Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, president of Health Literacy Consulting, founder of Health Literacy Month and your host of these Health Literacy Out Loud podcasts. You get to listen in on my conversations with some truly remarkable people. You will hear what health literacy is, why it matters and ways we all can help improve health understanding.

Today, I’m talking with Dr. John Santa, who is Director of the Consumer Reports Health Ratings Center. For many years, he worked as a primary care physician, healthcare executive, researcher and policy maker. Now, Dr. Santa and others are working to evaluate and compare health services, products and practitioners based on current, robust and independent sources of information.

Welcome, John.

John: Thanks for inviting me.

Helen: I’m a long-time subscriber to Consumer Reports. I always use it as my go-to reference when I’m buying appliances, cars and all kinds of important and costly things in my life. I’m curious to know about Consumer Reports’ new focus on health.

Where I’m a long-time fan of Consumer Reports, perhaps not all our listeners know about it. Can we take it from the top? What is Consumer Reports?

John: Consumer Reports is one of the most successful monthly publications in the world. For 75 years, Consumer Reports has been providing comparisons to folks involved in purchasing decisions for all kinds of products. In the very first edition of Consumer Reports in the late ‘30s, there was an article on Alka-Seltzer and on toothbrushes.

Right from the start, health has been an area of interest. The founders of Consumer Reports knew that, as they saw marketing coming in the ‘30s, the consumers would be at a disadvantage. The objective was to provide a counter to advertising and promotion.

Frankly, four years ago, the company and the board decided that more resources and priority should be given to health because of the looming health reform that was on the horizon but also because of the enormous amount of advertising and promotion.

Helen: You’re talking about the direct-to-consumer drug advertising and the devices. I can’t turn on the TV these days without being inundated with ads. Also, you’re talking about the empowerment that’s coming with healthcare reform in the US. Is that correct? These two factors came together.

John: That’s right. We’re all most familiar with drugs because the drug companies have exploited, if you will, advertising and promotion more than any other industry stakeholder. We’re certainly all familiar with billboards, advertising and television promotional spots by hospitals and increasingly even by doctors.

You’re correct that Consumer Reports saw, four or five years ago, that its likely reform was going to take a direction in which individuals would have to make more decisions.

Helen: Rather than having our practitioners deciding for us.

John: And employers deciding for us.

Helen: Now it’s up to us. It’s kind of like buying a washing machine. I’m pretty much out there on my own buying whatever washing machine I want. Is that the equivalent of healthcare?

John: I think many physicians, especially, hate to be compared to toasters or appliances.

Helen: I’m sorry. Don’t take that one personally.

John: No. The reality is that many of my colleagues would say, “I wish we knew as much about our doctors, hospitals and some of our medical devices and drugs as we know about toasters.” We don’t. In fact, we are becoming individual purchasers of health insurance and healthcare as we all have more cost-sharing.

Whether we like it or not, we’re headed to more market-based approaches to healthcare. Consumer Reports sees that as an opportunity to provide helpful information to its subscribers.

Helen: Thanks for putting that all into context about that market-based approach. Like it or not, we are now all consumers of healthcare.

I know from your ratings, because I’ve looked at them for years, that it’s all about those circle that are all red or black or half of one of one or the other. Can you describe for our listeners how you go about presenting this information and finding the information to present?

John: Those are good questions. We have the advantage of having had 75 years of practice. George Arthur, who designed those symbols, recently retired after 30 years. If he were here, he would tell you it has taken us several decades to come up with effective symbols, summaries and narratives.

Helen: Let’s talk about them all because they’re all relevant to healthcare. Wherever I go, people are talking about those stars. “We need more star ratings.” That’s a form of symbols. Let’s talk about that first. How do you present information symbolically?

John: We have developed the circle system. We call them “blobs.” We use five tiers. We think five tiers is an advantage, meaning there are five possible symbols you could get from best to worst.

We developed the color system, the red and black, in order to enable our readers to quickly look at a complex ratings table and get some sense. If there’s a lot of red, that’s good. If there’s a lot of black, that’s not good.

We know that a significant number of readers want to figure things out quickly. They either don’t have the time or aren’t prepared to spend the time on all the details. Symbols help the quick reader, the person who wants to decide what they want to do and only has a few minutes, or the person who wants to spend more time reading about all the details. Those symbols have become iconic for us. For our readers, they work well.

Helen: I look at this all the time. In fact, I was reading the latest issue just last night. It comes as a table. You compare different types of toasters or whatever down the left side. Across the top, you have different characteristics. Then you put in the different types of circles filled in different ways.

John: That’s right. If you go to our hospital ratings, you would see a table that has each hospital’s name on the left-hand side and then multiple columns. Many of those columns will have a blob or circle that is one of the five best to worst options.

Sometimes we will lead off with a bar that gives either an overall score or a score of something that we think is particularly important. We’ll start with a bar, so it’s a bit of different symbol. It’s kind of a summary.

Helen: Do you mean the graph types of things where you might compare five hospitals?

John: It’s a horizontal bar. It will have a number in it, usually within 100. The best score is 100%. You’ll see that the table is almost always organized in the rank of that first score.

Let’s say the bar will have an 85 for the top item being rated. You’ll see it can go all the way down to 65, let’s say. Then there will be columns on a variety of other details with our blobs in them.

Helen: We’re all advocates for health literacy. That means communicating health information in ways others can understand. The role of symbols comes out there a lot, but can people really understand tables, especially when there are many different variables in it? With all these different ways of presenting it, is this something that has been tested a lot? Does this make information available to a wide range of people?

John: We spend a lot of time testing our tables. We have the advantage that since our publication is based on a subscription model, we have a very loyal audience, like you, who has a sense of what our symbols, summaries and narratives do. We know that our subscribers can quickly use our ratings. They will know then where to go for details so that it works well for them.

I must point out that for a person who’s never seen one of our ratings tables, we know that it will not look obvious to them. Some training needs to occur. That happens in a variety of ways in the magazine and on our website that enables people to eventually figure out and then effectively use those symbols.

Helen: That’s very interesting about the training. You’re right. I could pick up any issue. I’ve been looking at it for so long that I inherently know what all this means.

Aside from Consumer Reports, I’ve worked on some health quality projects doing some web writing. They want to follow a similar path to what you’re doing using stars, but the audience coming to them is not trained in using the symbols.

What would you recommend to those of us in the healthcare world who are introducing symbols now?

John: It’s a lot more complex. There’s a lot more options and subtleties than you might realize. For example, until I came here, I hadn’t really thought “Let’s take stars.”

We use stars occasionally. A star is a symbol that, to the average person, suggests a good thing. One star is still good, isn’t it? Three stars are even better, and five stars must be really good. Stars have a disadvantage if you want to convey that the performance here is not very good. One star might mislead somebody.

We were looking at a variety of different options and stars came up. I remember one of our designers said, “The problem is that this is a print project. Stars take up a lot of real estate.”

Helen: It does. It gets wider if you have five stars.

John: If you’re looking at a restaurant, for example, where there’s only going to be stars in one place for one thing, it works just fine. If you’re talking about a ratings table that might have five or 10 columns and you start to put stars on each of those columns, you’re going to have problems fitting that on a page. It’s going to look a lot more chaotic than a simple circle that’s partially red or black.

It depends on the audience, how simple you want the presentation to be, and how you feel at both ends of the spectrum. Do you think that the item, individual or institution that’s getting the lowest rating deserves one star?

Helen: That’s interesting. I’ve also heard research about is the most always the best? Should it be consistent? Are five always good? What end of the scale is it at?

I’m asking on behalf of listeners everywhere. I’m convinced. I understand why the circles work so well for Consumer Reports. Is this a design that others can use or is this copyrighted to Consumer Reports?

John: The specifics of our design are copyrighted. You might notice that the top symbol, which is a red circle, has a blank dot in the middle kind of like a tire. The reason that the dot is in the middle is because when you make a black and white copy of our ratings table, you can’t really tell the difference between red and black. You can see that there’s a dot in our top rating.

There are a lot of intricacies in our symbols, and those are copyrighted. There are many other folks who use circles and colors in a different scheme. They’re certainly welcome to do that knowing that those aren’t intuitive to everybody, so they need to spend some time and effort to explain how their rating table works.

Helen: That is absolutely fascinating. Thank you so much for going into that level of detail. I feel like I get it a whole lot more about the symbols.

You talked about two other areas. Let’s talk about summaries.

John: Summaries are important, especially for the reader or user who has a limited amount of time or interest. A summary can be a symbol like that horizontal bar or a vertical bar that quickly conveys how overall a product has done.

Helen: It’s not just text.

John: By no means is it just text. Often, our goal in any ratings effort is to come up with a composite. A composite is a summary.

For example, we’re currently pleased to be presenting ratings on heart surgeons. The ratings come from the Heart Surgeons’ Society and the Society of Thoracic Surgeons. They spent several years doing the research to develop a composite. They have one measure that all the others roll up into. They use stars. We’re currently using stars with those ratings.

Helen: John, could you just give an example of what would be their one measure for heart surgeons? I can’t imagine what that would be.

John: There is no one measure for heart surgeons. The composite includes information about mortality, the likelihood that you would die from heart surgery, serious complications, the likelihood you would have serious complications, the degree to which surgeons followed guidelines and especially did one surgery that we know is very effective, and the degree to which they followed guidelines around using medicines before and after surgery.

Helen: It’s kind of like those HEDIS measures.

John: That’s right. Those four things that I just described are 11 measurements. Those 11 measurements all lead up to the one composite.

Helen: A lot of our listeners do a lot of research. You’ve been in practice a long time. I’ve been in practice. There are a lot of nuances out there.

When you’ve got to figure morbidity, how many people died from a procedure, we know there’s a lot behind it. Was that person really sick? Was that person healthy going into it? Is there a way to capture that nuance, or does that get missed in the summary?

John: There is a way. We’re trying in health, whenever possible, to risk-adjust.

Helen: That’s the appropriate term for what I was asking.

John: All of our hospital information is risk adjusted to some degree. All of the heart surgery information I just mentioned is risk adjusted. What that tries to do is level the playing field so that the reader can be at least somewhat assured that variables like how sick a patient is, race, gender and things of that sort have been adjusted so that the comparison is fair.

Helen: When we read this, it’s all about me. What we really want to know is, is this likely to happen to me, whatever that outcome is?

John: That’s right. Of course, to some degree, sometimes you can do things with information that gives you a good sense of what it’s like for people like you. Often in the overall ratings, it’s an average person.

For example, take the age of a person. Any health result is usually a combination of results from people who are a range of ages. In a very sophisticated data system, you could have someone enter their specific age and tell them, “Here’s how well people your age did.”

Helen: That’s one of those more interactive websites out there. You’re talking about your print magazine right now.

John: With print, it’s impossible to do things that are that interactive. On the web now, we can start to see that day coming and hope that eventually we will be able to produce information where our user could say, “I’m a 70-year-old woman, and I’m interested in knowing how this works for me.”

We’ve done that recently in rating for screening tests for heart disease where people do enter their gender and age.

Helen: Is that on the Consumer Reports website?

John: That’s right.

Helen: It’s actually getting more personalized as we go down the techno-path. You talked about narratives. Tell us about that.

John: Narratives involve doing what we just talked about a bit. It’s personalizing this so people get a sense of whether this is about people like them.

Much of that comes in the editorial content. We try to tell stories. Those stories mean we might have a picture of a person. We might have a picture of a physician. We try to tell a story in words, pictures and other presentation ways that give people a sense of what this is like.

Helen: I recall a magazine I was flipping through about health insurance. Somebody couldn’t afford it. Somebody was older and could. Somebody got totally wiped out from their health insurance. It’s those kinds of stories, right?

John: That’s right. When we did the ratings of heart surgeons, we produced a video. We’re fortunate to have a state-of-the-art video studio here and the resources to do videos that accompany our stories.

We did a video that focused on a woman who had had a stroke when she had heart surgery. That enabled us to focus on the benefits and risks of heart surgery for her to tell her story. It brought home the point that heart surgery is wonderful, but like many things in health, there are benefits and risks.

Helen: For listeners who would like to see any of this in action, they can go buy the magazine, Consumer Reports. Is there any way they can be learning anymore?

John: They can go to our website, www.ConsumerReports.org, and they will see a health part of that website. They should look around that health website. For example, our ratings of drugs are all free.

Helen: I didn’t know that.

John: That’s right. You don’t need to be a subscriber. You can go to “Best Buy Drugs.” They can also google “Best Buy Drugs” and get right to that free information.

The ratings I just mentioned around screening tests are also free. If they went to our health website and checked on “Conditions and Treatments,” they would see an option where they could go to heart disease. They’d click on that, and these ratings of screening tests would be there for them to pursue if they wanted to do so.

Helen: That’s wonderful. We will have a link to the part of Consumer Reportsyou’re talking about on the Health Literacy Out Loud web page. It sounds like that’s a wonderful service for listeners. We’re not going to be working at Consumer Reports, I don’t think, but we can put it into our practice and communication to the people we care about and care for.

John: That’s right. There’s a lot of free content on our site. Your readers might also be interested. We have an advocacy arm that advocates for consumers in the market and around regulation of various industries.

For example, they might want to check out www.SafePatientProject.org. That’s a website that our advocacy folks are pursuing to look at safety and error issues in healthcare, specifically in hospitals and with drugs. All of the information around the Safe Patient Project is free and available to the public.

Helen: That’s great. I didn’t realize how big a footprint Consumer Reportswas having on all this.

I have one last question. Out of all the things that you and Consumer Reports are doing, and it’s impressive indeed, what would surprise the rest of us about it?

John: I’m sad to say that I think what most of us would be surprised at, and I’ve been surprised after 35 years in practice, is this information about safety and errors.

Our healthcare system is struggling now around safety issues. For example, we’ve focused our hospital ratings around hospital-acquired infections.

I’m sure I’ve told hundreds of patients. “You got an infection in the hospital. That’s just bad luck.” It turns out that those infections are very preventable. Many of them can lead to death. They can lead to enormous suffering and cost. There are somewhere between 1.5 million and 2 million hospital-acquired infections every year.

The Office of the Inspector General has issued a couple of reports in the last couple of years. Sadly, one out of seven Medicare patients experiences an error that harms them, leading to either temporary disability or death.

One out of seven, additionally, has an error occur that doesn’t harm them but is a significant error. You have around one out of four people over 65, when they go into the hospital, for whom a significant error occurs. That’s much more than I realized. Sadly, it appears that in most of those cases, the hospitals aren’t even aware that an error has occurred.

Helen: We’ve been talking about the role of information, the role of the individual, comparisons, ratings, and doing all we can. Do you see that as any way to offset all that high risk just being a patient?

John: We do. We are advising and advocating very strongly that when it comes to safety and errors patients should have somebody with them when they’re in the hospital all the time, if they can.

Patients should constructively assert themselves. Ask people, doctors, nurses and their guests to wash their hands every time. When procedures are being done, pay attention to whether the appropriate procedure is being followed. When you’re going to a procedure, having a test done or getting medicine, make sure that they’ve got the right person.

Let’s say you have a central line or catheter in your bladder. It’s very reasonable to be asking, “When can this come out? I want this to come out as soon as I don’t need it.” It turns out that often it stays in too long.

We know from publically reported data that when it comes time for discharge, that’s a very chaotic and risky transition, so a lot of interaction is needed.

That’s when you especially want family, a friend or somebody to be helping you understand what medicines you are supposed to take, what tests you are supposed to get once you leave the hospital, which doctor you should call if you have a problem and which doctor you are scheduled to see.

Often, that transition doesn’t work well. A very high percentage of people, sometimes as high as 30% or 35% in some hospitals, are coming back. They’re being readmitted within 30 days. That’s not good.

Helen: What you are talking about, John, is really so aligned with health literacy, the work that I’ve been doing with thousands of advocates worldwide. It’s really helping people better understand and better communicate.

I thank you so much for the important and valuable work you are doing at Consumer Reports and for sharing some of the inside perspective with us. Thank you for being a guest on Health Literacy Out Loud.

John: It was great to talk to you.

Helen: I learned a lot from Dr. John Santa and hope that you did, too. Health literacy isn’t always easy. For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, sign up for the free e-newsletter, “What’s New in Health Literacy Consulting?”

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find us at iTunes, on the mobile application Stitcher Radio and the Health Literacy Out Loud website, www.HealthLiteracyOutLoud.com.

Did you like this podcast? Did you learn something new? If so, tell your colleagues. Tell your friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.