Limited Health Literacy is a Barrier to Medication Reconciliation
in Ambulatory Care
Stephen D. Persell, MD, MPH1, Chandra Y. Osborn, PhD1, Robert Richard, MD2,
Silvia Skripkauskas, BA1, and Michael S. Wolf, PhD, MPH1
1Health Literacy and Learning Program, Division of General Internal Medicine, and Institute for Healthcare Studies, Feinberg School of
Medicine, Northwestern University, Chicago, IL, USA;2Cherry Street Health Services, Grand Rapids, MI, USA.
BACKGROUND: Limited health literacy may influence
patients’ ability to identify medications taken; a serious
concern for ambulatory safety and quality.
OBJECTIVE: To assess the relationship between health
literacy, patient recall of antihypertensive medications,
and reconciliation between patient self-report and the
DESIGN: In-person interviews, literacy assessment,
medical records abstraction.
PARTICIPANTS: Adults with hypertension at three
community health centers.
MEASUREMENT: We measured health literacy using
the short-form Test of Functional Health Literacy in
Adults. Patients were asked about the medications they
took for blood pressure. Their responses were compared
with the medical record.
RESULTS: Of 119 participants, 37 (31%) had inade-
quate health literacy. Patients with inadequate health
literacy were less able to name any of their antihyper-
tensive medications compared to those with adequate
health literacy (40.5% vs 68.3%, p=0.005). After adjust-
ing for age and income, this difference remained
(adjusted odds ratio [OR]=2.9, 95% confidence interval
[95%CI]=1.3–6.7). Agreement between patient reported
medications and the medical record was low: 64.9% of
patients with inadequate and 37.8% with adequate
literacy had no medications common to both lists.
CONCLUSIONS: Limited health literacy was associated
with a greater number of unreconciled medications.
Future studies should investigate how this may impact
safety and hypertension control.
KEY WORDS: health literacy; medication reconciliation;
medication adherence; hypertension; knowledge; ambulatory care.
J Gen Intern Med 22(11):1523–6
© Society of General Internal Medicine 2007
manner, known as medication reconciliation, has been identi-
fied as a target for improving the quality and safety of health
care.1–3The inpatient setting, in particular, is the context
where reconciliation has usually been described. Through the
process of medication reconciliation, health care providers can
improve patient care by reducing adverse drug events and
medication errors (by conflict or unintentional omission) that
account for $3.5 billion in hospital costs each year.4However,
the Institute of Medicine (IOM) 2006 report, Preventing Medi-
cation Error, recommended attention be directed to outpatient
settings as well. One third of the 1.5 million adverse drug
events occur in ambulatory care, at a cost approaching $1
Current evidence detailing the causes of outpatient medi-
cation error is limited, yet unreconciled medicine regimens
may be a root cause.5,6From a provider/system perspective,
research suggests that physicians are missing opportunities to
communicate with patients about medicine regimens.7,8As a
result, information in the medical record may not be accurate
and current. From the patient perspective, limited health
literacy might be a less-recognized barrier to medication
reconciliation.9Prior studies have shown that patients with
limited health literacy have a poorer understanding of pre-
scription medication names, indications for use, and instruc-
tions.10–13We sought to document the prevalence of
medication discrepancies and determine whether limited
health literacy was significantly associated with reconciliation
romoting agreement between physicians and patients as
to which medications a patient is using and in what
Setting and Participants
Consecutive patients with diagnosed hypertension and sched-
uled appointments were recruited from three primary care
clinics in Grand Rapids, Michigan affiliated with a federally
qualified health center. Study procedures were approved by
the institutional review board at Michigan State University,
and participants provided informed consent. Eligible partici-
pants were at least 18 years old, had a diagnosis of hyperten-
sion in the medical record, and a clinic appointment between
July 2005 and March 2006. Patients were ineligible if they did
not speak English or if the clinic nurse determined (by
interaction or chart documentation) that they were too ill or
Presented in part at the American Medical Association/AMA Founda-
tion Health Literacy and Patient Safety Conference, November 16, 2006,
Received February 5, 2007
Revised July 12, 2007
Accepted July 24, 2007
Published online September 5, 2007
cognitively impaired to participate. Nurses reviewed medical
records of scheduled patients, identified those potentially
eligible for the study, and referred them to study staff who
met with interested patients, obtained consent, and scheduled
We assessed health literacy with the short version of the Test
of Functional Health Literacy in Adults (S-TOFHLA).14,15
Patients are classified as having inadequate, marginal, or
adequate health literacy skills. For this small study, we
defined patients as having either inadequate health literacy
or marginal/adequate health literacy. Although prior findings
are mixed regarding associations between health outcomes
and marginal health literacy, these individuals more often
appear to be similar to those with adequate rather than
Patients were asked to report how many different medica-
tions they were taking for high blood pressure and to name
them. A trained chart abstractor recorded the most recent
blood pressure and current medications from the medical
record retrospectively. A physician determined which of these
were antihypertensive medications. We compared the lists of
antihypertensive medications named by the patient with those
in the medical record and classified these comparisons as
containing all, some, or no medications in common. We also
classified patients as being able or unable to name any of their
Data was analyzed using the SAS (version 9.1). Categorical data
were compared using χ2or Fisher’s exact test. We compared
normal continuous variables with the Student’s t-test. We used
multivariable logistic regression to examine the relationship
between health literacy and ability to name antihypertensive
medications adjusted for age (<60 vs ≥60 years) and household
income (<$10,000, ≥$10,000, or missing).
A total of 161 eligible patients were approached, and 119
consented to be interviewed (73.9%). No differences were noted
by age between participants and nonparticipants (55.3 vs
56.2 years, p=0.46). Among those interviewed, 69.5% were
women, 60.5% were black, 33.6% were white, and 5.8% were
another race/ethnicity. 39.0% completed less than a high
school education and 45.5% reported annual household
incomes less than $10,000. One third (31.1%) had inadequate
health literacy according to the S-TOFHLA. These patients
tended to be older and had completed fewer years of schooling
than patients with adequate health literacy (Table 1).
Medical records indicated that hypertension patients with
inadequate health literacy were more likely than patients with
adequate health literacy to be prescribed two or more antihy-
pertensive medications (81.1% vs 53.7%, p=0.004). However,
health literacy was not associated with the number of antihy-
pertensive medications patients reported taking (two or more:
56.8% vs 47.6%, p=0.35). Only 22.7% of patients could name
two or more of their antihypertensive medications, and 40.3%
could not name any of these medicines. Patients with inade-
quate health literacy named fewer antihypertensive medica-
tions than those with adequate health literacy (Table 1) and
were more likely to be unable to name any antihypertensive
medication they were taking (59.5% vs 31.7%, odds ratio [OR]=
3.2, 95% confidence interval [95%CI]=1.4–7.1). After adjusting
for age and income, this difference remained (adjusted OR=2.9,
Table 1. Participant Characteristics and Antihypertensive
Medication Use, by Health Literacy
Age, mean (SD)55.3
58.4 (12.5) 53.8
Age ≥60 y (%)
Female sex (%)
Years of school
Less than 8th
High school or
3 or more
3 or more
3 or more
Persell et al.: Health Literacy and Medication Reconciliation
95%CI=1.3–6.7). Further adjustment for race and years of
school completed did not appreciably alter this relationship.
The agreement between patient-reported and medical
record-reported antihypertensive medications was lower for
patients with inadequate compared to adequate health liter-
acy (Table 2). For 64.9% of patients with inadequate health
literacy and 37.8% with adequate health literacy, there were
no antihypertensive medications common to the patient-
reported and record-abstracted lists (Table 2).
Patients with inadequate health literacy were less likely to
have blood pressure below 140/90 mm Hg compared to those
with adequate literacy, but this difference was not significant
(59.1% vs 70.7%; p=0.096) (Table 2). Blood pressures were
higher for patients with inadequate health literacy (difference
of 5.2/2.2 mmHg) but these differences also were not
Medication reconciliation problems were highly prevalent
among patients receiving hypertension care at three federally
qualified health centers. Patients frequently could not name
their antihypertensive medications, and there was little agree-
ment between antihypertensive medications in the medical
record and those named by patients. These deficits were
particularly striking for patients with inadequate health
literacy. Of these patients, 60% could not name any antihy-
pertensive medications and nearly two thirds named no
antihypertensive medication that was recorded in their medi-
cal record. Inadequate health literacy may therefore pose a
major obstacle to patients and their providers as they attempt
to reconcile medications used for hypertension.
Being unable to state which medications they are using by
name (and also by dose) could be especially important when
patients interact with health care providers other than their
usual source of outpatient care (e.g., emergency departments,
inpatient settings).17For patients routinely using safety-net
providers, poor reconciliation may further complicate the
challenge of coordination of care.
For chronic conditions, such as hypertension that frequent-
ly require multidrug regimens, the inability to name one’s
medications could increase the chance of medication errors or
nonadherence. This study did not assess adherence or medi-
cation errors directly, but supports a possible association
between health literacy and medication-taking behaviors. Our
finding that inadequate health literacy was associated with
having two or more antihypertensive medications recorded in
the medical record but not with the number of antihyperten-
sive medications patients reported taking could indicate a
relationship between inadequate health literacy and nonad-
herence in this population. Prior findings in HIV treatment
found inconclusive results as to the relationship between
health literacy and medication adherence.10,13,18–20Yet HIV
may differ from hypertension. Antiretroviral medications gen-
erally have a single manufacturer, and a prior study found that
patients with limited literacy often rely on pill characteristics
for identification.21This would be difficult with antihyperten-
sive drugs, which frequently come in multiple forms from
different manufacturers. Patients may be dispensed different
appearing versions of the same medication from 1 month to
the next. Using medications correctly by depending on pill
shape, size, or color seems particularly unreliable in this case.
A recent study found inadequate health literacy to be related to
lower refill adherence for cardiovascular-related diseases and
diabetes.22Further research is needed to explore plausible
causal pathways linking health literacy to medication errors
and adherence for hypertension.
Limitations of the study should be noted. Patients were
from one city, all spoke English, and all had diagnosed
hypertension. How these results generalize to other popula-
tions with different medical conditions is not known. The
medical record was intentionally abstracted 2 weeks after the
interview, yet it is possible that the record did not contain
the most up to date documentation. One might expect errors
or omissions to be more prevalent in paper chart documen-
tation compared to an electronic record. It is also possible
that medical information was incomplete as patients could
have received care from other sites. However, patients at
federally qualified health centers have fewer resources and,
therefore, may be less likely to access multiple providers.
Finally, our study population was small. We were able to
detect significant differences in the ability to name antihy-
pertensive medications by health literacy status but were
limited by our sample size to detect clinically meaningful
differences in blood pressure.
Greater attention should be directed to medication recon-
ciliation in ambulatory care and potential strategies to over-
come related health literacy barriers. Future research should
examine in detail the relationship between health literacy,
medication discrepancies, and chronic disease outcomes. The
efficacy of interventions to improve communication and pa-
tient recall of medicines should also be tested. At present,
Table 2. Antihypertensive Medications Reconciled and Blood
Pressure Control, by Health Literacy
Lists identical (%)
in common (%)
in common (%)
40.359.5 31.7 0.005
65.6 54.1 70.70.096
81.5 (11.1) 79.3 (12.6)0.32
Persell et al.: Health Literacy and Medication Reconciliation
clinicians might also encourage patients to bring their medica- Download full-text
tions with them to office visits.
Acknowledgements: Special thanks to Diane Cornelius and Mar-
olee Neuberger for their technical and methodological guidance in
conducting the research activities. Funding for this study was
provided in part by a research grant awarded to Cherry Street Health
Services by the Michigan Department of Community Health. Dr. Wolf
is supported by a Centers for Disease Control and Prevention Career
Development Award (K01 EH000067-01). Dr. Persell is supported in
part by a career development award 1 K08 HS015647-01 from the
Agency for Healthcare Research and Quality.
Conflict of Interest: Dr. Wolf has received research funding from
Target Corporation and Pfizer Pharmaceuticals for health literacy-
related intervention studies. No other conflicts are identified with
authors of this manuscript.
Corresponding Author: Michael S. Wolf, PhD, MPH; Health
Literacy and Learning Program, Division of General Internal Medi-
cine, and Institute for Healthcare Studies, Feinberg School of
Medicine, Northwestern University, 676 North St. Clair Street, Suite
200, Chicago, IL 60611, USA (e-mail: email@example.com).
1. American Hospital Association, American Society of Health-System
Pharmacists, Hospitals & Health Networks. Medication safety issue
brief. Medication reconciliation. Hosp Health Netw. 2005;79:33–4.
2. Boockvar KS, Carlson LH, Giambanco V, Fridman B, Siu AM.
Medication reconciliation for reducing drug-discrepancy adverse events.
Am J Geriatr Pharmacother. 2006;4:236–43.
3. Poon EG, Blumenfeld B, Hamann C, et al. Design and implementation
of an application and associated services to support interdisciplinary
medication reconciliation efforts at an integrated healthcare delivery
network. J Am Med Inform Assoc. 2006;13:581–92.
4. Institute of Medicine. Preventing Medication Errors. In: Aspden P,
Wolcott J, Bootman L, Cronenwett LR eds. Washington, D.C.:
National Academy Press; 2006.
5. Gandhi TK, Burstin HR, Cook EF, et al. Drug complications in
outpatients. J Gen Intern Med. 2000;15:149–54.
6. Plews-Ogan ML, Nadkarni MM, Forren S, Leon D, White D, Marineau
D, et al. Patient safety in the ambulatory setting. A clinician-based
approach. J Gen Intern Med. 2004;19:719–25.
7. Metlay JP, Cohen A, Polsky D, Kimmel SE, Koppel R, Hennessy S.
Medication safety in older adults: home-based practice patterns. J Am
Geriatr Soc. 2005;53:976–82.
8. Tarn DM, Heritage J, Paterniti DA, Hays RD, Kravitz RL, Wenger NS.
Physician communication when prescribing new medications. Arch
Intern Med. 2006;166:1855–62.
9. Institute of Medicine. Health literacy: a prescription to end confusion. In:
Nielsen-Bohlman L, Panzer A, Kindig DA, eds. Washington, D.C.:
National Academy Press; 2004.
10. Wolf MS, Davis TC, Arozullah A, Penn R, Arnold C, Bennett CL.
Relationship between literacy and HIV treatment knowledge among
individuals enrolled in HAART regimens. AIDS Care. 2005;17:863–73.
11. Davis TC, Wolf MS, Bass PF, Tilson H, Neuberger M, Parker RM.
Literacy and misunderstanding of prescription drug labels. Ann Intern
12. Dowse R, Ehlers MS. The influence of education on the interpretation of
pharmaceutical pictograms for communicating medicine instructions.
Int J Pharm Pract. 2003;11:11–8.
13. Kalichman SC, Ramachandran B, Catz S. Adherence to combination
antiretroviral therapies in HIV patients of low health literacy. J Gen
Intern Med. 1999;14:267–73.
14. 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(1):33–42.
15. Davis TC, Kennen EM, Gazmararian JA, Williams MV. Literacy testing
in health care research. In: Schwartzberg JG, VanGeest JB, Wang CC,
eds. Understanding health literacy: implications for medicine and public
health. Chicago, IL: AMA Press; 2004:157–79.
16. Wolf MS, Gazmararian JA, Baker DW. Health literacy and functional
health status among older adults. Arch Intern Med. 2005:165:1946–52.
17. Baker DW. The meaning and the measure of health literacy. J Gen Intern
18. Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy
and health outcomes: a systematic review of the literature. J Gen Intern
19. Kripalani S, Henderson LE, Chiu EY, Robertson R, Kolm P, Jacobson
TA. Predictors of medication self-management skill in a low-literacy
population. J Gen Intern Med. Aug 2006;21(8):852–6.
20. Wolf MS, Davis TC, Skripkauskas S, Bennett CL, Makoul G. Literacy,
self-efficacy, and HIV medication adherence. Patient Educ Couns.
21. Wolf MS, Davis TC, Marin E, Arnold C, Bennett CL. A qualitative study
of literacy and patient response to HIV medication adherence question-
naires. J Health Comm. 2005;10:1–9.
22. Gazmararian JA, Kripalani S, Miller MJ, Echt KV, Ren J, Rask K.
Factors associated with medication refill adherence in cardiovascular-
related diseases: a focus on health literacy. J Gen Intern Med.
Persell et al.: Health Literacy and Medication Reconciliation