BRIEF REPORT: Screening items to identify patients with limited health literacy skills

Background: Patients with limited literacy skills are routinely encountered in clinical practice, but they are not always identified by clinicians. Objective: To evaluate 3 candidate questions to determine their accuracy in identifying patients with limited or marginal health literacy skills. Methods; We studied 305 English-speaking adults attending a university-based primary care clinic. Demographic items, health literacy screening questions, and the Rapid Estimate of Adult Literacy in Medicine (REALM) were administered to patients. To determine the accuracy of the candidate questions for identifying limited or marginal health literacy skills, we plotted area under the receiver operating characteristic (AUROC) curves for each item, using REALM scores as a reference standard. Results: The mean age of subjects was 49.5; 67.5% were female, 85.2% Caucasian, and 81.3% insured by TennCare and/or Medicare. Fifty-four (17.7%) had limited and 52 (17.0%) had marginal health literacy skills. One screening question, "How confident are you filling out medical forms by yourself?" was accurate in detecting limited (AUROC of 0.82; 95% confidence interval [CI]=0.77 to 0.86) and limited/marginal (AUROC of 0.79; 95% CI=0.74 to 0.83) health literacy skills. This question had significantly greater AUROC than either of the other questions (P <.01) and also a greater AUROC than questions based on demographic characteristics. Conclusions: One screening question may be sufficient for detecting limited and marginal health literacy skills in clinic populations.