***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective To investigate the association between low functional health literacy ( ability to read and underst and basic health related information ) and mortality  in older adults . Design Population based longitudinal cohort study based on a stratified r and om sample of households . Setting Engl and . Participants 7857 adults aged 52 or more who participated in the second wave ( 2004 - 5 ) of the English Longitudinal Study of Ageing and survived more than 12 months after interview . Participants completed a brief four item test of functional health literacy  , which assessed underst and ing of written instructions for taking an aspirin tablet . Main outcome measure Time to death , based on all cause mortality through October 2009 . Results Health literacy was categorised as high ( maximum score , 67.2 % ) , medium ( one error , 20.3 % ) , or low ( more than one error , 12.5 % ) . During follow-up ( mean 5.3 years ) 621 deaths occurred : 321 ( 6.1 % ) in the high health literacy category , 143 ( 9.0 % ) in the medium category , and 157 ( 16.0 % ) in the low category . After adjusting for personal characteristics , socioeconomic position , baseline health , and health behaviours , the hazard ratio for all cause mortality for participants with low health literacy was 1.40 ( 95 % confidence interval 1.15 to 1.72 ) and with medium health literacy was 1.15 ( 0.94 to 1.41 ) compared with participants with high health literacy . Further adjustment for cognitive ability reduced the hazard ratio for low health literacy to 1.26 ( 1.02 to 1.55 ) . Conclusions A third of older adults in Engl and have difficulties reading and underst and ing basic health related written information . Poorer underst and ing is associated with higher mortality . The limited health literacy capabilities within this population have implication s for the design and delivery of health related services for older adults in Engl and OBJECTIVES This study analyzed whether inadequate functional health literacy is an independent risk factor for hospital admission . METHODS We studied a prospect i ve cohort of 3260 Medicare managed care enrollees . RESULTS Of the participants , 29.5 % were hospitalized . The crude relative risk ( RR ) of hospitalization was higher for individuals with inadequate literacy ( n = 800 ; RR = 1.43 ; 95 % confidence interval [ CI ] = 1.24 , 1.65 ) and marginal literacy ( n = 366 ; RR = 1.33 ; 95 % CI = 1.09 , 1.61 ) than for those with adequate literacy ( n = 2094 ) . In multivariate analysis , the adjusted relative risk of hospital admission was 1.29 ( 95 % CI = 1.07 , 1.55 ) for individuals with inadequate literacy and 1.21 ( 95 % CI = 0.97 , 1.50 ) for those with marginal literacy . CONCLUSIONS Inadequate literacy was an independent risk factor for hospital admission among elderly managed care enrollees Summary Background Patient education is essential for a safe and efficient oral anticoagulant treatment . We examined if a newly launched booklet with information on anticoagulant treatment with warfarin improved patient knowledge and the time spent in the therapeutic-range ( TTR ) . Methods St and ardized question naire was administered to 235 consecutive patients on warfarin  to assess their baseline knowledge and readministered it 2 months after they received the booklet . A control group of 51 patients was interviewed only after the booklet had been distributed . Results Patient ’s knowledge at the baseline was unsatisfying ( mean question naire score : 11/16 ) and a substantial progress was achieved after the educational intervention ( mean question naire score : 13/16 , p = 0.001 ) . TTR is significantly increased after the intervention ( 63.4 ± 22.3 vs. 74.6 ± 23.8 % ; p < 0.01 ) . The mean question naire score and TTR after education were not different in the intervention and the control group . Conclusions Knowledge about oral anticoagulant treatment and TTR is increased after the issue of the booklet in the majority of patients . However , for a small group of patients with unimproved knowledge new forms of education are needed Background Effective and safe management of oral anticoagulant treatment ( OAT ) requires a high level of patient knowledge and adherence . The aim of this study was to assess  patient knowledge about  OAT  and factors associated with patient knowledge . Methods This is a baseline survey of a cluster-r and omized controlled trial in 22 general practice s with an educational intervention for patients or their caregivers . We assessed  knowledge  about  general information on OAT  and key facts regarding  nutrition  , drug-interactions and other safety pre caution s of 345 patients at baseline . Results Participants rated their knowledge about OAT as excellent to good ( 56 % ) , moderate ( 36 % ) or poor ( 8 % ) . However , there was a discrepancy between self-rated knowledge and evaluated actual knowledge and we observed serious knowledge gaps . Half of the participants ( 49 % ) were unaware of dietary recommendations . The majority ( 80 % ) did not know which non-prescription analgesic is the safest and 73 % indicated they would not inform pharmacists about OAT . Many participants ( 35 - 75 % ) would not recognize important emergency situations . After adjustment in a multivariate analysis , older age and less than 10 years education remained significantly associated with lower overall score , but not with self-rated knowledge . Conclusions Patients have relevant knowledge gaps , potentially affecting safe and effective OAT . There is a need to assess patient knowledge and for structured education programs . Trial registration Deutsches Register Klinischer Studien ( German Clinical Trials Register ) : DRKS00000586.Universal Trial Number ( UTN U1111 - 1118 - 3464 ) BACKGROUND While limited literacy is common and its prevalence increases with age , no prospect i ve study has assessed whether limited literacy is associated with mortality in older adults . OBJECTIVE To assess the association of limited literacy with mortality . DESIGN AND SETTING Five-year prospect i ve study from 1999 to 2004 of community-dwelling elders from Memphis , TN , and Pittsburgh , PA , who were from the Health , Aging , and Body Composition study . Subjects ' literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine . Scores were categorized into limited ( 0 to 8th grade reading level ) or adequate literacy ( > or = 9th grade reading level ) . PARTICIPANTS Two thous and five hundred and twelve black and white elders without baseline functional difficulties or dementia . MEASUREMENTS Time to death . RESULTS Participants ' mean age was 75.6 years , 48 % were male , 38 % were black , and 24 % had limited literacy ; the median follow-up time was 4.2 years . Compared with those with adequate literacy , those with limited literacy had a higher risk of death ( 19.7 % vs 10.6 % ) with a hazard ratio ( HR ) of 2.03 ( 95 % confidence intervals [ CI ] , 1.62 to 2.55 ) . After adjusting for demographics and socioeconomic status , co-morbid conditions , self-rated health status , health-related behaviors , health care access measures , and psychosocial status , limited literacy remained independently associated with mortality ( HR 1.75 ; 95 % CI , 1.27 to 2.41 ) . CONCLUSIONS Limited literacy is independently associated with a nearly 2-fold increase in mortality in the elderly . Given the growth of the aging population and the prevalence of chronic diseases , the mechanisms by which limited literacy is associated with mortality in the elderly warrant further investigation BACKGROUND Individuals with low levels of health literacy have less health knowledge , worse self-management of chronic disease , lower use of preventive services , and worse health in cross-sectional studies . We sought to determine whether low health literacy levels independently predict overall and cause-specific mortality . METHODS We design ed a prospect i ve cohort study of 3260 Medicare managed-care enrollees in 4 US metropolitan areas who were interviewed in 1997 to determine their demographic characteristics , chronic conditions , self-reported physical and mental health , and health behaviors . Participants also completed the shortened version of the Test of Functional Health Literacy in Adults . Main outcome measures included all-cause and cause-specific ( cardiovascular , cancer , and other ) mortality using data from the National Death Index through 2003 . RESULTS The crude mortality rates for participants with adequate ( n = 2094 ) , marginal ( n = 366 ) , and inadequate ( n = 800 ) health literacy were 18.9 % , 28.7 % , and 39.4 % , respectively ( P < .001 ) . After adjusting for demographics , socioeconomic status , and baseline health , the hazard ratios for all-cause mortality were 1.52 ( 95 % confidence interval , 1.26 - 1.83 ) and 1.13 ( 95 % confidence interval , 0.90 - 1.41 ) for participants with inadequate and marginal health literacy , respectively , compared with participants with adequate health literacy . In contrast , years of school completed was only weakly associated with mortality in bivariate analyses and was not significant in multivariate models . Participants with inadequate health literacy had higher risk-adjusted rates of cardiovascular death but not of death due to cancer . CONCLUSIONS Inadequate health literacy , as measured by reading fluency , independently predicts all-cause mortality and cardiovascular death among community-dwelling elderly persons .  Reading fluency is a more powerful variable than education for examining the association between socioeconomic status and health Background : The ability to use printed material to function in society ( literacy ) and to h and le basic numerical concepts ( numeracy ) may have implication s in patients ’ ability to follow dosing schedules . We examined  literacy and numeracy skills among patients on warfarin and explored their association with anticoagulation control . Methods and Results : Patients older than 50 years attending two anticoagulation management units were prospect ively enrolled . We measured  literacy , numeracy , and international normalized ratio ( INR ) .  During a 3-month follow-up period , we calculated the variability of the INR and the amount of time a patient ’s INR was within his or her therapeutic range , variables associated with bleeding and effectiveness .  Among 143 patients , only 75 ( 52.4 % ) were able to read health-related words at the eighth grade level or less . Patients ’ self-reported grade completed was higher than the measured literacy grade level ( & kgr ; = 0.21 ) . While 79.0 % had completed at least eight grade s , only 47.6 % had a score at that grade level . Sixty-nine patients answered none or correctly answered fewer than two of the six numeracy questions ( 48.3 % ) . The INR variability was higher among patients with lower literacy ( P = 0.009 ) and lower numeracy skills ( P = 0.004 ) . The time in range was similar among patients at different literacy levels ( P = 0.9 ) . Patients with lower numeracy level spent more time above their therapeutic range ( P = 0.04 ) and had a trend of less time spent in range ( P = 0.10 ) . Conclusions : Low literacy was prevalent among study patients taking warfarin . Low literacy and numeracy were associated with measures of poor anticoagulation control OBJECTIVES With the aim to facilitate a more comprehensive review process in public health including patient safety , we established a tool that we have termed ICROMS ( Integrated quality Criteria for the Review Of Multiple Study design s ) , which unifies , integrates and refines current quality criteria for a large range of study design s including qualitative research . STUDY DESIGN Review , pilot testing and expert consensus . METHODS The tool is the result of an iterative four phase process over two years : 1 ) gathering of established criteria for assessing controlled , non-controlled and qualitative study design s ; 2 ) pilot testing of a first version in two systematic review s on behavioural change in infection prevention and control and in antibiotic prescribing ; 3 ) further refinement and adding of additional study design s in the context of the European Centre for Disease Prevention and Control funded project ' Systematic review and evidence -based guidance on organisation of hospital infection control programmes ' ( SIGHT ) ; 4 ) scrutiny by the pan-European expert panel of the SIGHT project , which had the objective of ensuring robustness of the systematic review . RESULTS ICROMS includes established quality criteria for r and omised studies , controlled before- and -after studies and interrupted time series , and incorporates criteria for non-controlled before- and -after studies , cohort studies and qualitative studies . The tool consists of two parts : 1 ) a list of quality criteria specific for each study design , as well as criteria applicable across all study design s by using a scoring system ; 2 ) a ' decision matrix ' , which specifies the robustness of the study by identifying minimum requirements according to the study type and the relevance of the study to the review question . The decision matrix directly determines inclusion or exclusion of a study in the review . ICROMS was applied to a series of systematic review s to test its feasibility and usefulness in the appraisal of multiple study design s. The tool was applicable across a wide range of study design s and outcome measures . CONCLUSION ICROMS is a comprehensive yet feasible appraisal of a large range of study design s to be included in systematic review s 
    Output:
    
Our results suggest that in patients taking OAC treatments there is a positive relationship between HL and the level of knowledge .
Lower HL level was associated with greater knowledge deficits and less adherence to treatment .
Conclusion There is a paucity of research evaluating the effect of HL on diverse aspects of OAC treatments .