., with the University of Florida (UF), College of Education; and my mentors

Rebecca Beyth, M.D., M. Sc., and Ron Shorr, M.D., M. S., with the University of Florida, College

of Medicine, for their support and guidance. My study would not have been possible without

their guidance and support. I would like to thank Marian Limacher, M.D., Program Director of

the Advanced Post-Graduate Program in Clinical Investigation (APPCI) with the University of

Florida, for sponsoring my education and being a role model as a successful clinician, educator,

and researcher. I am indebted to Marco Pahor, M.D., Chair of the Department of Aging and

Geriatrics, UF College of Medicine, for providing infrastructure and resources necessary in

completing this thesis. I truly value Elena Andresen, Ph.D., with the UF College of Public

Health, and Constance Uphold, Ph.D., with the UF College of Nursing, for their time and

incredible support to my career development in health services research. I thank Philip Scarpace,

Ph.D., and Nihal Tumer, Ph.D., with the UF College of Medicine; and Nannette Hoffman, M.D.,

and Bradley Bender, M.D., with the North Florida/South Georgia Veterans Affairs Health

System, for their heart-felt support and guidance. I also thank Ms. Eve Johnson, Program

Coordinator of the UF APPCI Program, and Ms. Crystal Quirin with the UF College of

Medicine, for providing administrative support. It is with much love that I thank my parents

Masayuki Kojima and Noriko Kojima; and my brother Kikuhiko Kojima for the strength and

courage they have given me to pursue my goals in my medical career. Finally, I thank my

husband, Jun Bautista, for his continued support.












TABLE OF CONTENTS


Page

ACKNOWLEDGMENT S .........__.. ..... .__. ...............4....


LIST OF TABLES ........._.___..... .__. ...............7....


AB S TRAC T ......_ ................. ............_........8


CHAPTER


1 INTTRODUCTION ................. ...............10.......... ......


Background ................. ... .......... ........... ...... .........10
Scope of Problems of Knee Osteoarthritis ................. ...............10...............
Utilization of Total Knee Arthroplasty ................. ...............11........... ...
Role of Health Literacy in Healthcare Utilization ................. .............................12
Statement of the Problem ................. ...............13................

Specific Aim and Hypothesis .............. ...............14....

2 M ETHODS ................. ...............15.......... .....


Participants .............. ...............15....
M measures ................. ...............16.......... .....
Health Literacy ................. ...............16.......... .....
Total Knee Arthroplasty ................. ...............18................
Demographic Characteristics............... ............1
Clinical Characteristics............... ............1
Knee pain............... ...............19..
Depression ................. ...............20.................
Cognitive function............... ...............21
Statistical Analy ses ................. ...............21.................

3 RE SULT S .............. ...............23....


Descriptive Analyses .............. ...............23....
Bivariate Analyses ................. ...............23.................
Logistic Regression Analyses ................. ...............24........... ....

4 DI SCUS SSION ................. ...............28................


Significance of the Study ................... ............ ...............28......
Role of Cognitive Function in Health Literacy .............. ...............30....
Dichotomization of Health Literacy .........._...__........_ ....._._....... ...............30
Strength of the Study ................. ...............3.. 1.............
Limitations of the Study .............. ...............3 1....













5 CONCLUSIONS .............. ...............33....


LIST OF REFERENCES ................. ...............34................


BIOGRAPHICAL SKETCH .............. ...............38....












LIST OF TABLES

Table page

3-1 Frequency distribution of the participants' characteristics ........._.__....... ._. ............25

3-2 Relationship of participants' characteristics with health literacy (HL) and total knee
arthroplasty (TKA)............... ...............26.

3-3 Relationship of health literacy (HL) with total knee arthroplasty--logi stic regression .....27









Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science

ROLE OF HEALTH LITERACY IN TOTAL KNEE ARTHROPLASTY IN OLDER ADULTS
WITH KNEE OSTEOARTHRITIS

By

Miho Kojima Bautista

August 2008

Chair: Cynthia Garvan
Major: Medical Science--Clinical Investigation

Health literacy is an important determinant of healthcare utilization. This is thought to be

related to inability for an individual with limited health literacy to advocate for his/her healthcare

needs. We sought to determine whether health literacy is associated with the use of total knee

arthroplasty (TKA)-an effective procedure to palliate an important cause of disability in older

adults-osteoarthritis of the knee.

Our specific aim was to investigate the association of health literacy with the utilization

of TKA among older adults with knee OA. We hypothesize that older adults with limited health

literacy have a decreased utilization of TKA for treatment of knee OA.

The study included 889 black and white community-dwelling men and women aged 70-

79 years participating in the Health, Aging and Body Composition Study (Health ABC Study)-a

10-year longitudinal cohort study. Participants were recruited in either Memphis, TN, or

Pittsburgh, PA. They were all high functioning at baseline without dementia, functional

difficulties, or life-limiting cancer. Participants took health literacy (HL) assessment during their

clinical visits in year 3, using the Rapid Estimate of Adult Literacy of Medicine (REALM).

They were excluded from the study if they had prior history of TKA or having no knee pain,

aches or stiffness in either knee for most days of the week in the past 30 days. The REALM









score was dichotomized into limited HL (=REALM score 0-60) and adequate HL (= REALM

score 61-66). The incidence of the first TKA surgery was assessed from year 3 through year 9 of

the Health ABC Study. Descriptive statistics, chi-square test, Wilcoxon rank test and logistic

regression were used to analyze the relationship of HL with TKA.

Overall, participants (n=889) were 40% male, 48% lived in Memphis, 49% had annual

household income less than $25,000, 37% reported their health status to be very good or

excellent, 56% Caucasians, 24% had less than high school equivalency, 97% reported having a

usual source of healthcare, and advice, 24% had limited health literacy. Their mean age was

73.5 & 2.9 years and body mass index of 28.515. 1 kg/m2. The overall incidence of TKA was

6.7%. The incidence of TKA varied significantly by HL-8.1% among persons with adequate HL

and 1.9% among persons with limited HL (p=0.0014). We removed body mass index, annual

household income, health status, age, depression and usual source of healthcare and advice from

the logistic regression model because they had no significant relationship with TKA (p>0.1).

Cognitive function was also removed from the model because it was highly collinear with HL

and TKA, and had a suppressive effect on the relationship of HL with TKA. The significant

association of HL with TKA persisted after adjusting for knee pain, race, education and clinical

site (p=0.03).

In this cohort of well-functioning older adults, limited health literacy was associated with

a decreased utilization of TKA. Future interventions to prevent disability in older adults may be

more successful if the role of health literacy is better understood.









CHAPTER 1
INTTRODUCTION

Background

Scope of Problems of Knee Osteoarthritis

Osteoarthritis (OA)-also known as degenerative joint disease-is the most common

rheumatologic disease that results in significant disability among middle-aged and older persons.

In 2005, estimated prevalence of OA was 46 million: 1 in 5 adults in the United States(1).

Osteoarthritis (OA) placed third among the leading causes of disability in the U.S. with

approximately 1 million years lived in disability and $13.2 billion in annual job-related costs due

to OA. Because of the considerable impact of OA on public health, the U. S. Public Health

Service Healthy People 2010 included an agenda on decreasing health disparity associated with

OA(2).

The knee is the most common joint affected by OA. The estimated prevalence of

symptomatic knee OA is 16 % among U.S. adults over 45 years old (18.7% female, 13.5% male)

(3), and the annual incidence of symptomatic knee OA is 240 per 100,000 person years(4). Knee

OA also results in destruction of the knee j points, which appears on knee radiographs in 0.9% of

U.S. adults(5). Chronic j oint pain, aching and stiffness in the knee can cause functional

limitation in 40% of knee OA patients in performing one of these activities-walking, stair

climbing, performing heavy home chores, carrying heavy objects, house keeping, cooking and

grocery shopping. Due to the significant pain and immobility, 14% need assistance in personal

care on the daily basis(6). Furthermore, knee OA significantly decreases patients' quality of life

as 40% of them reported either poor or fair health. With the expected growth of older segment

of the U. S. adult population in the future, knee OA will continue to place enormous healthcare

and economic burdens in the U.S(7).









Utilization of Total Knee Arthroplasty

Among treatment options available for knee osteoarthritis (OA), total knee arthroplasty

(TKA) is a surgical treatment to replace a diseased native knee j oint with a prosthetic j oint.

Total knee arthroplasty (TKA) ranks at or near the top among medical and surgical interventions

in its cost-effectiveness as it alleviates knee pain, restores physical function and improves the

quality of life in patients with an advanced stage of knee OA(8). Previous studies reported that

the effect sizes of short-term and long-term pain and functional outcomes of TKA ranged from

1.27 to 3.91(9). The complication rates are low-the mortality rate 0.5%, hospital readmission

rate 0.9%, pulmonary embolism 0.8%, wound infection 0.4%, pneumonia 1.4% and myocardial

infarction 0.8%(8).

In spite of its clinical benefits, TKA also has significant tradeoffs. The failure rate of

prosthetic joints is moderately high-10% at 10 years and 20% at 20 years after initial TKA.

Failed prosthetic j points will require revision surgery which has higher surgical complication rates

than initial TKA(10;11i). Although TKA is safer than other orthopedic surgeries(8), TKA is still

riskier than any other non-surgical interventions for knee OA. These non-surgical interventions

include physical therapy, analgesics and anti-inflammatory medications that are primarily

prescribed to provide temporary relief of pain and physical function with variable efficacy(12).

In addition, post-surgical care of TKA requires a prolonged period of intensive physical therapy-

from weeks to months-in restoring physical function, which makes TKA an inconvenient

treatment option to patients(12). Because of these tradeoffs of TKA, clinical guidelines

consensus groups agreed that TKA is indicated only at an advanced stage of knee OA in which

patients' function has declined to an unacceptable level and failed to respond to other non-

surgical treatments of knee OA(12;14).









Despite of these tradeoffs of TKA, the number of TKA performed in the United States has

steadily increased over the past 15 years. Between 1993 and 2005, TKA was the second fastest

growing reason for orthopedic-related hospital admissions among Medicare enrollees, with 89%

growth in the number of hospital admissions due to TKA(15). It also is the most frequently

performed elective orthopedic surgeries in the U.S. with approximately 478,000 TKA surgeries

were performed annually, accounting for one-quarter of all orthopedic-related surgeries(16). In

2000, the Medicare spent a total of $3.2 billion on TKA(17). As the aging population grows in

the U.S. and the indication for TKA broadens with improved performance of new prosthetic

joints and advances in surgical techniques of TKA, the Medicare expenditure for TKA is

proj ected to increase by 6-fold in year 2030(18).

Because TKA is a common, elective surgery that contributes to a substantial Medicare

expenditure, the utilization of TKA has come under increasing scrutiny. Numerous studies

documented considerable racial/ethnic and regional inequality in the utilization of TKA(19).

The reason behind the socio-cultural disparity in the utilization of TKA is not well known.

However, previous literature implicated a complex interaction of patient-level factors (e.g.

treatment preference), provider factors (e.g. surgeons' practice style and physician-patient

communication style) and system-level factors (e.g. access to specialist care) as a cause of such

disparity(20;21).

Role of Health Literacy in Healthcare Utilization

During the past 15 years, health literacy has emerged as an important patient-level factor

that explains the disparity in healthcare utilization(21-23). Health literacy refers to individuals'

capacity to obtain, process, and understand basic health information and services needed to make

appropriate healthcare decisions(23). A substantial body of evidence indicates that inadequate

health literacy significantly impairs patients' knowledge, understanding and decision making









about their own healthcare(22). However, previous studies have primarily investigated the

association of inadequate health literacy with the decreased utilization of preventive healthcare

services such as influenza vaccination and cancer screening tests for breast, prostate and colon

cancers(24-29). Evidence is currently lacking on whether there is an association between health

literacy and the utilization of TKA.

Statement of the Problem

Although the preponderance of evidence documents that inadequate health literacy impairs

patients' knowledge, understanding and decision making about their own healthcare, little is

known about health literacy's role in the utilization of total knee arthroplasty (TKA). Research in

this topic is justified at several levels of relevance to the current health care. First, examining

health literacy in regards to the utilization of TKA provides a unique health services research

model because TKA is a preference-sensitive healthcare. According to Wennberg, et al, a

preference-sensitive healthcare entails at least two valid alternative treatment options and the

choice of treatment involves trade-offs. Thus, decision making about preference-sensitive

healthcare should be based on patient' s opinions and values(20). Because having adequate

knowledge and understanding about TKA is a pre-requisite for patients to make an informed

decision, health literacy may play a critical role in the utilization of TKA. In today's consumer-

minded healthcare system in which shared-decision making is important(21), health literacy may

present an important paradigm in understanding the access to TKA. Secondly, health literacy is

clinically important because it presents an opportunity for an innovative strategy to improve

patients' knowledge, understanding and decision making for TKA. Lastly, research is needed to

understand the access to TKA in patients with limited health literacy because the maj ority of

TKA surgeries are performed on older patients who commonly use their Medicare benefits to

pay for TKA(21;30). Since the disparity in the utilization of TKA is related to federal healthcare









expenditures, health literacy has a significant implication to health policy and research on the

disparity in healthcare access to TKA.

For these reasons, it is important that health services research be conducted to investigate

the role of health literacy in the utilization of TKA. In this study, we investigated the association

of health literacy in the incidence of TKA among older patients with knee OA using available

data from the Health, Aging and Body Composition Study (Health ABC Study)-10-year

longitudinal cohort study of older adults. We hypothesize that limited health literacy is

associated with the decreased incidence of TKA-an effective procedure to palliate an important

cause of disability in older adults osteoarthritis (OA) of the knee.

Specific Aim and Hypothesis

Our specific aim was to investigate the association of health literacy with the utilization of

TKA among older adults with knee OA. We hypothesize that older adults with limited health

literacy have a decreased utilization of TKA for treatment of knee OA.









CHAPTER 2
METHOD S

Participants

Data were available from the Health ABC Study-a 10-year longitudinal cohort study of

older adults from 1997 through 2006. This study-funded by the National Institute of Aging with

the National Institute of Health-aims to investigate the epidemiology, demographics and

biometry associated with the decline in functional status and change in body composition of

older persons in transition from wellness to frailty(31). In 1997, investigators from the

University of Pittsburgh (Pittsburgh, Pennsylvania) and the University of Tennessee (Memphis,

Tennessee) recruited 3,075 English-speaking participants aged 70 to 79 years from a random

sample of white Medicare beneficiaries and all age-eligible African American community

residents to participate in the study. All participants were well functioning at baseline. The

eligibility criteria included self-reporting no difficulty in walking a distance of 400 meters or

climbing at least 10 stairs, free of life-threatening cancers, independently performing activities of

daily living and plans to living in the area for the next 3 years. Of baseline participants, 46% of

the women and 37% of the men were African Americans. Residents within designated ZIP codes

were mailed study brochures and then called on the phone to request study participation and

assess their functional status.

During the annual clinical visits in year 3 of the Health ABC Study (1999/2000), an in-

person clinical assessment of health literacy was performed in 2,5 12 participants. Of the original

3,075 participants, 563 subj ects did not complete health literacy assessment because of lack of an

in-person clinic interview (n=418), death (n=107), poor eye sight (n=14), refusal (n=13),

withdrawal from the study (n=6), and missing data (n=5)(24). Only the participants who

completed health literacy assessment (n=2512) were included in the study. Participants were









excluded from the study if they had: 1) prior history of TKA (n=29), or 2) having no knee pain,

aches or stiffness in either knee for most days of the week for the past 30 days (n=1,594). Eight

hundred and eighty-nine participants were included in the study. None of the participants

(n=889) reported having diagnoses other than osteoarthritis or degenerative joint disease for their

knee pain. The Institutional Review Board of the University of Florida approved this study.

Measures

Health Literacy

The Rapid Estimate of Adult Literacy in Medicine (REALM) was measured during the

clinical visits in year 3 of the Health ABC Study. The REALM is a verbal fluency test that

measures the ability to pronounce 66 common medical words and lay terms that adult primary

care patients are expected to recognize(32). These words are presented in the order of increasing

difficulty and syllable length, with one point given for each word pronounced correctly. These

words were originally chosen from patient education materials and patient intake forms used in

university-based primary care clinics. Item reduction from 125 to 66 words was based on

psychometric estimates of item difficulty and discrimination and the frequency of retained words

in written materials given to patients. It has a high concentration of words at lower difficulty

levels, which increases its discriminatory power when administered to patients with limited

reading ability. Participants are asked to read aloud as many words as they can, beginning with

the first word in the first column. When they encounter a word they cannot read, they asked to

do the best they can or say "blank" and go onto the next word. The raw score is the number of

correctly pronounced words with the dictionary pronunciation taken as the scoring standard(32).

The REALM scores range from 0 to 66 from the lowest to the highest health literacy.

Examples of words in the REALM are 'fat', 'pill', 'exercise', 'arthritis', 'medication' and

'obesity'. The REALM has a high face validity and criterion validity because it correlated well









with three other standardized reading recognition tests- 1) the revised Wide Range Achievement

Test-Third Edition (WRAT-3) (r=0.88), 2) the Slosson Oral Reading Test-Revised (SORT-R)

(r-0.96), and 3) the Peabody Individual Achievement Test-Revised (PIAT-R) (r-0.97)(33). The

REALM also correlated well with other standardized health literacy tests such as the Test of

Functional Health Literacy in Adults (TOHFLA) (r=0.84)(34) and the short version of the

TOHFLA(35). The REALM has a high test-retest reliability (r-0.99) and inter-rater reliability

(r-0.99) among 100 adults(33). The 66-item version of the REALM takes 1-2 minutes to

complete by personnel with minimal training. Uniform administration and scoring of the

REALM was achieved by standardized training and direct observation of a subset of test

admini stations.

The raw REALM scores were used to derive U.S. high school grade range estimates(32).

The grade level was determined by linear regression analysis using the REALM raw scores to

predict scores on the Slossan Oral Reading Test-Revised (SORT-R), which is a widely used

national standardized test in the U.S. The REALM scores were categorized into four levels to

estimate the reading ability(33;36). The first level (REALM score range: 0 to 18) approximates

a reading level of 3rd grade or less. At this level, participants may not be able to read materials

written even at or below the 3rd-grade reading level and may need repeated oral instructions in

order to understand most patient education materials that were written at a higher reading level.

The second level (REALM score range: 19 to 44) approximates a 4th- to 6th-grade reading level.

At this level, participants may be able to read low-literacy materials, but may not be able to read

instructions written on a prescription medication label. The third level (REALM score range:

45-60) approximates a 6th to 8th-grade reading level. At this level, participants may be able to

read instructions written on a prescription medication label, but may struggle with currently









available patient education materials that are mostly written at or above the 9th-grade reading

level. The fourth level (REALM score range: 61-66) approximates a 9th-grade reading level and

above. At this level, participants may be able to read most of the currently available patient

education materials. Because of a small sample size in the first and second levels of the

REALM, we combined them to create a three-level ordinal variable (REALM score range: 0-44,

45-60, and 61-66). The REALM score was also dichotomized into 2 levels by combining the

first 3 levels of the original four-level ordinal variable. We defined the 2 levels of the

dichotomized variable as follows: 1) Limited health literacy if the REALM score is 0 through

60, and 2) Adequate health literacy if the REALM score is 61 through 66.

Total Knee Arthroplasty

The incidence of total knee arthroplasty (TKA) was defined as the participants' first

hospitalization events due to TKA that they had ever had in their life. Data on hospitalization

events were available in the Detailed Hospitalization Listing dataset of the Health ABC Study

that contains information about hospitalization that resulted in at least an over-night stay in a

hospital. The study examiners initially obtained the hospitalization events from participants

during annual in-person follow-up visits and semi-annual phone call contacts with participants.

Information on the hospitalization events such as admission and discharge dates, diagnoses and

procedures performed during the hospitalization were adjudicated by reviewing medical records.

This adjudicated information on the hospitalization was subsequently entered into the Detailed

Hospital Listing dataset. At the time of this study, the hospitalization data were available from

year 1 (1997) at baseline clinical visits through November 20, 2007, when participants were last

contacted(37). In the Detailed Hospital Listing dataset, we censored hospitalization events due

to TKA if they met two criteria-1) osteoarthritis was the primary diagnosis for the

hospitalization, and 2) TKA was the primary procedure performed during hospitalization.










Demographic Characteristics

Demographics were obtained at baseline in year 1. The demographic characteristics were

age, gender, race/ethnicity (Caucasian or African American), education (
equivalency, >High school equivalency, > College Graduation with a bachelor' s degree), annual

household income (< $25,000, >$25,000 or Missing) and clinical site (Memphis, Tennessee, or

Pittsburgh, Pennsylvania), and whether they had a usual source of healthcare and advice. There

was a large number of missing observations in the annual family income. Because income is an

important socioeconomic variable that may affect the utilization of TKA, we included missing

observations as a level in the income variable. Since the demographics were obtained from

participants only once in year 1, we assumed that these demographics were constant throughout

this study.

Clinical Characteristics

Participants' clinical characteristics were obtained in year 3 and included-1) body mass

index (BMI) calculated as participants' body weight divided by their body height squared

(kilogram/meter2), 2) self-report of whether participants had a usual access to healthcare and

advice, 2) knee pain measured by a short version of the Western Ontario McMasters Universities

(WOMAC) Osteoarthritis Index, 3) depression measured by the Centers for Epidemiologic

Studies Depression 10-Item (CESD-10), and 4) cognitive function measured by the Teng' s

Modified Mini-Mental Status Exam (3MS). Knee pain, Depression and Cognitive function

variables are described below in more detail.

Knee pain

The short version of the Western Ontario McMasters Universities (WOMAC)

Osteoarthritis Index is a valid, reliable, and responsive measure of pain and function in knee

OA(38). The original long version of this index included 17 items addressing the degree of









difficulty in accomplishing 24 activities of daily life in 3 maj or domains-1) pain (=5 items), 2)

stiffness (=2 items), and 3) function (=17 items)(39). The long-version of the WOMAC

Osteoarthritis Index has been shortened to increase its applicability in epidemiologic studies,

clinical trials and daily clinical practices. The procedures used to derive the short version of the

WOMAC Osteoarthritis Index relied on statistical approaches as well as the perceived

importance of the items in the WOMAC Osteoarthritis Index by patients and physicians(3 8). In

this study, we used the short version of the WOMAC Osteoarthrits Index that consisted of a

questionnaire asking participants whether they had pain, aches or stiffness in either knee on most

days of the week for the past 30 days with the following six activities-1) Walking on a flat

surface, 2) Going up or down stairs, 3) at night while in bed, 4) Standing upright, 5) Getting in or

out of a chair, and 6) Getting in or out of a car. Participants rated their pain with each activity by

5-point Likert scale (0-4: from no pain to extreme pain) with a possible score range from 0 to

24.

Depression

The Center for Epidemiological Studies 10-Item Form (CESD-10) is a shortened version

of a long version of the CESD. The CESD-10 is a valid, reliable and responsive measure of

depression(40). In a 1,206 well-functioning older adults in an health maintenance organization,

the CESD-10 demonstrated good reliability with test-retest correlation coefficients ranged from r

= 0.21 to r = 0.84 with an overall correlation of r = 0.71 at an average time interval of 22 days.

Principal component factor analysis demonstrated that the CESD-10 collapsed into two factors of

positive affect and negative affect(40).

In the CESD-10, a study examiner asked participants about their feelings in the past week

as described in the following 10 items: 1) I was bothered by things that usually don't bother me;

2) I had trouble keeping my mind on what I was doing; 3) I was depressed; 4) I felt that









everything I did was an effort; 5) I felt hopeful about the future; 6) I felt fearful; 7) My sleep was

restless; 8) I was happy; 9) I felt lonely; and 10) I could not get going. For each of the 10 items,

the participants were asked how often they had these feeling in the past week in a 4-point Likert

scale from 0 to 3-from rarely or none of the time (<1 day) to most or all of the time (3-4 days).

The CESD-10 has a possible score range from 0 to 30 from no depression to severe depression.

Cognitive function

Teng' s Modified Mini-Mental Status Exam (3MS) is an extended version of the

Folstein's Mini-Mental Status Exam-the most widely used cognitive assessment in clinical and

research settings. The 3MS contains four additional subtests date of birth, place of birth, word

fluency and delayed recall of words. The score of the 3MS ranges from 0 to 100 points from

severe impairment to no impairment, and a modified scoring procedure permitted assignment of

partial credits on some items(41).

Statistical Analyses

First, we performed univariate analyses using summary statistics such as frequency plots,

histogram, tests for location and tests for normality to describe the characteristics of each

variable. Second, we performed bivariate analyses using the chi-square test for categorical

variables and the Wilcoxon rank test or student t-test for numerical variables to compare group

differences by the incidence of TKA. Because none of the continuous variables were normally

distributed, we performed the Wilcoxon rank test for these analyses. We also performed

bivariate analyses to compare the association of participants' characteristics with health literacy.

Third, we performed multivariate analyses using logistic regression to test the relationship of

health literacy with the incidence of TKA.

We performed separate logistic regression analyses using three different health literacy

variables- 1) numerical REALM scores, 2) three-level ordinal health literacy, and 3)









dichotomized health literacy. Because the distribution of the raw REALM scores was

significantly deviated from a normal distribution, we attempted transformation of the REALM

scores using logarithmic and inverse transformation methods. After transformation, the REALM

scores still had a significant deviation from normal. We also performed logistic regression using

the three-level ordinal health literacy, but the model did not meet the conversion criteria and had

a questionable model's validity. When we performed logistic regression using the dichotomized

health literacy, the model met the conversion criteria and had a good model fit. Thus, we used

the dichotomized health literacy in the subsequent analyses.

We used the SAS Statistical Software Version 9.1 (SAS Institute, Inc., Cary, North

Carolina) to perform statistical analyses.









CHAPTER 3
RESULTS

Descriptive Analyses

Overall, the participants (n=889) were 40 % male, 48 % lived in Memphis, 49% had

annual household income less than $25,000, 37 % reported their health status to be very good or

excellent, 56 % Caucasians, 24 % had less than high school equivalency, 97% reported having a

usual source of healthcare and advice and 24% had limited health literacy. The participants had

a mean age of 73.512.9 years, body mass index of 28.515.1 kg/m2, depression score (CESD-10)

of 5.314.5, cognitive function score (3MS) of 9017.9, maximum knee pain score of 6.014.2 and

health literacy score (REALM) of 60. ~111.6. The overall incidence of total arthroplasty (TKA)

in this cohort was 6.9%.

Next, we performed tests for location and normality to describe the frequency distribution

of the participants' characteristics. Specifically, we used skewness, kurtosis, minimum, median,

maximum, the Shapiro-Wilk test and the Kolomogorov-Smirnov test. Table 3-1 summarizes

results of these analyses. None of the numerical variables were normally distributed as

indicated by the Shapiro-Wilk and Kolomogorov-Smirnov tests (p-value <0.01). Particularly,

the health literacy score (REALM) had a significant deviation from a normal distribution with a

median score of 65. It also had a highly negative skewness and positive kurtosis. Based on these

findings, we performed subsequent statistical analyses using non-parametric tests.

Bivariate Analyses

We performed bivariate analyses using the chi-square test and Wilcoxon rank test to

compare the association of participants' characteristics with health literacy. Results of these

analyses are summarized in Table 2. Many of the participants' characteristics were significantly

associated with health literacy. Female gender (p=0.005), Pittsburgh site (p<0.0001), annual









household income of $25,000 or higher (p<0.0001), higher health status, (p<0.0001), Caucasian

race (p<0.0001), higher education (p<0.0001), lower body max index (p=0.0003), higher

cognitive function (p<0.0001) and less severe depression (p<0.0001) were more likely to be

associated with adequate health literacy. Age (p=0.3), having a usual source of healthcare and

advice (p=0.4), and knee pain (p=0.2) were not associated with health literacy.

Next, we performed bivariate analyses to compare the association of participants'

characteristics with total knee arthroplasty (TKA). Table 2 summarizes results of these analyses.

The incidence of TKA varied significantly by the levels of health literacy 8.1% among

participants with adequate health literacy and 1.9% among participants with limited health

literacy (p=0.014). Participants' characteristics such as Pittsburgh site (p=0.0003), Caucasian

race (p=0.05), higher education (p<0.02), higher knee pain (p<0.0001) and higher cognitive

function (p<0.0001) were also significantly associated with the incidence of TKA. Age (p=0.42),

gender (p=0.36), annual household income (p=0.1), health status (p=0.21), having a usual source

of healthcare and advice (p=0.25), body mass index (p=0. 16) and depression (p=0.46) were not

associated with the incidence of TKA.

Logistic Regression Analyses

We performed logistic regression analyses to measure the relationship of health literacy

with the incidence of TKA. Initially, we entered all the participants' characteristics into the

model to test this relationship. According to results of this model, we decided on which

variables would be included in the final model. If the variable had a significant relationship with

TKA (p<0. 1), we included the variable in the final model. We removed body mass index, annual

household income, health status, age, depression and usual source of healthcare and advice from

the final model because they had no significant relationship with TKA. Knee pain, gender, race,

education, school and cognitive function were included in the final logistic regression because










they had a significant relationship with TKA. Additionally, race, education and cognitive

function were highly collinear with health literacy and TKA. Thus, we performed logistic

regression with and without race, education and/or cognitive function to further investigate the

relationship of these variables with health literacy and TKA.

Table 3 summarizes results of the logistic regression analyses. We performed 4 logistic

regression models to investigate the relationship of race, education and cognitive function with

health literacy and TKA. The cognitive function was most collinear with health literacy because

it suppressed the association of health literacy with TKA in the first three models (Models 1, 2

and 3) with no significant association between health literacy and TKA. When the cognitive

function was removed from the model (Model 4), the association of health literacy and TKA

emerged (p=0.03). The association of knee pain and clinical site with TKA remained significant

in all four models.


Table 3-1. Frequency distribution of the participants' characteristics
Shapiro- Kolomogorov-
Wilk Smirnov
Characteri sti cs Skewness Kurtosis Min Median Max. (p-value) (p-value)
Age 0.35 -0.96 67 73 80 <0.0001 <0.01
Body mass index 0.67 0.95 16.8 27.8 52.1 <0.0001 <0.01
Knee pain 1.1 1.14 1 5 24 <0.0001 <0.01
Cognitive function -1.67 5.33 33 92 100 <0.0001 <0.01
Depression 1.05 0.89 0 4 23 <0.0001 <0.01
Health literacy -3.03 9.64 0 65 66 <0.0001 <0.01
n=889











Table 3-2. Relationship of participants' characteristics with health literacy (HL) and total knee
arthroplasty (TKA)
Limited Adequate
HL HL No TKA Had TKA
Characteri sti cs (n=2 13) (n=676) P-value (n=830) (n=5 9) P-value
Age (years), mean & SD 73.6 & 2.9 73.4 & 2.8 0.3 73.5 & 2.9 73.1 & 2.4 0.42


Gender
Male (%)
Female (%)
Site
Memphis (%)
Pittsburgh (%/)
Income
< $25,000 per year (%)
> $25,000 per year (%)
Missing income (%)
Health status
Excellent/very good (%)
Good (%)
Fair or poor (%)
Race
Caucasian (%)
African American (%)
Education
>High school eq.(%)
>College grad.(%)
Have a usual source of
healthcare and advice

Body mass index,
mean & SD
Knee pain, mean & SD

Cognitive function,
mean & SD
Depression, mean & SD
Health literacy
Adequate (%)
Limited (%)
n=889


0.005



<0.0001




<0.0001




<0.0001


0.36


<0.0003




0.10




0.21


<0.0001




<0.0001


0.05




0.02


76 0.4


6 0.25


29.3 & 5.5
6.5 & 4.8


82.4 & 9.4
6.7 & 4.8


28.2 & 4.9
5.9 & 4.0


92.4 & 5.5
4.8 & 4.3


0.003
0.2


<0.0001
<0.0001


28.4 & 5.1
5.9 & 4.1

89.7 &
8.0
5.3 & 4.5


29.2 & 4.3
8.2 & 4.7


93.9 & 4.2
5.2 & 4.8


0.16
<0.0001


<0.0001
0.46


91.9


1.9 0.014











Table 3-3. Relationship of health literacy (HL) with total knee arthroplasty-logistic regression
Model 1 Model 2 Model 3 Model 4
No race No education No race or education No cognitive function
Participants'
character sti cs Estimatei SD p-value Estimatei SD p-value EstimateiSD p-value Estimatei SD p-value
Limited HL -0.4510.29 0.13 -0.4010.29 0.17 -0.4310.29 0.13 -0.6310.29 0.03
Knee pain 0.1310.03 <0.0001 0.1310.03 <0.0001 0.1310.03 <0.0001 0.1310.03 <0.0001
White race --0. 1210. 16 0.46 --0. 1910. 16 0.21
Education
< High school eq. 0.05+0.30 0.36 ---- -0.1210.29
> High school eq. -0.2410.20---- -0.2210.20 0.20
Memphis site -0.4010.16 0.01 -0.4010.16 0.01 -0.3 810. 16 0.016 -0.4710.16 0.004
Cognitive function 0.0810.03 0.009 0.0810.03 0.009 0.0910.03 0.004
-2 log likelihood of
intercept 434 434 434 434
-2 log likelihood
overall 384 385 386 340
C statistics 0.75 0.75 0.74 0.74









CHAPTER 4
DISCUSSION

Significance of the Study

To our knowledge, this is the first study to demonstrate that health literacy is a predictor

of the utilization of total knee arthroplasty (TKA)-an effective surgical treatment for

osteoarthritis (OA) of the knee. Previous literature has demonstrated that socioeconomic,

geographic and clinical factors such as race, education, income, clinical site and knee pain were

the explanatory factors of the utilization of TKA(19;21;3 0;42;43). The reason behind these

differences in the utilization of TKA is not well known. Previous literature implicated a complex

interaction of patient-level factors (e.g. treatment preference), provider factors (e.g. surgeons'

practice style and physician-patient communication style) and system-level factors (e.g. access to

specialist care) as a cause of such disparity(21). However, based on our findings from this study,

we conclude that health literacy is a predictor of the utilization of TKA and has more significant

effect on the utilization of TKA than race, income or education.

Unlike race, education and income that are generally regarded as immutable, health

literacy represents a patient-level factor that can be modified or overcome by providing patients

with an innovative strategy that is tailored to their levels of health literacy. For instance, Weng

and his colleagues have recently developed a decision aid for patients with knee OA, which

consists of an educational videotape(44). This 45-minute video contains evidence-based

information on pathogenesis and treatment options for knee OA including TKA. The video also

included interviews of patients and physicians on why they chose particular medical or surgical

treatment for knee OA. These patient and physician commentaries were supplemented by

graphic presentation of data on treatment options for knee OA. Fifty-four African American and

48 Caucasian patients watched the video in a group setting, followed by a focus group meeting









and follow-up questionnaire. Results of this study showed that before the educational

intervention, African American patients had a significantly lower expectation of pain and

functional improvement after TKA and less willingness to consider TKA than Caucasian

patients. After receiving the educational intervention, African American patients had significant

improvement in their expectation of pain (p=0.04) and marginal improvement in their

expectation of function (p=0.09) after TKA. Caucasian patients had no significant changes in

their expectation of pain or function after TKA. Their willingness to consider TKA did not

change before and after the educational intervention in either the African American or Caucasian

group. Future studies are needed to investigate how a decision aid such as this will influence the

process of decision making for TKA in patients with low health literacy.

In this study, we found that 24% of the study participants had limited health literacy-the

REALM score of 60 and lower. According to the National Assessment of Adult Literacy

(NAAL) in 2003, as many as 43% of the U. S. adult population have a low reading proficiency,

and difficulty reading and understanding most health education materials(45). While

overwhelming evidence indicated that health literacy is a predictor of healthcare use and health

outcomes(22;23), recent evidence suggests that the problem of limited health literacy is often

unrecognized because patients are often ashamed and tend to hide their problem by avoiding

situations that could expose their lack of understanding(22). Wolf and his colleagues have

recently surveyed 313 patients in a general internal medicine clinic and found that limited health

literacy was associated with self-reporting difficulty taking medications, need for help with

health-related reading tasks and difficulty understanding and following instructions on

appointment slips (p<0.001). Among these patients, nearly half (47.8%) of patients reading at

the 3rd-grade level acknowledged having felt shame or embarrassment about their difficulties









reading, compared with 19.2% of patients reading at the 4th to 6th-grade level, and 6.5% of

patients reading at the 7th to 8th-grade level(46). The embarrassment or reluctance of patients to

seek more information and discuss with their doctors may delay decision making for effective

treatment for knee OA(22), which can manifest as the under-utilization of TKA as we observed

in this study.

Role of Cognitive Function in Health Literacy

We also found that participants' cognitive function-assessed by the Teng' s Mini-Mental

Status Exam (3MS)-had a suppressive effect on the association of health literacy with the

utilization of TKA. When the cognitive function was removed from the multivariate regression

model, the association between health literacy and TKA improved significantly. Previous

literature reported similar findings. For example, in a study of 3,260 community-dwelling adults

aged 65 years and older, their health literacy and cognitive function were partly collinear with

their mortality. Health literacy also predicted their mortality independently from their cognitive

function(47). These results suggest that, while the health literacy assessment shares a common

construct with the cognitive assessment, health literacy may also possess a unique construct that

is distinct from the construct of the cognitive assessment.

Dichotomization of Health Literacy

In this study, we performed multivariate regression analyses using a dichotomized health

literacy variable rather than using numerical scores of the REALM. Most statistical literature on

this topic cautioned against dichotomizing a predictor because it will introduce an extreme form

of rounding with an inevitable loss of information and power(48;49). If a normally distributed

variable is dichotomized at the median, asymptotic efficiency relative to analysis using an

ungrouped variable decreases by 35%(49). This means that dichotomizing at the median is

equivalent to losing a third of the data and serious loss of power to detect real relationships.









Literature also suggests that a three-level ordinal variable is a better alternative to a dichotomized

variable in a logistic regression model(50). However, we believe that recommendations from the

statistical literature do not apply to the REALM scores used in this study because the frequency

distribution of the REALM had a significant deviation from a normal distribution with highly

negative skewness and positive kurtosis. To confirm our belief, we performed logistic regression

analyses using three different health literacy variables-numerical, three-level ordinal and

dichotomized health literacy. After performing these analyses we found that the dichotomized

variable had the best result in preserving the relationship of health literacy with TKA with the

most significant p-value (p=0.03). Thus, in this study, we performed logistic regression analyses

using dichotomized health literacy.

Strength of the Study

The strength of this study is that participants were an inception cohort of a large sample

of racially diverse (African Americans vs. Caucasians) and well-functioning older adults at

baseline. This prospective cohort design provided evidence that there is a possible causal

relationship between health literacy and the utilization of TKA. Also, the incidence of TKA was

adjudicated by medical record review, which provided a more accurate account of TKA than

self-reported incidence of TKA.

Limitations of the Study

This study also has limitations. First, the REALM was measured only once at baseline

during this study. The stability of the REALM scores over time has not been previously

reported. However, previous literature suggested that other standardized word recognition tests

similar to the REALM appeared to be fairly stable over time and less dependent on subj ects'

current cognitive function(51). Thus, when we performed the analyses, we assumed that the

REALM score was constant throughout the study. Second, the REALM measures a very narrow









construct of health literacy-the ability to pronounce common medical words correctly.

However, health literacy will require a set of skills that are much more complex than mere word

pronunciation. The REALM has been compared with the Test of Functional Health Literacy in

Adults (TOFHLA)-another common assessment of health literacy. The TOFHLA assesses both

reading comprehension and numeracy skills related to healthcare issues. It consists of a 50-item

reading comprehension test that uses the modified Cloze procedure in which every fifth to

seventh word in a healthcare-related passage is omitted and 4 multiple-choice options are

provided. One of these 4 choices is correct and 3 of them are similar but grammatically or

contextually incorrect. The TOFHLA also contains a 17-item numeracy section that tests a

reader' s ability to comprehend directions for taking medicines, monitoring blood glucose,

keeping medical appointments and obtaining financial assistance(35). While there was a

correlation between the REALM and the TOHFLA(34;3 5), each of these health literacy

measures possesses a unique construct that is distinct from one another(32).

Our study is also limited because the results are not applicable to the general population.

Participants in this study were all healthy and well-functioning older adults at baseline, who

lived in one of two locations-Memphis, Tennessee, or Pittsburgh, Pennsylvania. Furthermore,

participants in this study had a much lower prevalence of limited health literacy (24%) than the

prevalence of limited health literacy in the general U.S. population (43%)(45). High health

literacy among this study cohort could contribute to inaccurate estimation of the incidence of

TKA.









CHAPTER 5
CONCLUSIONS

The role of health literacy in healthcare utilization remains an active area of research

because health literacy relates to patients' decision making capacity. In today's consumer-

minded healthcare system in which shared-decision making is important(21), health literacy may

present an important paradigm in understanding the access to TKA. Interventions to prevent

disability in older adults may be more successful if the role of health literacy is better

understood. Thus, further research is needed to investigate the effect of health literacy on

decision making process for TKA among older adults with knee OA-an important cause of

disability.









LIST OF REFERENCES


1. Hootman, J, Bolen, J, Helmick, C, Langmaid, G. Prevalence of doctor-diagnosed arthritis
and arthritis-attributable activitylimitation. Centers for Disease Control and Prevention-
United States, 2003-2005. 55 (40), 1089-1092. 2006. Atlanta, Centers for Disease Control
and Prevention. MMWR. Available at
http ://www.cdc.gov/mmwr/preview/mmwrhtml/mm5 540a2.htm (Last accessed July, 2008)

2. Centers for Disease Control and Prevention and National Institute of Health. Healthy People
2010. Objectives for improving health. 2008. Available at
http://www. cdc.gov/arthriti s/pub s_docs/healthy_people. htm (Last accessed July, 2008)

3. Jordan JM, Helmick CG, Renner JB, Luta G, Dragomir AD, Woodard J, et al. Prevalence of
knee symptoms and radiographic and symptomatic knee osteoarthritis in African Americans
and Caucasians: The Johnston County Osteoarthritis Project. J Rheumatol. 2007;34:172-80.

4. Oliveria SA, Felson DT, Reed JI, Cirillo PA, Walker AM. Incidence of symptomatic hand,
hip, and knee osteoarthritis among patients in a health maintenance organization. Arthritis
Rheum. 1995;38:1134-41.

5. Dillon CF, Rasch EK, Gu Q, Hirsch R. Prevalence of knee osteoarthritis in the United States:
Arthritis data from the Third National Health and Nutrition Examination Survey 1991-94. J
Rheumatol. 2006;33:2271-79.

6. Guccione AA, Felson DT, Anderson JJ, Anthony JM, Zhang Y, Wilson PW et al. The effects
of specific medical conditions on the functional limitations of elders in the Framingham
study. Am J Public Health. 1994;84:351-58.

7. Buckwalter JA, Saltzman C, Brown T. The impact of osteoarthritis: Implications for
research. Clin Orthop Relat Res. 2004; S6-15.

8. Mahomed NN, Barrett J, Katz JN, Baron JA, Wright J, Losina E. Epidemiology of total knee
replacement in the United States Medicare population. J Bone Joint Surg Am. 2005;87:1222-
28.

9. Kane RL, Saleh KJ, Wilt TJ, Bershadsky B. The functional outcomes of total knee
arthroplasty. J Bone Joint Surg Am. 2005;87:1719-24.

10. Khan F, Ng L, Gonzalez S, Hale T, Turner-Stokes L. Multidisciplinary rehabilitation
programmes following joint replacement at the hip and knee in chronic arthropathy.
Cochrane Database Syst Rev. 2008;CDOO4957.

1 1. Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy
exercise after knee arthroplasty for osteoarthritis: Systematic review and meta-analysis of
randomised controlled trials. BMJ. 2007;335:812.









12. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI
recommendations for the management of hip and knee osteoarthritis, Part II: OARSI
evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137-62.

13. NIH Consensus Statement on total knee replacement. NIH Consensus State of Sci
Statements. 2003;20:1-34.

14. Hawker G, Wright J, Coyte P, Paul J, Dittus R, Croxford R, et al. Health-related quality of
life after knee replacement. J Bone Joint Surg Am. 1998;80: 163-73.

15. Levit, K, Ryan, K, and Elixhauser, A. HCUP facts and figures: Statistics on hospital-based
care in the united states. 2007. Rockville, M.D., Agency for Healthcare Research and
Quality, 2007. Available at http://www.hcup-us. ahrq.gov/reports.j sp (Last Accessed July,
2008)

16. DeFrances CJ, Podgornik MN. 2004 National hospital discharge survey. Adv Data. 2006; 1-
19.

17. Kane, RL, Saleh, KJ, and Wilt, TJ. Total Knee Replacement: Evidence report/technology
assessment. 04-E0006-2, 1-150. 2003. Rockville, M.D., Agency for Healthcare Research and
Quality. Available at http://www. ahrq.gov/downloads/pub/evidence/pdf/knee/ke~d (Last
Accessed July, 2008)

18. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Proj sections of primary and revision hip and
knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am.
2007;89:780-785.

19. Skinner J, Zhou W, Weinstein J. The influence of income and race on total knee arthroplasty
in the United States. J Bone Joint Surg Am. 2006;88:2159-66.

20. Wennberg JE, O'Connor AM, Collins ED, Weinstein JN. Extending the P4P agenda, part 1:
How Medicare can improve patient decision making and reduce unnecessary care. Health
Aff (Mill wood ). 2007;26: 1564-74.

21. Ibrahim SA. Racial and ethnic disparities in hip and knee j oint replacement: a review of
research in the Veterans Affairs Health Care System. J Am Acad Orthop Surg. 2007;15
Suppl 1:S87-S94.

22. Cutilli CC. Health literacy in geriatric patients: An integrative review of the literature.
Orthop Nurs. 2007;26:43-48.

23. Health literacy: report of the Council on Scientific Affairs. Ad Hoc Committee on Health
Literacy for the Council on Scientific Affairs, American Medical Association. JAMA.
1999;281:552-57.

24. Sudore RL, Mehta KM, Simonsick EM, Harris TB, Newman AB, Satterfield S, et al. Limited
literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc.
2006;54:770-776.










25. Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventive health
care use among Medicare enrollees in a managed care organization. Med Care. 2002;40:395-
404.

26. Polacek GN, Ramos MC, Ferrer RL. Breast cancer disparities and decision-making among
U.S. women. Patient Educ Couns. 2007;65:158-65.

27. Guerra CE, Krumholz M, Shea JA. Literacy and knowledge, attitudes and behavior about
mammography in Latinas. J Health Care Poor Underserved. 2005;16:152-66.

28. Kim SP, Knight SJ, Tomori C, Colella KM, Schoor RA, Shih L, et al. Health literacy and
shared decision making for prostate cancer patients with low socioeconomic status. Cancer
Invest. 2001;19:684-91.

29. Guerra CE, Jacobs SE, Holmes JH, Shea JA. Are physicians discussing prostate cancer
screening with their patients and why or why not? A pilot study. J Gen Intern Med.
2007;22:901-7.

30. Skinner J, Weinstein JN, Sporer SM, Wennberg JE. Racial, ethnic, and geographic disparities
in rates of knee arthroplasty among Medicare patients. N Engl J Med. 2003;349: 13 50-13 59.

31. National Institute on Aging. Health ABC Study. 2-16-2008. Available at
http://www. nia.nih. gov/ResearchInformation/ScientificResource/elhB~srpinh
m (Last Accessed July, 2008)

32. Buchbinder R, Hall S, Youd JM. Functional health literacy of patients with rheumatoid
arthritis attending a community-based rheumatology practice. J Rheumatol. 2006;33:879-86.

33. Davis TC, Michielutte R, Askov EN, Williams MV, Weiss BD. Practical assessment of adult
literacy in health care. Health Educ Behav. 1998;25:613-24.

34. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in
adults: A new instrument for measuring patients' literacy skills. J Gen Intern Med.
1995;10:537-41.

3 5. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test
to measure functional health literacy. Patient Educ Couns. 1999;38:33-42.

36. Arozullah AM, Yarnold PR, Bennett CL, Soltysik RC, Wolf MS, Ferreira RM, et al.
Development and validation of a short-form, rapid estimate of adult literacy in medicine.
Med Care. 2007;45:1026-33.

37. Health, Aging and Body Composition Study Group. Hospital Prevalent Disease File
(HPREVDIS.SD2) Analysis file documentation. Version 2.2, 1-8. 11-30-2007. Available at
http ://keeptrack.ucsf.edu/ (Last accessed July, 2008)









3 8. Baron G, Dubach F, Raved P, Loge art I, Doodads M. Validation of a short form of the
Western Ontario and McMaster Universities osteoarthritis index function subscale in hip and
knee osteoarthritis. Arthritis Rheum. 2007;57:633-38.

39. Kuptniratsaikul V, Rattanachaiyanont M. Validation of a modified Thai version of the
Western Ontario and McMaster (WOMAC) osteoarthritis index for knee osteoarthritis. Clin
Rheumatol. 2007;26:1641-45.

40. Schootman M, Andresen EM, Wolinsky FD, Malmstrom TK, Miller JP, Miller DK.
Neighborhood environment and the incidence of depressive symptoms among middle-aged
African Americans. J Epidemiol Community Health. 2007;61:527-32.

41. Tombaugh TN. Test-retest reliable coefficients and 5-year change scores for the MMSE and
3MS. Arch Clin Neuropsychol. 2005;20:485-503.

42. Hawker GA, Guan J, Croxford R, Coyte PC, Glazier RH, Harvey BJ, et al. A prospective
population-based study of the predictors of undergoing total j oint arthroplasty. Arthritis
Rheum. 2006;54:3212-20.

43. Weinstein JN, Bronner KK, Morgan TS, Wennberg JE. Trends and geographic variations in
maj or surgery for degenerative diseases of the hip, knee, and spine. Health Aff (Millwood ).
2004; Suppl Web Exclusives:VAR8 1-VAR8 9.

44. Weng HH, Kaplan RM, Boscardin WJ, Maclean CH, Lee IY, Chen W, et al. Development of
a decision aid to address racial disparities in utilization of knee replacement surgery. Arthritis
Rheum. 2007;57:568-75.

45. Kutner, M., Greenberg, E., and Baer, J. A First Look at the literacy of America's adults in the
21st Century. NCES 2006-470. 2005. Jessup, MD, U.S. Department of Education. National
Assessment of Adult Literacy (NAAL). Available at:
http://nces.ed. gov/pub search/pub sinfo. asp?pubid=2006470 (Last accessed July, 2008)

46. Wolf MS, Williams MV, Parker RM, Parikh NS, Nowlan AW, Baker DW. Patients' shame
and attitudes toward discussing the results of literacy screening. J Health Commun.
2007;12:721-32.









BIOGRAPHICAL SKETCH

Miho Kojima Bautista grew up in Gifu, Japan. After graduating from high school in

Japan, she moved to the United States in 1988, to pursue her goal of developing a career in

medicine. She earned her A.A. degree in nutrition from Broward Community College in Fort

Lauderdale, Florida, in 1990, and B.S. degree in nutrition from the University of Florida, in

Gainesville, Florida, in 1992. Upon her graduation from the University of Florida, she took a

position as a clinical nutritionist with the Halifax Medical Center in Daytona Beach, Florida. In

her role as a clinical nutritionist, she provided nutritional therapy and counseling to acutely ill

patients in the hospital. While she worked full-time at the Halifax Medical Center, she took

courses at the Daytona Beach Community College in Daytona Beach, Florida, to prepare for her

application to medical school.

In August, 1997, Miho entered medical school at Meharry Medical College in Nashville,

Tennessee. Upon earning her M.D. in 2001, she entered residency training in internal medicine

with the University of Florida in Gainesville, Florida. During her internal medicine residency,

she earned an Excellence in Outpatient Care award from the University of Florida Internal

Medicine Residency Program, for her achievement in providing outstanding patient care. On

completion of her internal medicine residency in 2004, she entered fellowship in geriatrics

medicine with the University of Florida. During her geriatrics medicine fellowship, Miho has

successfully competed for and obtained a Geriatric Academic Career Award from the U.S.

Department of Health and Human Services. Such an outstanding achievement afforded her

many wonderful opportunities including an academic appointment with the UF Department of

Medicine and North Florida/South Georgia Veterans Affairs Health System (NF/SGVHS) in

2005, the junior research scholar award from the UF Claude Pepper Older American










Independence Center of Excellence in 2006, and completion of the M. S. program with the UF

Advanced Postgraduate Program in Clinical Investigation in 2008.

Upon completion of her M.S. program in 2008, Miho will continue an academic

appointment as a Clinical Assistant Professor with the UF Department of Aging and Geriatrics,

and staff physician with the NF/SGVHS, Geriatric Research, Education and Clinical Center

(GRECC). Miho has been married to Jun Baldoz Bautista for 12 years.





PAGE 1

ROLE OF HEALTH LITERACY IN TOTAL KNEE ARTHROPLASTY IN OLDER ADULTS WITH KNEE OSTEOARTHRITIS By MIHO KOJIMA BAUTISTA A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2008 1

PAGE 2

2008 Miho Kojima Bautista 2

PAGE 3

To my husband, Dad, Mom, and my brother 3

PAGE 4

ACKNOWLEDGMENTS I express my most sincere appreciation to my supervisory committee chair, Cynthia Garvan, Ph.D., with the University of Florida (UF), College of Education; and my mentors Rebecca Beyth, M.D., M.Sc., and Ron Shorr, M.D., M. S., with the University of Florida, College of Medicine, for their support and guidance. My study would not have been possible without their guidance and support. I w ould like to thank Marian Limach er, M.D., Program Director of the Advanced Post-Graduate Program in Clinical Investigation (APPCI) w ith the University of Florida, for sponsoring my education and being a role model as a successful clinician, educator, and researcher. I am indebted to Marco Pahor M.D., Chair of the Department of Aging and Geriatrics, UF College of Medi cine, for providing infrastructu re and resources necessary in completing this thesis. I truly value Elena A ndresen, Ph.D., with the UF College of Public Health, and Constance Uphold, Ph.D., with the UF College of Nursing, for their time and incredible support to my career de velopment in health services research. I thank Philip Scarpace, Ph.D., and Nihal Tumer, Ph.D., with the UF Co llege of Medicine; and Nannette Hoffman, M.D., and Bradley Bender, M.D., with the North Flor ida/South Georgia Veterans Affairs Health System, for their heart-felt s upport and guidance. I also thank Ms. Eve Johnson, Program Coordinator of the UF APPCI Program, and Ms. Crystal Quirin with the UF College of Medicine, for providing administrativ e support. It is with much love that I thank my parents Masayuki Kojima and Noriko Kojima; and my brother Kikuhiko Kojima for the strength and courage they have given me to pursue my goals in my medical career Finally, I thank my husband, Jun Bautista, for his continued support. 4

PAGE 5

TABLE OF CONTENTS Page ACKNOWLEDGMENTS ...............................................................................................................4 LIST OF TABLES ...........................................................................................................................7 ABSTRACT .....................................................................................................................................8 CHAPTER 1 INTRODUCTION................................................................................................................. .10 Background .............................................................................................................................10 Scope of Problems of Knee Osteoarthritis ......................................................................10 Utilization of Total Knee Arthroplasty ............................................................................11 Role of Health Literacy in Healthcare Utilization ...........................................................12 Statement of the Problem ........................................................................................................13 Specific Aim and Hypothesis .................................................................................................14 2 METHODS...................................................................................................................... .......15 Participants .............................................................................................................................15 Measures .................................................................................................................................16 Health Literacy ................................................................................................................16 Total Knee Arthroplasty ..................................................................................................18 Demographic Characteristics ...........................................................................................19 Clinical Characteristics ....................................................................................................19 Knee pain ..................................................................................................................19 Depression ................................................................................................................20 Cognitive function ....................................................................................................21 Statistical Analyses .................................................................................................................21 3 RESULTS...................................................................................................................... .........23 Descriptive Analyses ..............................................................................................................23 Bivariate Analyses ..................................................................................................................23 Logistic Regression Analyses .................................................................................................24 4 DISCUSSION................................................................................................................... ......28 Significance of the Study ........................................................................................................28 Role of Cognitive Function in Health Literacy ......................................................................30 Dichotomization of Health Literacy .......................................................................................30 Strength of the Study ..............................................................................................................31 Limitations of the Study .........................................................................................................31 5

PAGE 6

5 CONCLUSIONS.................................................................................................................. ..33 LIST OF REFERENCES ...............................................................................................................34 BIOGRAPHICAL SKETCH .........................................................................................................38 6

PAGE 7

LIST OF TABLES Table page 3-1 Frequency distribution of the participants ch aracteristics................................................25 3-2 Relationship of participants characteristic s with health literacy (HL) and total knee arthroplasty (TKA)............................................................................................................. 26 3-3 Relationship of health literacy (HL) with total knee arthroplasty --logistic regression.....27 7

PAGE 8

Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science ROLE OF HEALTH LITERACY IN TOTAL KNEE ARTHROPLASTY IN OLDER ADULTS WITH KNEE OSTEOARTHRITIS By Miho Kojima Bautista August 2008 Chair: Cynthia Garvan Major: Medical ScienceClinical Investigation Health literacy is an important determinant of healthcare utilization. This is thought to be related to inability for an indivi dual with limited health literacy to advocate for his/her healthcare needs. We sought to determine whether health li teracy is associated w ith the use of total knee arthroplasty (TKA)an effective procedure to pallia te an important cause of disability in older adultsosteoarthritis of the knee. Our specific aim was to investigate the associat ion of health literacy with the utilization of TKA among older adults with knee OA. We hy pothesize that older adults with limited health literacy have a decreased utilization of TKA for treatment of knee OA. The study included 889 black and white community-dwelling men and women aged 7079 years participating in the Health, Aging and Body Compos ition Study (Health ABC Study)a 10-year longitudinal cohort study. Participants were recruited in either Memphis, TN, or Pittsburgh, PA. They were all high functioni ng at baseline without dementia, functional difficulties, or life-limiting cancer. Participants took health litera cy (HL) assessment during their clinical visits in year 3, using the Rapid Estim ate of Adult Literacy of Medicine (REALM). They were excluded from the study if they ha d prior history of TKA or having no knee pain, aches or stiffness in either knee for most days of the week in the past 30 days. The REALM 8

PAGE 9

score was dichotomized into limited HL (=REALM score 0-60) and adequate HL (= REALM score 61-66). The incidence of the first TKA surg ery was assessed from year 3 through year 9 of the Health ABC Study. Descriptiv e statistics, chi-square test, Wilcoxon rank test and logistic regression were used to analyze th e relationship of HL with TKA. Overall, participants (n=889) were 40% ma le, 48% lived in Memphis, 49% had annual household income less than $25,000, 37% reported th eir health status to be very good or excellent, 56% Caucasians, 24% had less than high school equivalency, 97% reported having a usual source of healthcare, and advice, 24% ha d limited health literacy. Their mean age was 73.5 2.9 years and body mass index of 28.5.1 kg/m 2 The overall incidence of TKA was 6.7%. The incidence of TKA varied significan tly by HL.1% among persons with adequate HL and 1.9% among persons with limited HL (p =0.0014). We removed body mass index, annual household income, health status, age, depression a nd usual source of healthcare and advice from the logistic regression model because they had no significant relationship with TKA (p 0.1). Cognitive function was also removed from the m odel because it was highly collinear with HL and TKA, and had a suppressive effect on the re lationship of HL with TKA. The significant association of HL with TKA pers isted after adjusting for knee pai n, race, education and clinical site (p=0.03). In this cohort of well-functioning older adults limited health literacy was associated with a decreased utilization of TKA. Future interventi ons to prevent disability in older adults may be more successful if the role of hea lth literacy is better understood. 9

PAGE 10

CHAPTER 1 INTRODUCTION Background Scope of Problems of Knee Osteoarthritis Osteoarthritis (OA)also know n as degenerative joint diseaseis the most common rheumatologic disease that results in significant disability among middle-ag ed and older persons. In 2005, estimated prevalence of OA was 46 million: 1 in 5 adults in the United States(1). Osteoarthritis (OA) placed thir d among the leading causes of di sability in the U.S. with approximately 1 million years lived in disability and $13.2 billion in annual job-related costs due to OA. Because of the considerable impact of OA on public health, the U.S. Public Health Service Healthy People 2010 included an agenda on decreasing health disparity associated with OA(2). The knee is the most common joint affect ed by OA. The estimated prevalence of symptomatic knee OA is 16 % among U.S. adults over 45 years old (18.7% female, 13.5% male) (3), and the annual incidence of symptomatic knee OA is 240 per 100,000 person years(4). Knee OA also results in destruction of the knee join ts, which appears on knee radiographs in 0.9% of U.S. adults(5). Chronic joint pain, aching and stiffness in the knee can cause functional limitation in 40% of knee OA patie nts in performing one of th ese activitieswalking, stair climbing, performing heavy home chores, carryin g heavy objects, house keeping, cooking and grocery shopping. Due to the significant pain and immobility, 14% need assistance in personal care on the daily basis(6). Furthe rmore, knee OA significantly decr eases patients quality of life as 40% of them reported either poor or fair hea lth. With the expected growth of older segment of the U.S. adult population in the future, knee OA will continue to place enormous healthcare and economic burdens in the U.S(7). 10

PAGE 11

Utilization of Total Knee Arthroplasty Among treatment options available for knee osteoarthritis (OA), tota l knee arthroplasty (TKA) is a surgical treatment to replace a diseas ed native knee joint with a prosthetic joint. Total knee arthroplasty (TKA) ranks at or near the top among medical and surgical interventions in its cost-effectiveness as it al leviates knee pain, restores ph ysical function and improves the quality of life in patients with an advanced stage of knee OA(8). Previous studies reported that the effect sizes of short-term and long-term pain and functional outcomes of TKA ranged from 1.27 to 3.91(9). The complication rates are low the mortality rate 0.5%, hospital readmission rate 0.9%, pulmonary embolism 0.8%, wound in fection 0.4%, pneumonia 1.4% and myocardial infarction 0.8%(8). In spite of its clinical benefits, TKA also has significant tradeoffs. The failure rate of prosthetic joints is moderately high% at 10 years and 20% at 20 years after initial TKA. Failed prosthetic joints will require revision surg ery which has higher surgical complication rates than initial TKA(10;11). Although TKA is safer than other orthopedic surg eries(8), TKA is still riskier than any other non-surgical interventions for knee OA. These non-surgical interventions include physical therapy, analge sics and anti-inflammatory me dications that are primarily prescribed to provide temporary re lief of pain and physical functi on with variable efficacy(12). In addition, post-surgical care of TKA requires a prolonged period of intensive physical therapy from weeks to monthsin restoring physical function, which makes TKA an inconvenient treatment option to patients(12). Because of these tradeoffs of TKA, clinical guidelines consensus groups agreed that TKA is indicated on ly at an advanced stage of knee OA in which patients function has declined to an unaccep table level and failed to respond to other nonsurgical treatments of knee OA(12;14). 11

PAGE 12

Despite of these tradeoffs of TKA, the numbe r of TKA performed in the United States has steadily increased over the past 15 years. Between 1993 and 2005, TKA was the second fastest growing reason for orthopedic-related hospital ad missions among Medicare enrollees, with 89% growth in the number of hospital admissions due to TKA(15). It also is the most frequently performed elective orthopedic surgeries in the U.S. with approximately 478,000 TKA surgeries were performed annually, accounting for one-quarter of all orthopedic-related surgeries(16). In 2000, the Medicare spent a total of $3.2 billion on TKA(17). As the aging population grows in the U.S. and the indication for TKA broadens with improved performance of new prosthetic joints and advances in surgical techniques of TKA, the Medicare expenditure for TKA is projected to increase by 6fold in year 2030(18). Because TKA is a common, elective surgery th at contributes to a substantial Medicare expenditure, the utilization of TKA has come under increasing scruti ny. Numerous studies documented considerable racial/ethnic and regional inequality in the utilization of TKA(19). The reason behind the socio-cultural disparity in the utilizatio n of TKA is not well known. However, previous literature implicated a complex interactio n of patient-level factors (e.g. treatment preference), provider factors (e.g. su rgeons practice style and physician-patient communication style) and system-level factors (e. g. access to specialist care ) as a cause of such disparity(20;21). Role of Health Literacy in Healthcare Utilization During the past 15 years, health literacy has emerged as an important patient-level factor that explains the disparity in healthcare utilizat ion(21-23). Health literac y refers to individuals capacity to obtain, process, and understand basic h ealth information and services needed to make appropriate healthcare decisions( 23). A substantial body of eviden ce indicates that inadequate health literacy significantly impairs patients knowledge, understandi ng and decision making 12

PAGE 13

about their own healthcare(22). However, prev ious studies have primarily investigated the association of inadequate health literacy with th e decreased utilization of preventive healthcare services such as influenza vaccination and cancer screening tests for breast, prostate and colon cancers(24-29). Evidence is currently lacking on wh ether there is an association between health literacy and the utili zation of TKA. Statement of the Problem Although the preponderance of evid ence documents that inadequate health literacy impairs patients knowledge, understanding and decision making about their own healthcare, little is known about health literacy s role in the utilizati on of total knee arthroplasty (TKA). Research in this topic is justified at several levels of relevance to the current health care. First, examining health literacy in regards to the utilization of TKA provides a unique heal th services research model because TKA is a preference-sensitive healthcare. According to Wennberg, et al, a preference-sensitive healthcare en tails at least two valid altern ative treatment options and the choice of treatment involves trade-offs. T hus, decision making about preference-sensitive healthcare should be based on patients opinions and values(20). Because having adequate knowledge and understanding about TKA is a pre-requ isite for patients to make an informed decision, health literacy may play a critical role in the utilization of TKA. In todays consumerminded healthcare system in which shared-decision making is important(21), health literacy may present an important paradigm in understanding the access to TKA. Secondly, health literacy is clinically important because it presents an oppor tunity for an innovative strategy to improve patients knowledge, understanding a nd decision making for TKA. Lastly, research is needed to understand the access to TKA in pati ents with limited health liter acy because the majority of TKA surgeries are performed on older patients who commonly use their Medicare benefits to pay for TKA(21;30). Since the dispar ity in the utilization of TKA is related to federal healthcare 13

PAGE 14

expenditures, health literacy has a significant implication to health policy and research on the disparity in healthcar e access to TKA. For these reasons, it is important that health services resear ch be conducted to investigate the role of health literacy in the utilization of TKA. In this st udy, we investigated the association of health literacy in the incidence of TKA among older patie nts with knee OA using available data from the Health, Aging and Body Composition Study (Health ABC Study)-year longitudinal cohort study of older adults. We hypothesize that limited health literacy is associated with the decreased incidence of TKAan effective procedure to palliate an important cause of disability in older adults osteoarthritis (OA) of the knee. Specific Aim and Hypothesis Our specific aim was to investigate the associat ion of health literacy w ith the utilization of TKA among older adults with knee OA. We hypothesize that older adults with limited health literacy have a decreased utilization of TKA for treatment of knee OA. 14

PAGE 15

CHAPTER 2 METHODS Participants Data were available from the Health ABC Studya 10-year longitu dinal cohort study of older adults from 1997 through 2006. This studyf unded by the National Institute of Aging with the National Institute of Healthaims to i nvestigate the epidemiology, demographics and biometry associated with the decline in functional status a nd change in body composition of older persons in transi tion from wellness to frailty(31). In 1997, investigators from the University of Pittsburgh (Pittsburgh, Pennsylvania) and the University of Tennessee (Memphis, Tennessee) recruited 3,075 English-speaking part icipants aged 70 to 79 years from a random sample of white Medicare beneficiaries and all age-eligible African American community residents to participate in the study. All participants were we ll functioning at baseline. The eligibility criteria incl uded self-reporting no difficulty in walking a distance of 400 meters or climbing at least 10 stairs, free of life-threateni ng cancers, independently performing activities of daily living and plans to living in the area for the next 3 years. Of baseline participants, 46% of the women and 37% of the men were African Amer icans. Residents within designated ZIP codes were mailed study brochures and then called on the phone to request st udy participation and assess their functional status. During the annual clinical vis its in year 3 of the Health ABC Study (1999/2000), an inperson clinical assessment of hea lth literacy was performed in 2,512 participants. Of the original 3,075 participants, 563 subjects did not complete health literacy assessment because of lack of an in-person clinic interview (n =418), death (n=107), poor eye sight (n=14), refusal (n=13), withdrawal from the study (n=6), and missing da ta (n=5)(24). Only the participants who completed health literacy assessment (n=2512) were included in the study. Participants were 15

PAGE 16

excluded from the study if they ha d: 1) prior history of TKA (n=29), or 2) having no knee pain, aches or stiffness in either knee for most days of the week for the past 30 days (n=1,594). Eight hundred and eighty-nine participan ts were included in the stu dy. None of the participants (n=889) reported having diagnoses other than osteoarthritis or de generative joint disease for their knee pain. The Institutional Review Board of th e University of Florid a approved this study. Measures Health Literacy The Rapid Estimate of Adult Literacy in Medicine (REALM) was measured during the clinical visits in year 3 of the Health ABC St udy. The REALM is a verbal fluency test that measures the ability to pronounce 66 common medical words and lay terms that adult primary care patients are expected to rec ognize(32). These words are presented in the order of increasing difficulty and syllable length, with one point gi ven for each word pronounced correctly. These words were originally chosen from patient education materials and patient intake forms used in university-based primary care clinics. Item reduction from 125 to 66 words was based on psychometric estimates of item difficulty and disc rimination and the frequency of retained words in written materials given to patients. It has a high concentration of words at lower difficulty levels, which increases its discriminatory power when administered to patients with limited reading ability. Participants are asked to read aloud as many words as they can, beginning with the first word in the first column. When they encounter a word they cannot read, they asked to do the best they can or say blank and go onto th e next word. The raw score is the number of correctly pronounced words with th e dictionary pronunciation taken as the scoring standard(32). The REALM scores range from 0 to 66 from th e lowest to the highest health literacy. Examples of words in the REALM are fat, pil l, exercise, arthritis, medication and obesity. The REALM has a high face validity a nd criterion validity because it correlated well 16

PAGE 17

with three other standardized reading recognition tests 1) the revised Wide Range Achievement Test-Third Edition (WRAT-3) (r= 0.88), 2) the Slosson Oral Read ing Test-Revised (SORT-R) (r=0.96), and 3) the Peabody Indivi dual Achievement Test-Revised (PIAT-R) (r=0.97)(33). The REALM also correlated well with other standardized health literacy tests such as the Test of Functional Health Literacy in Adults (TOHFLA) (r=0.84)(34) a nd the short version of the TOHFLA(35). The REALM has a high test-retest reliability (r=0.99) and in ter-rater reliability (r=0.99) among 100 adults(33). The 66-item ve rsion of the REALM takes 1-2 minutes to complete by personnel with minimal training. Uniform administration and scoring of the REALM was achieved by standardized training a nd direct observation of a subset of test administrations. The raw REALM scores were used to derive U.S. high school grade range estimates(32). The grade level was determined by linear regres sion analysis using the REALM raw scores to predict scores on the Slossan Oral Reading Test -Revised (SORT-R), which is a widely used national standardized test in the U.S. The REAL M scores were categorized into four levels to estimate the reading ability(33;36). The first level (REALM score range: 0 to 18) approximates a reading level of 3 rd grade or less. At this level, particip ants may not be able to read materials written even at or below the 3 rd -grade reading level and may need repeated oral instructions in order to understand most patient education materials that were written at a higher reading level. The second level (REALM score range: 19 to 44) approximates a 4 th to 6 th -grade reading level. At this level, participants may be able to read low-literacy materials, but may not be able to read instructions written on a prescr iption medication label. The th ird level (REALM score range: 45-60) approximates a 6 th to 8 th -grade reading level. At this level, participants may be able to read instructions written on a prescription medi cation label, but may struggle with currently 17

PAGE 18

available patient education materials that are mostly written at or above the 9 th -grade reading level. The fourth level (REALM scor e range: 61-66) approximates a 9 th -grade reading level and above. At this level, participants may be able to read most of the cu rrently available patient education materials. Because of a small samp le size in the first and second levels of the REALM, we combined them to create a threelevel ordinal variable (REALM score range: 0-44, 45-60, and 61-66). The REALM score was also di chotomized into 2 levels by combining the first 3 levels of the original four-level ordi nal variable. We defined the 2 levels of the dichotomized variable as follows: 1) Limited health literacy if the REALM score is 0 through 60, and 2) Adequate health literacy if the REALM score is 61 through 66. Total Knee Arthroplasty The incidence of total knee arthroplasty (T KA) was defined as the participants first hospitalization events due to TKA that they had ev er had in their life. Data on hospitalization events were available in the Detailed Hospitali zation Listing dataset of the Health ABC Study that contains information about hospitalization that resulted in at least an over-night stay in a hospital. The study examiners initially obtained the hos pitalization events from participants during annual in-person follow-up visits and semi-annual phone call contacts with participants. Information on the hospitalization events such as admission and discharge dates, diagnoses and procedures performed during the hospitalization were adjudicated by reviewing medical records. This adjudicated information on the hospitalization was subsequently entered into the Detailed Hospital Listing dataset. At the time of this study, the hospitalization da ta were available from year 1 (1997) at baseline clini cal visits through November 20, 2007, when participants were last contacted(37). In the Detailed Hospital Listi ng dataset, we censored hospitalization events due to TKA if they met two criteria) osteoa rthritis was the primary diagnosis for the hospitalization, and 2) TKA was the primary procedure performed during hospitalization. 18

PAGE 19

Demographic Characteristics Demographics were obtained at baseline in ye ar 1. The demographic characteristics were age, gender, race/ethnicity (Caucasian or African American), e ducation ($25,000 or Missing) a nd clinical site (Memphis, Tennessee, or Pittsburgh, Pennsylvania), and whether they had a usual source of healthcare and advice. There was a large number of missing observations in the annual family income. Because income is an important socioeconomic variable that may aff ect the utilization of TKA, we included missing observations as a level in the income variable Since the demographics were obtained from participants only once in year 1, we assumed that these demographices were constant throughout this study. Clinical Characteristics Participants clinical charact eristics were obtained in ye ar 3 and included) body mass index (BMI) calculated as participants body we ight divided by their body height squared (kilogram/meter 2 ), 2) self-report of whether participants had a usual access to healthcare and advice, 2) knee pain measured by a short versio n of the Western Ontari o McMasters Universities (WOMAC) Osteoarthritis Index, 3) depression measured by the Centers for Epidemiologic Studies Depression 10-Item (CESD-10), and 4) cognitive function measured by the Tengs Modified Mini-Mental Status Exam (3MS). Knee pain, Depression and Cognitive function variables are described below in more detail. Knee pain The short version of the Western Onta rio McMasters Universities (WOMAC) Osteoarthritis Index is a valid, reliable, and responsive measure of pain and function in knee OA(38). The original long version of this i ndex included 17 items addressing the degree of 19

PAGE 20

difficulty in accomplishing 24 activities of daily li fe in 3 major domains) pain (=5 items), 2) stiffness (=2 items), and 3) function (=17 ite ms)(39). The long-version of the WOMAC Osteoarthritis Index has been s hortened to increase its applicability in epidemiologic studies, clinical trials and daily clinical practices. The procedures used to derive the short version of the WOMAC Osteoarthritis Index relied on statistical approaches as well as the perceived importance of the items in the WOMAC Osteoarthr itis Index by patients and physicians(38). In this study, we used the short version of the WO MAC Osteoarthrits Index that consisted of a questionnaire asking participants whether they had pain, aches or stiffness in either knee on most days of the week for the past 30 days with the following six activities) Walking on a flat surface, 2) Going up or down stairs 3) at night while in bed, 4) Standing upright, 5) Getting in or out of a chair, and 6) Getting in or out of a car. Participants rated their pain with each activity by 5-point Likert scale (0-4: from no pain to extr eme pain) with a possible score range from 0 to 24. Depression The Center for Epidemiological Studies 10-It em Form (CESD-10) is a shortened version of a long version of the CESD. The CESD-10 is a valid, reliable and responsive measure of depression(40). In a 1,206 well-functioning older adults in an health maintenance organization, the CESD-10 demonstrated good reliab ility with test-retest correlati on coefficients ranged from r = 0.21 to r = 0.84 with an overall correlation of r = 0.71 at an average time interval of 22 days. Principal component factor analys is demonstrated that the CESD10 collapsed into two factors of positive affect and negative affect(40). In the CESD-10, a study examiner asked participan ts about their feelings in the past week as described in the following 10 items: 1) I was bothered by things that usually dont bother me; 2) I had trouble keeping my mi nd on what I was doing; 3) I wa s depressed; 4) I felt that 20

PAGE 21

everything I did was an effort; 5) I felt hopeful ab out the future; 6) I felt fearful; 7) My sleep was restless; 8) I was happy; 9) I fe lt lonely; and 10) I could not get going. For each of the 10 items, the participants were asked how often they had thes e feeling in the past week in a 4-point Likert scale from 0 to 3from rarely or none of the time (< 1 day) to most or all of the time (3-4 days). The CESD-10 has a possible score range from 0 to 30 from no depression to severe depression. Cognitive function Tengs Modified Mini-Mental Status Exam (3MS) is an extended version of the Folsteins Mini-Mental Status Examthe most widely used cognitive assessment in clinical and research settings. The 3MS contains four additiona l subtests date of birth, place of birth, word fluency and delayed recall of words. The scor e of the 3MS ranges from 0 to 100 points from severe impairment to no impairment, and a modi fied scoring procedure permitted assignment of partial credits on some items(41). Statistical Analyses First, we performed univariate analyses usi ng summary statistics such as frequency plots, histogram, tests for location and tests for normality to describe the characteristics of each variable. Second, we performed bivariate analys es using the chi-square test for categorical variables and the Wilcoxon rank test or student t-test for numerical variables to compare group differences by the incidence of TKA. Because none of the continuous variables were normally distributed, we performed the Wilcoxon rank test for these analyses. We also performed bivariate analyses to compare the association of pa rticipants characteristics with health literacy. Third, we performed multivariate analyses using l ogistic regression to test the relationship of health literacy with the incidence of TKA. We performed separate logistic regression analyses using thre e different health literacy variables 1) numerical REAL M scores, 2) three-level ordi nal health literacy, and 3) 21

PAGE 22

dichotomized health literacy. Because th e distribution of the raw REALM scores was significantly deviated from a normal distribution, we attempte d transformation of the REALM scores using logarithmic and inverse transfor mation methods. After transformation, the REALM scores still had a significant deviation from normal. We also performed logistic regression using the three-level ordinal health literacy, but the m odel did not meet the conv ersion criteria and had a questionable models validity. When we performed logistic regression using the dichotomized health literacy, the model met the conversion cr iteria and had a good model fit. Thus, we used the dichotomized health literacy in the subsequent analyses. We used the SAS Statistical Software Version 9.1 (SAS Institute, Inc., Cary, North Carolina) to perform statistical analyses. 22

PAGE 23

CHAPTER 3 RESULTS Descriptive Analyses Overall, the participants (n=889) were 40 % male, 48 % lived in Memphis, 49% had annual household income less than $25,000, 37 % reporte d their health status to be very good or excellent, 56 % Caucasians, 24 % had less than high school equi valency, 97% reported having a usual source of healthcare and advice and 24% ha d limited health literacy. The participants had a mean age of 73.5.9 years, body mass index of 28.5.1 kg/m 2 depression score (CESD-10) of 5.3.5, cognitive function score (3MS) of 90.9, maximum knee pain score of 6.0.2 and health literacy score (REALM) of 60.1.6. The overall incidence of total arthroplasty (TKA) in this cohort was 6.9%. Next, we performed tests for location and normality to describe the frequency distribution of the participants characteristics. Specificall y, we used skewness, kurtosis, minimum, median, maximum, the Shapiro-Wilk test and the Kolomogorov-Smirnov test. Table 3-1 summarizes results of these analyses. None of the num erical variables were normally distributed as indicated by the Shapiro-Wilk and Kolomogorov -Smirnov tests (p-value <0.01). Particularly, the health literacy score (REALM) had a signifi cant deviation from a normal distribution with a median score of 65. It also had a highly nega tive skewness and positive kurtosis. Based on these findings, we performed subsequent statistical analyses using non-parametric tests. Bivariate Analyses We performed bivariate analyses using the chi-square test and Wilcoxon rank test to compare the association of partic ipants characteristics with health literacy. Results of these analyses are summarized in Table 2. Many of the participants characteristics were significantly associated with health literacy. Female gender (p=0.005), Pittsburgh site (p<0.0001), annual 23

PAGE 24

household income of $25,000 or higher (p<0.0001) higher health status, (p<0.0001), Caucasian race (p<0.0001), higher education (p<0.0001) lower body max index (p=0.0003), higher cognitive function (p<0.0001) and less severe depression (p<0.0001) were more likely to be associated with adequate health literacy. Age (p=0.3), having a usual source of healthcare and advice (p=0.4), and knee pain (p=0.2) were not associated with health literacy. Next, we performed bivariate analyses to compare the association of participants characteristics with total knee arthroplasty (TKA). Table 2 summarizes results of these analyses. The incidence of TKA varied significantly by the levels of health literacy 8.1% among participants with adequate he alth literacy and 1.9% among part icipants with limited health literacy (p=0.014). Participants characteristics such as Pittsburgh site (p=0.0003), Caucasian race (p=0.05), higher education (p<0.02), higher knee pain (p<0.0001) and higher cognitive function (p<0.0001) were also significantly associated with the in cidence of TKA. Age (p=0.42), gender (p=0.36), annual household income (p=0.1), h ealth status (p=0.21), having a usual source of healthcare and advice (p=0.25), body mass i ndex (p=0.16) and depression (p=0.46) were not associated with the incidence of TKA. Logistic Regression Analyses We performed logistic regres sion analyses to measure the re lationship of health literacy with the incidence of TKA. Initially, we ente red all the participants characteristics into the model to test this relationship. According to results of this model, we decided on which variables would be included in the final model. If the variable had a significant relationship with TKA (p<0.1), we included the variable in the final model. We removed body mass index, annual household income, health status, age, depression a nd usual source of healthcare and advice from the final model because they had no significant re lationship with TKA. Knee pain, gender, race, education, school and cognitive function were incl uded in the final logistic regression because 24

PAGE 25

they had a significant relationship with TKA. Additionally, race, education and cognitive function were highly collinear wi th health literacy and TKA. Thus, we performed logistic regression with and without race education and/or cognitive func tion to further investigate the relationship of these variables with health literacy and TKA. Table 3 summarizes results of the logistic re gression analyses. We performed 4 logistic regression models to investigate the relationshi p of race, education a nd cognitive function with health literacy and TKA. The cognitive function was most collinear with h ealth literacy because it suppressed the association of health literacy wi th TKA in the first three models (Models 1, 2 and 3) with no significant association between health literacy and TKA. When the cognitive function was removed from the model (Model 4), the association of health literacy and TKA emerged (p=0.03). The association of knee pain a nd clinical site with TKA remained significant in all four models. Table 3-1. Frequency di stribution of the participants characteristics Characteristics Skewness Kurtosis Min Median Max. ShapiroWilk (p-value) KolomogorovSmirnov (p-value) Age 0.35 -0.96 67 73 80 <0.0001 <0.01 Body mass index 0.67 0.95 16.8 27.8 52.1 <0.0001 <0.01 Knee pain 1.1 1.14 1 5 24 <0.0001 <0.01 Cognitive function -1.67 5.33 33 92 100 <0.0001 <0.01 Depression 1.05 0.89 0 4 23 <0.0001 <0.01 Health literacy -3.03 9.64 0 65 66 <0.0001 <0.01 n=889 25

PAGE 26

26 Table 3-2. Relationship of partic ipants characteristics with hea lth literacy (HL) and total knee arthroplasty (TKA) Characteristics Limited HL (n=213) Adequate HL (n=676) P-value No TKA (n=830) Had TKA (n=59) P-value Age (years), mean SD 73.6 2.9 73.4 2.8 0.3 73.5 2.9 73.1 2.4 0.42 Gender Male (%) 29 71 94 6 Female (%) 21 79 0.005 92 8 0.36 Site Memphis (%) 34 66 97 3 Pittsburgh (%) 15 85 <0.0001 90 10 <0.0003 Income < $25,000 per year (%) 34 66 95 5 $25,000 per year (%) 10 90 92 8 Missing income (%) 30 70 <0.0001 91 9 0.10 Health status Excellent/very good (%) 19 81 Good (%) 21 79 92 8 Fair or poor (%) 37 63 <0.0001 95 5 0.21 Race Caucasian (%) 10 90 92 8 African American (%) 41 59 <0.0001 95 5 0.05 Education
PAGE 27

27 Table 3-3. Relationship of health literacy (HL) with total knee arthroplastylogistic regression Model 1 Model 2 Model 3 Model 4 No race No education No race or education No cognitive function Participants characteristics EstimateSD p-value EstimateSD p-value EstimateSD p-value EstimateSD p-value Limited HL -0.45.29 0.13 -0.40.29 0.17 -0.43.29 0.13 -0.63.29 0.03 Knee pain 0.13.03 <0.0001 0.13.03 <0.0001 0.13.03 <0.0001 0.13.03 <0.0001 White race 0.12.16 0.46 0.19.16 0.21 Education < High school eq. 0.05.30 0.36 -0.12.29 High school eq. -0.24.20 -0.22.20 0.20 Memphis site -0.40.16 0.01 -0.40.16 0.01 -0.38.16 0.016 -0.47.16 0.004 Cognitive function 0.08.03 0.009 0.08.03 0.009 0.09.03 0.004 -2 log likelihood of intercept 434 434 434 434 -2 log likelihood overall 384 385 386 340 C statistics 0.75 0.75 0.74 0.74

PAGE 28

CHAPTER 4 DISCUSSION Significance of the Study To our knowledge, this is the first study to demo nstrate that health li teracy is a predictor of the utilization of total knee arthroplasty (TKA) an effective surgical treatment for osteoarthritis (OA) of the knee. Previous li terature has demonstrated that socioeconomic, geographic and clinical factors such as race, education, income, c linical site and knee pain were the explanatory factors of the utilization of TKA(19;21;30;42;43). The reason behind these differences in the utilization of TKA is not well known. Previous literatur e implicated a complex interaction of patient-level factors (e.g. treatm ent preference), provider factors (e.g. surgeons practice style and physician-patient communication st yle) and system-level factors (e.g. access to specialist care) as a cause of such disparity(21). However, based on our findings from this study, we conclude that health literacy is a predictor of the utilizatio n of TKA and has more significant effect on the utilization of TKA than race, income or education. Unlike race, education and income that are generally regarded as immutable, health literacy represents a patient-level factor that can be modified or overc ome by providing patients with an innovative strategy that is tailored to th eir levels of health lite racy. For instance, Weng and his colleagues have recently developed a decision aid for patients with knee OA, which consists of an educational videotape(44). Th is 45-minute video contains evidence-based information on pathogenesis and treatment options for knee OA including TKA. The video also included interviews of patients and physicians on why they chose particular medical or surgical treatment for knee OA. These patient and physician commentaries were supplemented by graphic presentation of data on treatment options for knee OA. Fifty-four African American and 48 Caucasian patients watched the video in a group setting, followed by a focus group meeting 28

PAGE 29

and follow-up questionnaire. Results of this study showed that before the educational intervention, African American patients had a significantly lower expectation of pain and functional improvement after TKA and less wi llingness to consider TKA than Caucasian patients. After receiving the educational intervention, African American patients had significant improvement in their expecta tion of pain (p=0.04) and marginal improvement in their expectation of function (p=0.09) after TKA. Caucasian patients had no significant changes in their expectation of pain or function after TKA. Their wil lingness to consider TKA did not change before and after the educational interventi on in either the African American or Caucasian group. Future studies are needed to investigate how a d ecision aid such as this will influence the process of decision making for TKA in pa tients with low health literacy. In this study, we found that 24% of the study participants had limited health literacythe REALM score of 60 and lower. According to the National Assessment of Adult Literacy (NAAL) in 2003, as many as 43% of the U.S. adult population have a low reading proficiency, and difficulty reading and understanding most health education materials(45). While overwhelming evidence indicated that health literacy is a predicto r of healthcare use and health outcomes(22;23), recent evidence suggests that the problem of limited health literacy is often unrecognized because patients are often ashamed and tend to hide their problem by avoiding situations that could expose their lack of understanding(22). Wolf and his colleagues have recently surveyed 313 patients in a general internal medicine clinic and found that limited health literacy was associated with self-reporting diffi culty taking medications, need for help with health-related reading tasks and difficulty understanding and following instructions on appointment slips (p<0.001). Among these patient s, nearly half (47.8%) of patients reading at the 3 rd -grade level acknowledged having felt shame or embarrassment about their difficulties 29

PAGE 30

reading, compared with 19.2% of patients reading at the 4 th to 6th-grade level, and 6.5% of patients reading at the 7 th to 8 th -grade level(46). The embarrassment or reluctance of patients to seek more information and discuss with their doctors may delay decision making for effective treatment for knee OA(22), which can manifest as the under-utilization of TKA as we observed in this study. Role of Cognitive Function in Health Literacy We also found that participants cognitive functionassessed by the Tengs Mini-Mental Status Exam (3MS)had a suppressive effect on the association of hea lth literacy with the utilization of TKA. When the cognitive functi on was removed from the multivariate regression model, the association between health liter acy and TKA improved significantly. Previous literature reported similar findings. For exampl e, in a study of 3,260 community-dwelling adults aged 65 years and older, their health literacy and cognitive function were partly collinear with their mortality. Health literacy also predicted their mortality i ndependently from their cognitive function(47). These results suggest that, while the health literacy assessment shares a common construct with the cognitive assessment, health literacy may also possess a unique construct that is distinct from the construct of the cognitive assessment. Dichotomization of Health Literacy In this study, we performed multivariate regression analyses using a dichotomized health literacy variable rather than using numerical scores of the REALM. Most statistical literature on this topic cautioned against dichotomizing a pred ictor because it will introduce an extreme form of rounding with an inevitable loss of informa tion and power(48;49). If a normally distributed variable is dichotomized at the median, asymptotic efficiency relative to analysis using an ungrouped variable decreases by 35 %(49). This means that dichotomizing at the median is equivalent to losing a third of th e data and serious loss of power to detect real relationships. 30

PAGE 31

Literature also suggests that a three-level ordinal variable is a better altern ative to a dichotomized variable in a logistic regressi on model(50). However, we believe that recommendations from the statistical literature do not apply to the REALM scores used in this study because the frequency distribution of the REALM had a significant deviation from a normal distribution with highly negative skewness and positive kurtosis. To confirm our belief, we performed logistic regression analyses using three different health literacy variablesnumerical, three-level ordinal and dichotomized health literacy. After performing these analyses we found that the dichotomized variable had the best result in preserving the rela tionship of health literacy with TKA with the most significant p-value (p=0.03). Thus, in this study, we performed logistic regression analyses using dichotomized health literacy. Strength of the Study The strength of this study is that participants were an inception cohort of a large sample of racially diverse (African Americans vs. Ca ucasians) and well-functioning older adults at baseline. This prospective cohort design provi ded evidence that there is a possible causal relationship between health liter acy and the utilization of TKA. Also, the incidence of TKA was adjudicated by medical record review, which provided a more accurate account of TKA than self-reported incide nce of TKA. Limitations of the Study This study also has limitations. First, th e REALM was measured only once at baseline during this study. The stability of the REALM scores over time has not been previously reported. However, previous literature suggested that other standardized word recognition tests similar to the REALM appeared to be fairly stable over time and less dependent on subjects current cognitive function(51). Thus, when we performed the analyses, we assumed that the REALM score was constant throughout the study. Second, the REALM measures a very narrow 31

PAGE 32

construct of health literacythe ability to pronounce comm on medical words correctly. However, health literacy will require a set of skil ls that are much more complex than mere word pronunciation. The REALM has been compared with the Test of Functional Health Literacy in Adults (TOFHLA)another common assessment of health literacy. The TOFHLA assesses both reading comprehension and numeracy skills related to healthcare issu es. It consists of a 50-item reading comprehension test that uses the modified Cloze proc edure in which every fifth to seventh word in a healthcare-related passage is omitted and 4 multiple-choice options are provided. One of these 4 choices is correct a nd 3 of them are similar but grammatically or contextually incorrect. The TOFHLA also cont ains a 17-item numeracy section that tests a readers ability to comprehe nd directions for taking medici nes, monitoring blood glucose, keeping medical appointments a nd obtaining financial assistan ce(35). While there was a correlation between the REALM and the TOHFLA (34;35), each of thes e health literacy measures possesses a unique construct that is distinct from one another(32). Our study is also limited because the results are not applicable to the general population. Participants in this study were all healthy a nd well-functioning older adults at baseline, who lived in one of two locationsM emphis, Tennessee, or Pittsburgh, Pennsylvania. Furthermore, participants in this study had a much lower prev alence of limited health literacy (24%) than the prevalence of limited health literacy in the ge neral U.S. population (43%)(45). High health literacy among this study cohort could contribute to inaccurate estimation of the incidence of TKA. 32

PAGE 33

CHAPTER 5 CONCLUSIONS The role of health literacy in healthcare ut ilization remains an active area of research because health literacy relate s to patients decision making capacity. In todays consumerminded healthcare system in which shared-decision making is important(21), health literacy may present an important paradigm in understanding the access to TKA. In terventions to prevent disability in older adults may be more successful if the role of health literacy is better understood. Thus, further research is needed to investigate the effect of health literacy on decision making process for TKA among older a dults with knee OAan important cause of disability. 33

PAGE 34

LIST OF REFERENCES 1. Hootman, J, Bolen, J, Helmick, C, Langmaid, G. Prevalence of doc tor-diagnosed arthritis and arthritis-attributable ac tivitylimitation. Centers for Dis ease Control and Prevention United States, 2003-2005. 55 (40), 1089-1092. 2006. Atlanta, Centers for Disease Control and Prevention. MMWR. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5540a2.htm (Last accessed July, 2008) 2. Centers for Disease Control and Prevention and National Institute of Health. Healthy People 2010. Objectives for improving health. 2008. Available at http://www.cdc.gov/arthritis/ pubs_docs/healthy_people.htm (Last accessed July, 2008) 3. Jordan JM, Helmick CG, Renner JB, Luta G, Drag omir AD, Woodard J, et al. Prevalence of knee symptoms and radiographic and symptomatic knee osteoarthritis in African Americans and Caucasians: The Johnston County Osteoart hritis Project. J Rheumatol. 2007;34:172-80. 4. Oliveria SA, Felson DT, Reed JI, Cirillo PA Walker AM. Incidence of symptomatic hand, hip, and knee osteoarthritis among patients in a health maintenance organization. Arthritis Rheum. 1995;38:1134-41. 5. Dillon CF, Rasch EK, Gu Q, Hirsch R. Prevalen ce of knee osteoarthritis in the United States: Arthritis data from the Third National Hea lth and Nutrition Examination Survey 1991-94. J Rheumatol. 2006;33:2271-79. 6. Guccione AA, Felson DT, Anderson JJ, Anthony JM, Zhang Y, Wilson PW et al. The effects of specific medical conditions on the functional limitations of elders in the Framingham study. Am J Public Health. 1994;84:351-58. 7. Buckwalter JA, Saltzman C, Brown T. The impa ct of osteoarthritis: Implications for research. Clin Orthop Relat Res. 2004;S6-15. 8. Mahomed NN, Barrett J, Katz JN, Baron JA, Wright J, Losina E. Epidemiology of total knee replacement in the United States Medicar e population. J Bone Joint Surg Am. 2005;87:122228. 9. Kane RL, Saleh KJ, Wilt TJ, Bershadsky B. The functional outcomes of total knee arthroplasty. J Bone Joint Surg Am. 2005;87:1719-24. 10. Khan F, Ng L, Gonzalez S, Hale T, Turn er-Stokes L. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev. 2008;CD004957. 11. Minns Lowe CJ, Barker KL, Dewey M, S ackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthr itis: Systematic review and meta-analysis of randomised controlled tr ials. BMJ. 2007;335:812. 34

PAGE 35

12. Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, et al. OARSI recommendations for the management of hi p and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16:137-62. 13. NIH Consensus Statement on total knee replacement. NIH Consensus State of Sci Statements. 2003;20:1-34. 14. Hawker G, Wright J, Coyte P, Paul J, Dittus R, Croxford R, et al. Health-related quality of life after knee replacement. J Bone Joint Surg Am. 1998;80:163-73. 15. Levit, K, Ryan, K, and Elixhauser, A. HCUP facts and figures: Statistics on hospital-based care in the united states. 2007. Rockville, M. D., Agency for Healthcare Research and Quality, 2007. Available at http://www.hcup-us.ahrq.gov/reports.jsp (Last Accessed July, 2008) 16. DeFrances CJ, Podgornik MN. 2004 National ho spital discharge survey. Adv Data. 2006;119. 17. Kane, RL, Saleh, KJ, and Wilt, TJ. Total Knee Replacement: Evidence report/technology assessment. 04-E0006-2, 1-150. 2003. Rockville, M. D., Agency for Healthcare Research and Quality. Available at http://www.ahrq.gov/downloads/pub/ evidence/pdf/knee/knee.pdf (Last Accessed July, 2008) 18. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780-785. 19. Skinner J, Zhou W, Weinstein J. The influence of income and race on total knee arthroplasty in the United States. J Bone Joint Surg Am. 2006;88:2159-66. 20. Wennberg JE, O'Connor AM, Collins ED, Weinstein JN. Extending the P4P agenda, part 1: How Medicare can improve patient decision making and reduce unnecessary care. Health Aff (Millwood ). 2007;26:1564-74. 21. Ibrahim SA. Racial and ethnic disparities in hip and knee joint replacement: a review of research in the Veterans Affairs Health Care System. J Am Acad Orthop Surg. 2007;15 Suppl 1:S87-S94. 22. Cutilli CC. Health literacy in geriatric patients: An integrat ive review of the literature. Orthop Nurs. 2007;26:43-48. 23. Health literacy: report of th e Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Sc ientific Affairs, American Medical Association. JAMA. 1999;281:552-57. 24. Sudore RL, Mehta KM, Simonsick EM, Harris TB, Newman AB, Satterfield S, et al. Limited literacy in older people and disp arities in health and health care access. J Am Geriatr Soc. 2006;54:770-776. 35

PAGE 36

25. Scott TL, Gazmararian JA, Williams MV, Baker DW. Health literacy and preventive health care use among Medicare enrollees in a ma naged care organization. Med Care. 2002;40:395404. 26. Polacek GN, Ramos MC, Ferrer RL. Breast canc er disparities and decision-making among U.S. women. Patient Educ Couns. 2007;65:158-65. 27. Guerra CE, Krumholz M, Shea JA. Literacy and knowledge, attitudes and behavior about mammography in Latinas. J Health Ca re Poor Underserved. 2005;16:152-66. 28. Kim SP, Knight SJ, Tomori C, Colella KM, Schoor RA, Shih L, et al. Health literacy and shared decision making for prostate cancer pa tients with low socioeconomic status. Cancer Invest. 2001;19:684-91. 29. Guerra CE, Jacobs SE, Holmes JH, Shea JA. Are physicians discussing prostate cancer screening with their patients and why or why not? A pilot stud y. J Gen Intern Med. 2007;22:901-7. 30. Skinner J, Weinstein JN, Sporer SM, Wennberg JE. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medica re patients. N Engl J Med. 2003;349:1350-1359. 31. National Institute on Aging. Health ABC Study. 2-16-2008. Available at http://www.nia.nih.gov/ResearchInformation/ ScientificResources/H ealthABCDescription.ht m (Last Accessed July, 2008) 32. Buchbinder R, Hall S, Youd JM. Functional heal th literacy of patients with rheumatoid arthritis attending a community-based rheumatology practice. J Rheumatol. 2006;33:879-86. 33. Davis TC, Michielutte R, Askov EN, Williams MV Weiss BD. Practical assessment of adult literacy in health care. Health Educ Behav. 1998;25:613-24. 34. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: A new instrument for measuring patients' literacy skills. J Gen Intern Med. 1995;10:537-41. 35. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literac y. Patient Educ Couns. 1999;38:33-42. 36. Arozullah AM, Yarnold PR, Bennett CL, Solty sik RC, Wolf MS, Ferreira RM, et al. Development and validation of a short-form, ra pid estimate of adult literacy in medicine. Med Care. 2007;45:1026-33. 37. Health, Aging and Body Composition Study Group. Hospital Prevalent Disease File (HPREVDIS.SD2) Analysis file documenta tion. Version 2.2, 1-8. 11-30-2007. Available at http://keeptrack.ucsf.edu/ (Last accessed July, 2008) 36

PAGE 37

38. Baron G, Dubach F, Raved P, Loge art I, D oodads M. Validation of a short form of the Western Ontario and McMaster Universities oste oarthritis index functio n subscale in hip and knee osteoarthritis. Arthritis Rheum. 2007;57:633-38. 39. Kuptniratsaikul V, Rattanachai yanont M. Validation of a modi fied Thai version of the Western Ontario and McMaster (WOMAC) osteoart hritis index for knee osteoarthritis. Clin Rheumatol. 2007;26:1641-45. 40. Schootman M, Andresen EM, Wolinsky FD, Malmstrom TK, Miller JP, Miller DK. Neighbourhood environment and the incidence of depressive symptoms among middle-aged African Americans. J Epidemio l Community Health. 2007;61:527-32. 41. Tombaugh TN. Test-retest reliable coefficients and 5-year change scor es for the MMSE and 3MS. Arch Clin Neuropsychol. 2005;20:485-503. 42. Hawker GA, Guan J, Croxford R, Coyte PC, Glazier RH, Harvey BJ, et al. A prospective population-based study of the predictors of unde rgoing total joint arthroplasty. Arthritis Rheum. 2006;54:3212-20. 43. Weinstein JN, Bronner KK, Morgan TS, Wennberg JE. Trends and geographic variations in major surgery for degenerative diseases of the hip, knee, and spine. Health Aff (Millwood ). 2004;Suppl Web Exclusives:VAR81-VAR89. 44. Weng HH, Kaplan RM, Boscardin WJ, Maclean CH Lee IY, Chen W, et al. Development of a decision aid to address racial disparities in utilization of knee replacement surgery. Arthritis Rheum. 2007;57:568-75. 45. Kutner, M., Greenberg, E., and Baer, J. A First L ook at the literacy of America's adults in the 21st Century. NCES 2006-470. 2005. Jessup, MD, U. S. Department of Education. National Assessment of Adult Literacy (NAAL). Available at: http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006470 (Last accessed July, 2008) 46. Wolf MS, Williams MV, Parker RM, Parikh NS, Nowlan AW, Baker DW. Patients' shame and attitudes toward discussing the results of literacy screen ing. J Health Commun. 2007;12:721-32. 37

PAGE 38

BIOGRAPHICAL SKETCH Miho Kojima Bautista grew up in Gifu, Japa n. After graduating from high school in Japan, she moved to the United States in 1988, to pursue her goal of developing a career in medicine. She earned her A.A. degree in nutriti on from Broward Community College in Fort Lauderdale, Florida, in 1990, and B.S. degree in nutrition from the University of Florida, in Gainesville, Florida, in 1992. Upon her graduati on from the University of Florida, she took a position as a clinical nutritionist with the Halifax Medical Center in Daytona Beach, Florida. In her role as a clinical nutritionist, she provide d nutritional therapy and counseling to acutely ill patients in the hospital. While she worked fu ll-time at the Halifax Medical Center, she took courses at the Daytona Beach Community College in Daytona Beach, Florida, to prepare for her application to medical school. In August, 1997, Miho entered medical school at Meharry Medical College in Nashville, Tennessee. Upon earning her M.D. in 2001, she entered residency training in internal medicine with the University of Florida in Gainesville, Fl orida. During her internal medicine residency, she earned an Excellence in Outpatient Care aw ard from the University of Florida Internal Medicine Residency Program, for her achievement in providing outstanding patient care. On completion of her internal medicine residency in 2004, she entered fellowship in geriatrics medicine with the University of Florida. Du ring her geriatrics medicine fellowship, Miho has successfully competed for and obtained a Geriatric Academic Career Award from the U.S. Department of Health and Human Services. Such an outstanding achievement afforded her many wonderful opportunities including an academic appointment with the UF Department of Medicine and North Florida/South Georgia Vete rans Affairs Health System (NF/SGVHS) in 2005, the junior research scholar award from the UF Claude Pepper Older American 38

PAGE 39

Independence Center of Excellence in 2006, and co mpletion of the M.S. program with the UF Advanced Postgraduate Program in Clinical Investigation in 2008. Upon completion of her M.S. program in 2008, Miho will continue an academic appointment as a Clinical Assistant Professor wi th the UF Department of Aging and Geriatrics, and staff physician with the NF/SGVHS, Geriatri c Research, Education and Clinical Center (GRECC). Miho has been married to Jun Baldoz Bautista for 12 years. 39


xml version 1.0 encoding UTF-8
REPORT xmlns http:www.fcla.edudlsmddaitss xmlns:xsi http:www.w3.org2001XMLSchema-instance xsi:schemaLocation http:www.fcla.edudlsmddaitssdaitssReport.xsd
INGEST IEID E20101222_AAAAAS INGEST_TIME 2010-12-22T10:51:17Z PACKAGE UFE0022677_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES
FILE SIZE 8672 DFID F20101222_AAANEC ORIGIN DEPOSITOR PATH bautista_m_Page_11thm.jpg GLOBAL false PRESERVATION BIT MESSAGE_DIGEST ALGORITHM MD5
5cbc3286d74e3c67e46b660664032b9f
SHA-1
46c8a5d50bf0f78d27a27f0816829c351203dac2
109161 F20101222_AAAMXF bautista_m_Page_30.jpg
a04453369f70e8e1584cdfab5ce8ae13
3c73df53c6169e617c79d118844f6286d6616cc0
534 F20101222_AAANED bautista_m_Page_02thm.jpg
164050c603d11114a4c5c77f177cc81e
3e6cd4b71758ae7792617a7d55d35b50324c9733
107916 F20101222_AAAMXG bautista_m_Page_31.jpg
cffc3d0cd589e6f09ee17c88ebaacbc3
c407dad235cae0b5f82b737cef69ef1d19fe86a4
34526 F20101222_AAANEE bautista_m_Page_15.QC.jpg
9f5f359d898092ac98179f829e0f1248
24b57218f65aab5fb3ad602b9f15fb9d492308e7
39424 F20101222_AAAMXH bautista_m_Page_33.jpg
f7c20eef154e7464a0f5dec026eb8941
79fa933ee12766b9cc92e5d59e1b51d56e3d1f39
35203 F20101222_AAANEF bautista_m_Page_38.QC.jpg
13dde8d1cebf464e18df4befb04de7bd
809f41fc18ecaf53cfe6878165971d29b12aa17d
132833 F20101222_AAAMXI bautista_m_Page_34.jpg
b8dd0a53ec2e29933aeabc9d1761d136
2731fabba35a2e531a4e5bab127e6567d0ee839e
12208 F20101222_AAANEG bautista_m_Page_33.QC.jpg
dbceb7c309063aabfb21bcb1d0b1a018
ff75aa9c430047b6bb75a62a842c8acbf4b554ef
133328 F20101222_AAAMXJ bautista_m_Page_35.jpg
760e9f085b8a307c6260c7c8dac06bf4
1ed315dcfab7fc4465852f7dff5a87912f9883ad
9444 F20101222_AAANEH bautista_m_Page_36thm.jpg
b3fea107c572bece4706cce94be61141
5b83196415c601a5f24822cfe60beb5adaf3134f
111209 F20101222_AAAMXK bautista_m_Page_37.jpg
ea34986b84581cb54b6ab2b349172610
33110f3dfebe8714f5ccdcbc9e7d927bb2733f88
16062 F20101222_AAANEI bautista_m_Page_22.QC.jpg
cae709f97aff078f3ac1547dfa09f5bb
295591b3845050c673bdc165da616f87066811a5
109603 F20101222_AAAMXL bautista_m_Page_38.jpg
02cfd81f2b48322ca202083349a1f925
c79943f86613c43a000a08fdf19d829eede1bda1
4079 F20101222_AAANEJ bautista_m_Page_22thm.jpg
d38d61173b3883c586dcc03950ebb165
f308722147a1eef7afb2c589e5f9eeaa73ae59ea
30300 F20101222_AAAMXM bautista_m_Page_39.jpg
eb5cb1a91f276ee7093f85a6293d97c7
84e441e748e9a14ae559340373bffa59b7270907
250204 F20101222_AAAMXN bautista_m_Page_01.jp2
378eefa43f30c728ff29803d06d1f8e0
7e2b8ef8a911f9b7aec67e09d1376878f2527b58
8089 F20101222_AAANEK bautista_m_Page_10thm.jpg
780e0ddc9e5e100681f138d065b110d0
8c5a7574a8fd059cda5798749406d98539815355
29726 F20101222_AAAMXO bautista_m_Page_02.jp2
5e893d2754e823c16ed0d873c7a31b2f
0522ead182722104b741c3ca8d4d8c486c3bf61a
37866 F20101222_AAANEL bautista_m_Page_18.QC.jpg
e9981f55c326408530c54fc44caa83d4
1c0809d825eca517eed6c56e43a593db5916b553
35621 F20101222_AAAMXP bautista_m_Page_03.jp2
3a5f26c03c7e68529bd17610ba34dca5
021923ab802ac52d86e2f1360b8bdbb11ca27656
9177 F20101222_AAANEM bautista_m_Page_34thm.jpg
476e2ddacd04792e6798acb466b82116
e301c59a791ceec59947cc1c6725c0ce65a2aa8b
18560 F20101222_AAANEN bautista_m_Page_14.QC.jpg
7f1b07b8ff1a2728014a210f8707ac64
a69779fa6239bfe72b8a3f244cdc94aede3f4a23
231284 F20101222_AAAMXQ bautista_m_Page_06.jp2
8befe1efceb2ef22e42eb41625a5abef
1862aea3464a9398ff856a2cac882e276e9b477c
8937 F20101222_AAANEO bautista_m_Page_13thm.jpg
6bef67e14d92a207149bf777bb317a93
5cff08b0f529f79d877e0bc9a7629566fb7cb593
446697 F20101222_AAAMXR bautista_m_Page_07.jp2
23474444c4ff770769fcf012282bd757
8a78d69bb6bdfe48642cbaa0b582f2f05afef80f
33884 F20101222_AAANEP bautista_m_Page_11.QC.jpg
30ecd13a75e1a231ae009bc8761b9568
5c16d7bf1c4b160799ff96ec48d67d3fee033fbf
1051975 F20101222_AAAMXS bautista_m_Page_08.jp2
978eaa096164cea1198d656a1c563ba2
91bab7ff57c93151f6156e9abfea47df562bb5f9
4330 F20101222_AAANEQ bautista_m_Page_06.QC.jpg
8a5ed5f19374ef2495f57b107954b571
faef5a87c8d86b2c014827aedf63c9f1791ebffc
1051979 F20101222_AAAMXT bautista_m_Page_10.jp2
6ee6345df97905bff95e79cb51ae12e1
5a31d311724a1ad181b7b75f5f3b0141eca06718
3226 F20101222_AAANER bautista_m_Page_33thm.jpg
33e69a60b0c7660be83caa02f5fd3207
d32048ac8324433af930bacc18390463289dc7bd
1051955 F20101222_AAAMXU bautista_m_Page_11.jp2
87d472411f3535a10970d224fcc70621
c22815940829ba858c4109fda51464d3d690f000
33050 F20101222_AAANES bautista_m_Page_04.QC.jpg
a4feea2757b7999e6979e81228482c9c
c72c0c2c4e7daf07a95e18e7d1292afe18f87941
1051978 F20101222_AAAMXV bautista_m_Page_12.jp2
a6a29a36cce32aaf3d244baf40543df5
7c2f45165c31ace5946b617b5bb94dd18ec93cc5
8610 F20101222_AAANET bautista_m_Page_28thm.jpg
190fd1a9ec03cd0ceea90317366279cc
52b5829445b9289f7be32bf3f8961ac02ca62251
1051981 F20101222_AAAMXW bautista_m_Page_13.jp2
868a8a919aeb84d1d405dba132bfd1e8
158a2044fdd7bc90a809081cd80610f1b4504fab
30562 F20101222_AAANEU bautista_m_Page_37.QC.jpg
8698ec86361cfe5aa8ba9dc21ed0fa30
12d4ed4c177d3f78666f02bdbee7233ebfa6d42d
625301 F20101222_AAAMXX bautista_m_Page_14.jp2
75788a8bfe1f0a5876c8490dbb341c75
03701f420aab8c3d027af7316a2b89e2d84ac364
35219 F20101222_AAANEV bautista_m_Page_21.QC.jpg
c0bc56c778e70aa37c74400e3ac91301
9d0749382e794749fc53129f4d9b96b6b98c5349
1051953 F20101222_AAAMXY bautista_m_Page_15.jp2
2823bab8a661fbb7bcd3e72fe0cbbd37
252338bea3cf226234ef83e9e6332767c998819a
8790 F20101222_AAANEW bautista_m_Page_38thm.jpg
da0ab1ed44df489b23a7806c8708a166
9a9f79b2d1ce7f53ba4589e8462862237d72f334
65159 F20101222_AAAMVA bautista_m_Page_34.pro
26a29362c8aed01192c07415389d1f89
a0120c7198f714d1efbff3f92c6c66e21093cc29
1051909 F20101222_AAAMXZ bautista_m_Page_16.jp2
c57e185f22194723c74616df492cc245
69fc0c91b45b292f3770b946c57684aafa404b36
9779 F20101222_AAANEX bautista_m_Page_35thm.jpg
630923b958c9ff65813cf38e23e72617
3e74f1ca3cae5c25a18e6386e0076be28cafea96
140600 F20101222_AAAMVB bautista_m_Page_36.jpg
a8b020046acf072868b6a6d02f242859
3c8d87b79ce38fc0affc2f647bab572c9f44e3d9
33314 F20101222_AAANEY bautista_m_Page_23.QC.jpg
ae74ad25574110f617bb883606607802
29530715ee349ad2730c1459c98b88295a61ebb3
7910 F20101222_AAAMVC bautista_m_Page_07.QC.jpg
bb678eb24dd5ecda8bfe3e03d2bd4883
a206252608a5942e0d64d5b97edf041d38870255
2239 F20101222_AAANCA bautista_m_Page_18.txt
bcab9e71d0086b6179f6975a0a048610
bb49b8faa05c7117ff41443a9f50b775fd4ed746
39185 F20101222_AAANEZ bautista_m_Page_36.QC.jpg
c7eab6aef8d3cd193eae0161108acd6d
ba264fc4840625577bbfaca710a48d9ca3845696
24289 F20101222_AAAMVD bautista_m_Page_26.QC.jpg
9e4336c40e5bbe54668de5c1574320fa
61e9bb6693842177bdea520f6e7d7dfdf400fd44
1938 F20101222_AAANCB bautista_m_Page_19.txt
20727c3ddc81c71149a81b7dc6db1756
10341506fa0746eab42569b04f63d697b467e36f
765711 F20101222_AAAMVE bautista_m_Page_26.jp2
ed7658d3cbf403fc330920445177abf1
c1db3d55a6cb764a9f161dd03b5ccde6bb105d9e
2138 F20101222_AAANCC bautista_m_Page_20.txt
047f3cd4e7090da52fae1c8584ef8fcc
64bbe05262293d8529c82940cc4cd14f7a55a15e
7586 F20101222_AAAMVF bautista_m_Page_06.pro
27a2c4da5f2d97dfd174c50e2de4f9a5
073b57525bafac46c2cf13de14b37dfdd7a7408d
2130 F20101222_AAANCD bautista_m_Page_21.txt
5d229c078eda5b891a62621d13756c65
5ad0bd2b0669ebeec177b5597dcaf460ad38b42e
74602 F20101222_AAAMVG bautista_m_Page_26.jpg
a9302f813ce115162f50d2383e9faf2e
8562ab867e54cd7c18177cd8c9a2d4d06047a4e1
892 F20101222_AAANCE bautista_m_Page_22.txt
fddbba92680ce92e10f55c7ec2db3d24
51430c7dd72d5f4b20edd239b9a0415b800bbe0b
2083 F20101222_AAAMVH bautista_m_Page_38.txt
e446a838da477e33ffb6271d4294eea2
672c3815c36c025146afeca69058ef67a012308d
2082 F20101222_AAANCF bautista_m_Page_23.txt
5212b73c3d08146ce0146fe6dfe2f027
f6f54f9fb3d52edd9ff6fdbb93ea62be97f2be45
467 F20101222_AAAMVI bautista_m_Page_01.txt
a1a510d956549d49ec447f7d9a997d9e
fe67ec459016fa36d735600fc94dd9ba58ce90b0
1673 F20101222_AAANCG bautista_m_Page_25.txt
3ea20676af7ad660fe81bcb861c184b4
015cc2e526b98fa78429a992c940cec35319d946
1051970 F20101222_AAAMVJ bautista_m_Page_05.jp2
df4da2d7489e2b7900c897678862a8b0
9c39f6725bd4e2e87192d78cec179ab5f8c09218
1500 F20101222_AAANCH bautista_m_Page_26.txt
4a79c460252045863ca6bde698c6b873
1278bc4eb94acc98261c22b3540ec5c235a6dc5f
38910 F20101222_AAAMVK bautista_m_Page_25.pro
9c15eecdcb58370e93434454aa25b5bc
2b63388431adaaf5f32b9e533207c5fb5344fe95
1099 F20101222_AAANCI bautista_m_Page_27.txt
277b7d2f67cda789cf3ab6cac5d557ca
b9441f0714a9647a77b9d36435d36ecf82113926
25271604 F20101222_AAAMVL bautista_m_Page_38.tif
bcb7e668ffee1690d34424fa6b684f9b
a22a9d216bacc0593cde2909bb3f0c65b59cd8d8
2196 F20101222_AAANCJ bautista_m_Page_28.txt
5af667608813f7c6422ed4de7dcb2bf4
b9f1ce153eb3c934072c02488811ca4654ecdc22
1022840 F20101222_AAAMVM bautista_m_Page_09.jp2
997b25d9b66dfc898bbf40f11300b3f6
afdefe1d2961d0f66200ec3cc9a98baa494fe392
2179 F20101222_AAANCK bautista_m_Page_29.txt
c0fc9560b3944c0bdebee4ed4f47e656
901f8ca14609cdba6f7233ef6b894728cd6c411f
F20101222_AAAMVN bautista_m_Page_10.tif
d86c2e7a40a42071a0c5624548adb3ac
7746db700d0d50b0dcb3c6d3164da19233836f0b
2184 F20101222_AAANCL bautista_m_Page_30.txt
210a7456d7a414581440906126f3363f
7a128963c595912537f89ae14e4d52d0d0045a07
2145 F20101222_AAANCM bautista_m_Page_31.txt
f90f11340525d63332542afadcec3c3c
d2ddce7a8945126af9938d319f9cb140cc8cb67a
26714 F20101222_AAAMVO bautista_m_Page_07.jpg
3523b9ce80c1a45d4e90e3812070d713
bf6d652d6ccfaa911be6afcb61b392bb52f9787b
1803 F20101222_AAANCN bautista_m_Page_32.txt
21c09a906e1541822a6b907c010a1921
5bbb80bd308350be951f4dbcc1be8ad1a0130b70
94192 F20101222_AAAMVP bautista_m_Page_32.jpg
cc5273c7661a809bd7381e33f344f234
aaace8d9dafac9e2f0690bba1d876496bcb89ba0
795 F20101222_AAANCO bautista_m_Page_33.txt
bc817a611a6dc4c69c5da996bde5710e
a6cae9112e7af1ceaa981264614e05de808eec93
2231 F20101222_AAAMVQ bautista_m_Page_24.txt
0df26ecea035de6724eedf0b95b7a4b7
1cfa2f15374ff48ba05ecada447a67c674d02765
2590 F20101222_AAANCP bautista_m_Page_34.txt
d22018a921a1cf6713414c3bbe6c2f63
be34ee2de2f100b0dda619db2a3fd65c98409e6c
F20101222_AAAMVR bautista_m_Page_05.tif
b792d25a0c27d33bac768562bd22736a
a7d1922a599692e011ca00ce6b8120ed41c7fa09
2597 F20101222_AAANCQ bautista_m_Page_35.txt
0cae767f372b0f41e8ed40681ed078e1
daab929e384f683e0261194fb2bc43195ea4b500
987 F20101222_AAAMVS bautista_m_Page_02.pro
b9f3d6db79953486d7add27251e976d0
ddb146eaf3b8e83290798d0caee0da1fa538fc5d
2491 F20101222_AAANCR bautista_m_Page_36.txt
9a5e2f0ce834642462dca6ebb9d38ca6
72a387daf379ead2fa609033c0dabeb5064c2fd1
F20101222_AAAMVT bautista_m_Page_17.tif
0ae26b614b898eae465cf5ddf88294a5
c3f55c80ae810c9bca3f8f5c00622b51262fea52
2070 F20101222_AAANCS bautista_m_Page_37.txt
a9428a3916d01c5dce89211be321f68b
2490a531a8946025f4d91a4d7945bb3acb5ed9f9
2166 F20101222_AAAMVU bautista_m_Page_12.txt
5cbfc8b74c6e96266eb7675d6e65ea6c
cfad17cafeebe8ad4e22daa56477ffcc9e8fe499
523 F20101222_AAANCT bautista_m_Page_39.txt
cbc6605a0439859f51d5d5f168e5c5c4
54b3e5b5d53862ac94bbb813f6a5869145a8d62a
1051961 F20101222_AAAMVV bautista_m_Page_04.jp2
7b023c31e5e22701badb12ac7521ac65
5cb3cccc1861662cc8e093aac06e224366c806c5
2230 F20101222_AAANCU bautista_m_Page_01thm.jpg
7ef279f8a16afeaaba5798e81f0d995d
b48da249f9452fa5808a16e2d1378d0ca12bfab4
47281 F20101222_AAAMVW bautista_m_Page_04.pro
176f3daa83c720f99b6d1b4e12611fed
8ef69d581f612a1890eb97136ad71192b55eb491
6918 F20101222_AAANCV bautista_m_Page_25thm.jpg
1577890e97f3e79c8429ae6f4c11699a
5a8d6549a1c8998ba7f4f28afe9cc0b288466120
225087 F20101222_AAAMVX bautista_m.pdf
92df508a2a4e2100676a0a865b5a7d11
f1e9980ff2c880cf759d731fe36387d4333c5872
37173 F20101222_AAANCW bautista_m_Page_16.QC.jpg
d07666888b5d8e442812b68a3be4d693
2ede75e5b92df9bcca6cf1c4fb546bad6e173766
27363 F20101222_AAAMVY bautista_m_Page_25.QC.jpg
1c32f2784e366fd4b4f846602919c8a1
41f061ccd00d6fab79ad00d1ea3ad1731c7d736f
8336 F20101222_AAANCX bautista_m_Page_19thm.jpg
15a344f3a76d039f308e6fb93cebc61c
0578cbc895f0ea277deb55921f63400f9560f2e5
F20101222_AAAMVZ bautista_m_Page_19.jp2
a7a2f62d4bddee4e14e44b0cd1a76642
bc09afc98af90093e5ad46b0ba2157dec89d2f13
2542 F20101222_AAANCY bautista_m_Page_39thm.jpg
cb0066bd676c1067b9bbb490d8ac1eae
6cebb6dd8ce5148dc6ac0004c509214e58a66a0d
4912 F20101222_AAANCZ bautista_m_Page_14thm.jpg
17dc34650400974b16ffc06ebe3f208f
9b663684b06769e08a68f22f3e56c22031cc838c
1051951 F20101222_AAAMYA bautista_m_Page_17.jp2
7445036e335bd63a537b752e8971af1c
6f13061dbf2de3d61fa8a11997f3208d8479aac8
F20101222_AAANAA bautista_m_Page_35.tif
af0393d8eccc516040e10875d813686d
0ea25b08ff076584ecaea3321ffd2dff16545006
1051931 F20101222_AAAMYB bautista_m_Page_18.jp2
b914b5ebf93ed0e521957be0e3ab94fa
425a14c08c5f809aaded14d6aee7eea31478011a
F20101222_AAANAB bautista_m_Page_36.tif
4919afae18b02a6e253eecf322194d8e
30bc4f75d9a153017ef0cd5e498c0f631293efe1
F20101222_AAAMYC bautista_m_Page_20.jp2
034c009e303e261472c9d4d75d321b9c
649733795460c56848fcd26637cce75b05361773
F20101222_AAANAC bautista_m_Page_37.tif
5f78add086edec4b20fb2f01ed9e3220
bbb2f93e054381b7b4dedcdf6887d71965d041ea
22930 F20101222_AAANFA bautista_m_Page_05.QC.jpg
4eeb1188affd767054c3af02a8bc52cf
452a17047349bd8403e082d1bcab4a1eb0e26be9
1051971 F20101222_AAAMYD bautista_m_Page_21.jp2
bf612f13e2a71d4117fe445e6f0d196b
bb060123f515ba2f65a02a8b7c5206800498c4b9
F20101222_AAANAD bautista_m_Page_39.tif
1a87e1c5a2a449c3edcf4741716bd2f6
069e0f89b72cf180947cfc74f746fc3a1d61ad74
5850 F20101222_AAANFB bautista_m_Page_05thm.jpg
47e80b7ce8f7eca8580f46015d530ca8
65b93d398462888e53608221a7b4d88c814c724f
512256 F20101222_AAAMYE bautista_m_Page_22.jp2
4481601c4144e531c688b60597b98aec
505cf4433c715deec2c6ab32711f1040f4c5d893
8429 F20101222_AAANAE bautista_m_Page_01.pro
10af5bfeee7f67ce19cfa512c1ad6229
851a82ef437d2757c2244be4701cb6056679fed1
2389 F20101222_AAANFC bautista_m_Page_07thm.jpg
e6c6576e5b21750df876b647e7ec520e
7b64a41e963de598dc075af5b3cbf4879b774925
F20101222_AAAMYF bautista_m_Page_23.jp2
42e5b079bc806f5406c97f20fab7b96c
019373263cdef8d4ba8564bcb60a00fd868120ae
1299 F20101222_AAANAF bautista_m_Page_03.pro
d5d933fbd6f3dede8005e95f27f401e5
6ca1bc1fe89025b1ced4172e27f62cfb01763831
9065 F20101222_AAANFD bautista_m_Page_29thm.jpg
539f2bdbb3b1ef57720f827fc4cdedd6
2270561e71fb3622568d575a194d962860f54f19
1051950 F20101222_AAAMYG bautista_m_Page_24.jp2
c021ea9dd2808cf75b26ec890d214e62
a92d8f34b2b6bf5f024c1ddc5eb349fc5543c545
70670 F20101222_AAANAG bautista_m_Page_05.pro
82c05f6387086086f96ee1760cf15121
6118f8ba6bc3aa51eb49970562dbf7b763d5d16d
1265 F20101222_AAANFE bautista_m_Page_02.QC.jpg
982d58b9f6862ed55c34511a157202de
516b1badb86e3d3ded8cc7faa39753217d00035a
890762 F20101222_AAAMYH bautista_m_Page_25.jp2
c5fc1510cf796546d885809afa1ba9a2
1a4a6ea4ef50e5c76374be0e86b540e4d43bc0ed
10114 F20101222_AAANAH bautista_m_Page_07.pro
270d3d0f0fb378a64083cdda549c9500
8f26daae7c7f2e24a2d5da4ca64355dad6789551
36205 F20101222_AAANFF bautista_m_Page_30.QC.jpg
3ce05340af44b872064d7ee9280bb271
6539c2d06377dd8545780148b45ee53ee60d9ea6
552659 F20101222_AAAMYI bautista_m_Page_27.jp2
83919ceba57ee511a6d2df2cbd422788
04ccb31549bfdf66e270dfa88d19c691df0dd285
47237 F20101222_AAANAI bautista_m_Page_08.pro
43ffbea36070cbb825df9d35c43fbb69
5b8e7eb24f74bc2530b53a17e4a03b660f432bed
32989 F20101222_AAANFG bautista_m_Page_10.QC.jpg
aad2e4c9a3aec576de473f9a20e39e6c
be0063a12ce1c18cd0867a771a55f1d5df222a4d
1051947 F20101222_AAAMYJ bautista_m_Page_28.jp2
6767788513bd2d2a4d3c282e92db419e
e0bdc83f44d42211c130f9c9d717c5da66f3cbcf
44900 F20101222_AAANAJ bautista_m_Page_09.pro
16acd77d3a95f4c73918f349436eceb3
d7de0cf97a19cdec09eb0fb3f3a81c59108d2817
36511 F20101222_AAANFH bautista_m_Page_17.QC.jpg
fb191be5423ca9c9509164a27c886d80
98c67db7d2e139820476dc422d4d56c3b576eba2
1051969 F20101222_AAAMYK bautista_m_Page_29.jp2
84c4b2a73e9817abfb9dde80b4531039
69c33b5803897ac582b5153d7291bd940fee63b2
47482 F20101222_AAANAK bautista_m_Page_10.pro
45d27341a318d3643b174f2e9821100a
24636e039d0f93671d83118558540668ae0acfd5
9206 F20101222_AAANFI bautista_m_Page_17thm.jpg
e56a08ca8c8a882a2ff598c1c9132ea9
522f9090a2b58820de8458b6d30d8d1aa1ff4856
F20101222_AAAMYL bautista_m_Page_30.jp2
0f7a493ada6de688f366efa7a6b703a4
e3a1b10c8da137d5b651f2b65bc4542777b8e40c
52382 F20101222_AAANAL bautista_m_Page_11.pro
6380ee015eaa9b0acd31be288e9a2fa4
95673265a20dad9d5cef701e814b648b28aa2e9f
7409 F20101222_AAANFJ bautista_m_Page_32thm.jpg
ae6d990788270076cb5d4570582bf3d9
90c3319c9e7a55b018ada470c038fd3d44f9ea7a
1051976 F20101222_AAAMYM bautista_m_Page_31.jp2
8914457c59ed9c673030604d0cb95331
1152a6c071be441d6cfcd0dfd05742375ca078bd
55109 F20101222_AAANAM bautista_m_Page_12.pro
dea9f772300d486c80140e062cbd4cb3
59e0ce01f4fadd1141504893cf273641b2321b4f
9084 F20101222_AAANFK bautista_m_Page_24thm.jpg
c19eb93674f7db85240c15e4664574f7
fe466da857f0983213b30b290dcdea083c76e906
1021786 F20101222_AAAMYN bautista_m_Page_32.jp2
7f1df91313aefc1c39116749fdc7203c
7ce0b60e4bb02c8c620b3e16ecf448e24b43abaf
57028 F20101222_AAANAN bautista_m_Page_13.pro
49230f30504a2850e7d80d432df64622
9bdbb7ac83d2208efd40393984f1d509f6926992
35275 F20101222_AAANFL bautista_m_Page_31.QC.jpg
4d12c43d1d51fcfa1b6fbbad42115759
5bfe5566124212b31c225741a6b58b4fd79d78a4
410562 F20101222_AAAMYO bautista_m_Page_33.jp2
76220c53265dd18cf06d789a5407554a
5cf11d40099d11ffb508f00348d4c33a11f264e4
27635 F20101222_AAANAO bautista_m_Page_14.pro
192af01bee22fa26e163a1a67707db6c
6310caf61a26dbe0b4231049b693184f4456ed04
8509 F20101222_AAANFM bautista_m_Page_21thm.jpg
7b688863e8f92e6fedc85a1b090bb8fb
0293d63d937e4590f1f6cf7f4894eefac3d3ff4a
1051972 F20101222_AAAMYP bautista_m_Page_34.jp2
e0309c329669e7f4d2985aff9f9a2155
510c6cb356cda2002627fbd34105aa3216e9beb8
51282 F20101222_AAANAP bautista_m_Page_15.pro
1f0ec812f46e241629a094f617b1ad54
92e74a7c2aec7ab0e5079e581c92c26a917d6fec
62512 F20101222_AAANFN UFE0022677_00001.xml FULL
3362d79efe2e13177d10df7bc01329ab
49942e106d4c69f09155b9443c4751711cd8307e
1051944 F20101222_AAAMYQ bautista_m_Page_35.jp2
e71f6c460342afeadaa355824539aa41
8ffbc221986eaccad431d965d929573f48afbaf3
55483 F20101222_AAANAQ bautista_m_Page_16.pro
8014f6bc4949f6694e4c534f67bfe6a5
756ac27af54a5a0305c845f03be7c71d89e9e5ef
7888 F20101222_AAANFO bautista_m_Page_08thm.jpg
38ec45e446824f650bae0a5c7d88cf91
ce4e7fa6a59f0b65aedaa8f59a9f66ce552bea4e
54662 F20101222_AAANAR bautista_m_Page_17.pro
f0c4703d5c1e17c1eb9f3a3051b23bfc
0f6acb15d46f81e8de020d2ebd5cc23a42bf36df
36825 F20101222_AAANFP bautista_m_Page_20.QC.jpg
7174cd948ec46788037f39bfbc18d1c5
002a148d9e93b0b838e02f1b0456fb46192238ef
1051973 F20101222_AAAMYR bautista_m_Page_36.jp2
324970d00e06565a60af67d9b5ce8ee3
50b13a43f097ec2916e6dff6d907fecb9bc56972
57264 F20101222_AAANAS bautista_m_Page_18.pro
9e4b48782b09deb7ec9608fea49238b2
a3043853dae0fece4a5bd9d16df633a728fa86e1
8971 F20101222_AAANFQ bautista_m_Page_30thm.jpg
35dc7088b8d953a0c4b2f2a3ff0139e2
42d5900c44126f143a89117357fce43393dbb849
F20101222_AAAMYS bautista_m_Page_37.jp2
b93bbc231214282189253baee98b3762
63db8592a489ee2481e34b8ef7486a2e78541bda
48763 F20101222_AAANAT bautista_m_Page_19.pro
00d7ff37e21079396e26db9b74635a34
ed25eab64885497e2d951b095d097150387b656f
7637 F20101222_AAANFR bautista_m_Page_37thm.jpg
3866ebe52179916a2bd18850cd5fa21c
ad406cfc2a050bb833c0106be7e5f8af5c723b2e
F20101222_AAAMYT bautista_m_Page_38.jp2
d66bbf10c06dd3b3d84ab1c982744a61
b6179f88c172dd279f1900b9c38ddf5d9b828987
54346 F20101222_AAANAU bautista_m_Page_20.pro
3b01185a911d237aa0c0fd547c01955b
0682528674a6d39ff7542fe0307c65118315fab2
308686 F20101222_AAAMYU bautista_m_Page_39.jp2
d182e9c731cde8d5e84f3683e8c15a5d
b85d521b08ab11f18150ba638bdabc772dfcd9b2
53016 F20101222_AAANAV bautista_m_Page_21.pro
e5cd117543bf41ba4b30bacf0270d1fe
eff72fe69b4096fda060fee3092649b7a8fe8594
F20101222_AAAMYV bautista_m_Page_01.tif
c6bd5cfdca55fa5e7eda8a008815a11c
1ddd1b463ee6b66c23e0ae24e2d65dfa6c28cfb7
22287 F20101222_AAANAW bautista_m_Page_22.pro
b1a668b39d494bce9d1a15fe46935953
eca7a30a0286cc5546ccd3cccb79ced2e4bc4b1f
F20101222_AAAMYW bautista_m_Page_02.tif
3e45b0e73a1a9796fc37881edea80622
1acb9c6ba78f9b2792378d1930d9b900c39d0462
48891 F20101222_AAANAX bautista_m_Page_23.pro
b603fc92b75c200f2b8da4b890eea5b0
b6f03d410c4c7ddcd1d8785de539c7f2b4ee24a4
F20101222_AAAMYX bautista_m_Page_03.tif
3e96e2da16c2f64c9378fce95e4467bd
bc74bf5574795840176c221d0d877d206a2a87ec
62621 F20101222_AAAMWA bautista_m_Page_36.pro
e5f31a0f3d9083869da0c9de6cdb73e7
0646afa8a256b69d0755bdbfdd86b12f7cd3fc00
F20101222_AAAMYY bautista_m_Page_04.tif
67c87f483812e94447aefc9a45e9ca55
8ff52804faefa178981e39df0799d36d6a48b9c8
56088 F20101222_AAANAY bautista_m_Page_24.pro
ad2395d89557cc9bc466530a0d3edcf0
fb46fbc67d0525510825d38efc0412412535ddc7
48745 F20101222_AAAMWB UFE0022677_00001.mets
606803aa945073b71db6a9c966577cb0
0db209c1dfab7c64e8d783767de383184a4c7a24
F20101222_AAAMYZ bautista_m_Page_06.tif
11ae7626aabc71b386affcf99e599d35
4b54d10790f2e0a70b4bb950ae6b6d7c0d98bc1e
31962 F20101222_AAANAZ bautista_m_Page_26.pro
a04a99aa6b5e0b2ab4ded832eab90bf4
84d62a11f92f6ed9432db797d3a439eae4281dfd
8793 F20101222_AAANDA bautista_m_Page_16thm.jpg
9179a9e37a4f245be15bdd4fb96205a8
3ad0aa85f9cfb08a043ef7a46da86a418f4c5dda
26696 F20101222_AAAMWE bautista_m_Page_01.jpg
9fa7a2d8e4cf3c1ed5b2621a88e3539e
6f9e17946a447eb5c6e7218bf32a8d83a7edef85
8227 F20101222_AAANDB bautista_m_Page_01.QC.jpg
a6184effa4ef4b11fcff4197467f3923
8acc6bd68e744e3d9d3e008b17d45f4fef41366d
4209 F20101222_AAAMWF bautista_m_Page_02.jpg
64c4e3a77a4057204bc1b989eda6987e
c93da0c4f8781415cc266fe4989de085def86b49
37251 F20101222_AAANDC bautista_m_Page_12.QC.jpg
78e9afdf1bcdf54ccd04deec2d226e72
9ebdb5ba2e6225d088cf14c9cb7083dc2cd952af
5093 F20101222_AAAMWG bautista_m_Page_03.jpg
a549483fad95c6dbdb8887df6d4dab86
cfb553b626eaf020c484b53107d937a383c09c95
3075 F20101222_AAANDD bautista_m_Page_27thm.jpg
afc9e1334630d92ce3647639847632c9
e44eff2ecb59c88f8066aa324fa287413e9edcb5
100403 F20101222_AAAMWH bautista_m_Page_04.jpg
fa19e6b3623a7e9339134f77050ebc6f
dccd6acae29987bb62209a083a554cd5b7df1f48
10504 F20101222_AAANDE bautista_m_Page_39.QC.jpg
e72fa61b89d3d75a46b6541289528580
01035c0e050640b3388a4d8047d06d9f897ea6d0
107327 F20101222_AAAMWI bautista_m_Page_05.jpg
a368e02efc809b4c95ddb027be509178
eb64a593c9033e9409af717bd7a1e4ea4b412f00
666 F20101222_AAANDF bautista_m_Page_03thm.jpg
f563a78c1b534413f0da605025d6cfc4
4cbd8b39a2756d7926bb1d5d90149bea72c199b0
16335 F20101222_AAAMWJ bautista_m_Page_06.jpg
fa09cd994dae0a572770b6243f3a4d78
eddde3d89482069899d6fe5e4c272784d3a4f65b
1907 F20101222_AAANDG bautista_m_Page_03.QC.jpg
a421b8a91d1b2fdce236b283f3d5c4f7
78820df74f8ce63377b7ac591b6e21b062f4cc0f
99821 F20101222_AAAMWK bautista_m_Page_08.jpg
ff63b767987f4bd69f8e9e5444ecd8eb
51f4e1da587b0139b3229e7d013e53c88a595344
31924 F20101222_AAANDH bautista_m_Page_08.QC.jpg
c29a57988508706a4ba3e892a1c9fd69
d66c8f78a9446c4deed9ccda61f2a9963eb1552c
38300 F20101222_AAANDI bautista_m_Page_35.QC.jpg
feb4b69700fcfe2ff4013ee804920d4c
14b0688ac07b10cdaf678446f0f341ffb8279114
94547 F20101222_AAAMWL bautista_m_Page_09.jpg
7003a3ee690606e9272c8a5dd6b181e6
8f5f33207eb257d8cfa7bf6c793536d4f3145f12
37463 F20101222_AAANDJ bautista_m_Page_13.QC.jpg
aacb1b69a1f870239f302881ad0c7ae1
f2879633a67bd0f2b21216973dd51eaf608cbbba
99320 F20101222_AAAMWM bautista_m_Page_10.jpg
81fc995b4c78c50e30aa25ab10c4bb2f
2838586ccfef2aa68de422e99815225cedbc975e
30787 F20101222_AAANDK bautista_m_Page_32.QC.jpg
2f6faa64a721d4e36ebecfc0d9782f36
9cd189be905463ebd4d835a7e79835708d350834
106258 F20101222_AAAMWN bautista_m_Page_11.jpg
18b6a67e0a7c10264c19b6befa5356a3
42f9162fddfd3c24d3782ce29a0cb5000138ac77
8084 F20101222_AAANDL bautista_m_Page_04thm.jpg
0acec2704537fe33a18b518461943164
824d4a5b0b5ee33aa0e4daa9764646e0fbf65bbb
111267 F20101222_AAAMWO bautista_m_Page_12.jpg
9d4821ec988ef399ad01b637a7db728a
ac8a7919dc9489244ea8a90db326f4370e28a0c1
1404 F20101222_AAANDM bautista_m_Page_06thm.jpg
eec11c5cbc2234ec812050385c335bae
d6ff0eadd96730678bf56be7b3756fb14c43ccca
9109 F20101222_AAANDN bautista_m_Page_18thm.jpg
7f8cb47a38bda5e568953e105d9bb1cf
6f61488ee8a3c24bacbe9e8590b7b394359fb8a8
113882 F20101222_AAAMWP bautista_m_Page_13.jpg
6b1a241cdd311cedc22f6e7edf605fb9
b3984d6fb063388ca7d169ff530269bc7770218a
34282 F20101222_AAANDO bautista_m_Page_19.QC.jpg
82b46571ac84560667d6d634bc3195ae
3468d947c9ecc42b7d34468f027d34ad40596806
58413 F20101222_AAAMWQ bautista_m_Page_14.jpg
65b965190d439d1b8b855b6cac762272
ea3a6dccaa032031ddf970dc4e7560898bf73836
8262 F20101222_AAANDP bautista_m_Page_23thm.jpg
9689255f14a676ac503dbe2c27d0a1cd
a345e01414149b3b441d3579abdbdcf884f5ab0a
105684 F20101222_AAAMWR bautista_m_Page_15.jpg
afdd26e6f35d53c978698ee611e0995e
d49caa289a9390cfc3acb857638b59ada35ab9cb
37524 F20101222_AAANDQ bautista_m_Page_24.QC.jpg
d22b1b48b3fe3864e73bc1bb39c9f1f6
59c99239c8542bddfebb9030f640b19d77b003fb
111639 F20101222_AAAMWS bautista_m_Page_16.jpg
7b63613fa4de1cc6fd5d913c1b805ba0
16f476701db3200db9b83efa64e03f5dfc2db83f
8778 F20101222_AAANDR bautista_m_Page_31thm.jpg
fd8717607fe967d17522b92b0682c915
4b22625058643d4714be874aa5477457194d5bc8
112158 F20101222_AAAMWT bautista_m_Page_17.jpg
91efcb31264fa58558ec51cc22b3c61b
0d301bc036d3d439ed4d80312f62634dbf4e4db2
36454 F20101222_AAANDS bautista_m_Page_29.QC.jpg
282376432eefc0dfaaf20e6e18fd7107
e4adc1de87abf8d969c44d84998048bff3a87d70
116278 F20101222_AAAMWU bautista_m_Page_18.jpg
4d03c5f4cf2c9a8b1be1d6f9c7131aa9
d38d120f69e0da4573218c462624b0ba4f04c3fc
F20101222_AAANDT bautista_m_Page_12thm.jpg
207a8bbdb961201a67ec3db930100fcc
054535ac9c876606bf3ace60097ae8cb6941583f
102355 F20101222_AAAMWV bautista_m_Page_19.jpg
42d9a36e74e37a78be080d0fc9ff7ead
2aec92fa3052ea7b4b8ab7f14e4918cf25ecce4f
8442 F20101222_AAANDU bautista_m_Page_20thm.jpg
de7df760124192192c31fa9bc0d1081c
84f0ac3118925b30d9a5eaf4bb1906684e5d92fe
109396 F20101222_AAAMWW bautista_m_Page_20.jpg
df525c0d8cc1bf8e85cff0e68b0d045d
a3dc438ed577ee951ac82970a2bf03b153412fb6
10907 F20101222_AAANDV bautista_m_Page_27.QC.jpg
90429100792ab58264fcb17e9156a8c4
cc8455d28e99f461ade825a90562b2052ed4e99e
105009 F20101222_AAAMWX bautista_m_Page_21.jpg
a6a976d3dbed20442c44334b41770c0e
30dfb90119376f86e1fc1a9f7c8f388dd7f00717
35069 F20101222_AAANDW bautista_m_Page_28.QC.jpg
45bb69c999a436a375c14ad6c58e02a7
f40a3fb4ff989c7015865450077b9a331042a5c3
48172 F20101222_AAAMWY bautista_m_Page_22.jpg
619593c50159fd7de0edcd593f18b33a
51dbdfaf0dc7979175f771f70f85943f3b85eee2
7886 F20101222_AAANDX bautista_m_Page_09thm.jpg
b36b92de24869217785f45f376946820
d94cac74242b40881d790a1e6e2c140d061829ba
101311 F20101222_AAAMWZ bautista_m_Page_23.jpg
d26e43b690e85dd4b569ffc2fbc35b58
244e51096c838e72109299fe372ad9fa348fe96b
32146 F20101222_AAANDY bautista_m_Page_09.QC.jpg
c8e8e9ba91a75e393ef379a8e8830689
24b6f515d394b2ad1abfb278800986f08ddff609
F20101222_AAAMZA bautista_m_Page_07.tif
1fd0f080c1f731e67350245d8449f9b5
7b6f4c6fd7e69635158e21fe5371186a298aa041
25915 F20101222_AAANBA bautista_m_Page_27.pro
e6dbf4cbac700cbd3db2fe287cfae0ae
9e2c1e3a1a66cef522ce0effb0fe44876a14f443
8339 F20101222_AAANDZ bautista_m_Page_15thm.jpg
383f5f4b5ab7141d23e9b2dd5f19b3e2
717633034635ac5ea46520433d281f85504c1acb
F20101222_AAAMZB bautista_m_Page_08.tif
f1c6063a09eeae2d12f6a5ea7e2b2b26
ba4fc0172414ac929e065b5f2cbd5c0e24f5e93c
53032 F20101222_AAANBB bautista_m_Page_28.pro
bad9d0fc6b1cd13cca11b1285f7b83cd
e7206c0bf5b2b18492d0c8f8007ca19bd4aaee1c
F20101222_AAAMZC bautista_m_Page_09.tif
04e11c49bc3b13b1f6aad67233726aaa
a933752b5cad7d9e3c205fa8dfd926e252e42a6b
55623 F20101222_AAANBC bautista_m_Page_29.pro
159789c79d85687074d69ba436b7ab49
2708d2debe4fb5907862d1f4985862313f05980c
F20101222_AAAMZD bautista_m_Page_11.tif
8e60a76b706734ce6ea511a19a8907d9
d43cbcac7788a5e86cbf889af72dc117423e1a65
54323 F20101222_AAANBD bautista_m_Page_30.pro
89c2fa0861460af0da378cdfe63c2600
5f583246b9972da751038da8f07a3bc0baadb1df
F20101222_AAAMZE bautista_m_Page_12.tif
40f15c22697964bbf6380a00fa838c2f
13432ba91919b8554c53d167ead82d4f066e77df
52856 F20101222_AAANBE bautista_m_Page_31.pro
d8c68583c1fe1c290e6a998cbe4c7571
3de1619def01d4d1de1f645b5d56f496056698e4
F20101222_AAAMZF bautista_m_Page_13.tif
3d96228d9e89edcdf5b027bbb90fe63a
bcee3cbf36e754556722f8939fb6f7edc9efa388
45349 F20101222_AAANBF bautista_m_Page_32.pro
53133d3712e1ec9816c4ac16734e9b8e
6fa397fad7f4110d5b416005daeefae619bc8c57
F20101222_AAAMZG bautista_m_Page_14.tif
fc954d368e054bc1fea7ea2cb29a3a41
68f2276b881c8696a70d1a9f40b28e6f55862109
17841 F20101222_AAANBG bautista_m_Page_33.pro
eb14f7f3e770a7c819816c8a2ab6b110
5265d88d94c058fed25dbd6917d59353a496da6f
65327 F20101222_AAANBH bautista_m_Page_35.pro
a4332f2a408864ed91f759b6097bbfde
499eec6061442b8fe095ba77efd1e78d5040f8d7
F20101222_AAAMZH bautista_m_Page_15.tif
5bf82ce536982699830ec0d8f710e15f
4ace8023b741cf31f8ea6caf33961833fc377e1a
51553 F20101222_AAANBI bautista_m_Page_37.pro
931f9c6911eff257b21c11f32c5da150
72252a2e7a47212109595750801c43ac6532f6d6
F20101222_AAAMZI bautista_m_Page_16.tif
2d5f3b95df51ea30eec7b7165e5d6a27
ca32d465aa95ee5f650d8998997180771813b31e
52048 F20101222_AAANBJ bautista_m_Page_38.pro
f1d00f85961428d9afd4adc68cfd1441
41a72e0b6986685f8ca1f98296479d1a1a06b7f5
F20101222_AAAMZJ bautista_m_Page_18.tif
f7c652b59b3b173b5b3c43d6e466835b
614cf53a4a39fd22adcfaf575ea4339dc6a5a908
12891 F20101222_AAANBK bautista_m_Page_39.pro
1090244d996ab1d06d8f51487a28fc6c
9b024f95db72c7f10884952dd6861dc08148187e
F20101222_AAAMZK bautista_m_Page_19.tif
12184f4318a9228acde3de83a3266751
2b869e1a866c1fd1fbb3d0ae665042dc983d923f
90 F20101222_AAANBL bautista_m_Page_02.txt
22ece6089a46379325202a7273081c89
870f3065e0917cce5eb22d4edeb01754ef132ad2
F20101222_AAAMZL bautista_m_Page_20.tif
6ebdefbe1f8725876545c620bebddba6
1446c37ec8ab4ea3d333adfd6bfe0c0022c972f8
104 F20101222_AAANBM bautista_m_Page_03.txt
56ca88d5f8ec75a3563d4067bed0ee1a
6b33e4b4c53b4aefe4161d85c129ff96907ee9f0
F20101222_AAAMZM bautista_m_Page_21.tif
a1ad3a92b84539b1f90ee0d6f4ae8412
f24972a26dbc7da231440e2dcc4c8f1449458344
1871 F20101222_AAANBN bautista_m_Page_04.txt
fa0fcc0763b3427b2a9b35bbb275937b
45e99e8030cfb03d606940cb48af9ea5e7f6a040
F20101222_AAAMZN bautista_m_Page_22.tif
f600f58a3e20615dcef76b5b949fc61a
20d0bff51734dd383097e441f4336528f81055a7
F20101222_AAAMZO bautista_m_Page_23.tif
4c6e262eb4dbc692e59393ed568a790b
28eab93de7d24bf96ce1fff0b707bbca60dc76b2
3212 F20101222_AAANBO bautista_m_Page_05.txt
a9d1ea8e5cdc9425e9d73b153a79c118
f6e96127cbc8c256a9fed4824c1337949b2d9cfa
F20101222_AAAMZP bautista_m_Page_24.tif
d465cb06180975c0b3069c2f8bb48c94
86c610956b5cafc7a5be6ab6ce8677d3f12ee9b1
280 F20101222_AAANBP bautista_m_Page_06.txt
0a4bfffb7b07f2c2d2fba67687409d99
7cef23f289531cc0d500b4e74f0fe59515b85cb1
F20101222_AAAMZQ bautista_m_Page_25.tif
de6917c4ddbd7c6d132caf3038d42ec1
dc7d837b358978c9ab317226c92d6c92f995a50b
458 F20101222_AAANBQ bautista_m_Page_07.txt
ea0ae8d346178ed5971ac2e859242532
a8a13272e2e5935c4fc9177230a708a5589f882c
F20101222_AAAMZR bautista_m_Page_26.tif
f1a6aa73bcad5e945afb2c5d40a5dce2
95250551bccfe752d6d759a525733ef907e96d6f
2067 F20101222_AAANBR bautista_m_Page_08.txt
c5eb99f9bc6284d8cdcd9a9b000abf14
5a6303883534973fcfe264a5bd67246e89afbfba
1789 F20101222_AAANBS bautista_m_Page_09.txt
c7277794052aa9713a6b3d3a2a287698
02e20777cc4421282631e73c65aa77f01b7b6bf5
25265604 F20101222_AAAMZS bautista_m_Page_27.tif
bf1d0714b5d8a9d5f6a68c19bd9ec6c2
326e7228a79e9cd6506be3f048c04ce3a42d7b44
1989 F20101222_AAANBT bautista_m_Page_10.txt
79d8886eabc9a7460927beb507222fa7
1f0ec43fbe3737121db96d3dd71ff520e04f996b
F20101222_AAAMZT bautista_m_Page_28.tif
642699695121192367daa60f7d716313
fdb25d518f904a14dc5e71c6a5c205f94c27d3cb
2065 F20101222_AAANBU bautista_m_Page_11.txt
d8846819fc2ad05257ecef4f9220c7ae
ac161e1feda083b6ebab30d2cb6089a4086b9cbd
F20101222_AAAMZU bautista_m_Page_29.tif
38df0ed7af69db87cddeab9f544a5f72
4da707eb693d76f6d0d87f04f62abf25e58ddfc2
2261 F20101222_AAANBV bautista_m_Page_13.txt
dda5aa2161a45efe9d0fdf7d6de8994d
1be9bc99403126d89ab84372fd25647ca9c4b6e9
F20101222_AAAMZV bautista_m_Page_30.tif
9e922999d9f071d895931dc01793560c
6debbb59294a605b0950a652e4b312593d081cda
1141 F20101222_AAANBW bautista_m_Page_14.txt
4cd6e315ae5b421fa71a8c92a0caa439
7fd8897e28a31851c24222d4700950c2db536870
F20101222_AAAMZW bautista_m_Page_31.tif
9a290868d997df400595e7e760e3b3b0
d2427e31e356cae37e4f7a53a8f8f452d0b0d426
2135 F20101222_AAANBX bautista_m_Page_15.txt
65b8143c4f1367fef0cb6406aa2995db
1bc54c8cfd0efb1bcbdf54ae7297a736e78129b6
F20101222_AAAMZX bautista_m_Page_32.tif
e70d2753f5d5595e39900337512f10b3
ade9c726136e75a972a27a3d14adb217dcbd6d49
2219 F20101222_AAANBY bautista_m_Page_16.txt
13c6f1ccdc167e9d7de8d056bfd87b59
b7299f36c388fdb1f7509f027d015e762bb88a72
113886 F20101222_AAAMXA bautista_m_Page_24.jpg
41e1feef534ac51e4482befec24766c9
ea5058450b2be432382d5a4796332a3e539c9ebc
F20101222_AAAMZY bautista_m_Page_33.tif
78363330bfbe49410d6163533c811d44
214afc24697f8966d840fb136b20e2ee892f8511
83412 F20101222_AAAMXB bautista_m_Page_25.jpg
82c7f396ff4363354277a998142e3109
1bfbe1ab26cd2c9cc0ceb0d979a8f3939a78ebfa
F20101222_AAAMZZ bautista_m_Page_34.tif
b571df1fe9a3731b26d0ed41079146d4
a08ecf9d1e7e0846b2dda7a1895489549f3cecc9
2141 F20101222_AAANBZ bautista_m_Page_17.txt
9ae2bab0cd01d62e93f03bea5e5e8317
50a7aa031ae76324aeba9d060155204b6d4960ee
36208 F20101222_AAAMXC bautista_m_Page_27.jpg
4aae3e5fdc89d95fd824d492b54acb5c
583987322e5cc236e5fde87ea41dcef6fedbfdfd
37808 F20101222_AAANEA bautista_m_Page_34.QC.jpg
fe65e36afa856d58d408b78692c15365
31126672a41317b979bf42a1d81aadb57fc9487d
107214 F20101222_AAAMXD bautista_m_Page_28.jpg
8914edeebcbb107a2f7565a06983c4d4
256ef5570b2bc2a227c8d11e203be94710ffab07
7256 F20101222_AAANEB bautista_m_Page_26thm.jpg
9274e7a2cb4876fe92089416789a7318
8d86d4bde427d0d9116049e84af6f2ec107c308a
113079 F20101222_AAAMXE bautista_m_Page_29.jpg
48ce8a59db0c418315cb8c69055663d1
1f0bc2199826c37aad7a663db6556abdc76e78d8