Strategies for improving minority healthcare quality

Cultural responsiveness in applied behavior analysis: Research and practice

The new Ethics Code for Behavior Analysts requires that certificants engage in training related to culturally responsive service delivery (BACB, 2020). There is limited work in the area of culturally responsive evidence-based practice within our field. Therefore, it is incumbent on researchers and practitioners to identify best practices for working with diverse populations. Hence, the purpose of this paper is three-fold: a) to review research within and outside the field of ABA related to culturally responsive assessment and treatment and provide practice recommendations, b) to examine the extent to which current practices in behavior assessment and treatment align with aspects of culturally responsive practices, and c) to inspire research in the areas of behavior assessment and treatment to identify best practices with regard to culturally responsive behavior analytic practices. The content of this paper is grounded in the framework described by Beaulieu and Jimenez-Gomez (2022).

A Qualitative Analysis of Surgical Faculty and Surgical Resident Perceptions of Potential Barriers to Implementing a Novel Surgical Education Curriculum

OBJECTIVE

Sociocultural differences between patients and physicians affect communication, and suboptimal communication can lead to patient dissatisfaction and poor health outcomes. To mitigate disparities in surgical outcomes, the Provider Awareness and Cultural dexterity Toolkit for Surgeons was developed as a novel curriculum for surgical residents focusing on patient-centeredness and enhanced patient-clinician communication through a cultural dexterity framework. This study's objective was to examine surgical faculty and surgical resident perspectives on potential facilitators and barriers to implementing the cultural dexterity curriculum.

DESIGN, SETTING, AND PARTICIPANTS

Focus groups were conducted at 2 separate academic conferences, with the curriculum provided to participants for advanced review. The first 4 focus groups consisted entirely of surgical faculty (n = 37), each with 9 to 10 participants. The next 4 focus groups consisted of surgical residents (n = 31), each with 6 to 11 participants. Focus groups were recorded and transcribed, and the data were thematically analyzed using a constant, comparative method.

RESULTS

Three major themes emerged: (1) Departmental and hospital endorsement of the curriculum are necessary to ensure successful rollout. (2) Residents must be engaged in the curriculum in order to obtain full participation and "buy-in." (3) The application of cultural dexterity concepts in practice are influenced by systemic and institutional factors.

CONCLUSIONS

Institutional support, resident engagement, and applicability to practice are crucial considerations for the implementation of a cultural dexterity curriculum for surgical residents. These 3 tenets, as identified by surgical faculty and residents, are critical for ensuring an impactful and clinically relevant education program.

What initiatives do healthcare leaders agree are needed for healthcare system improvement? Results of a modified-Delphi study

PURPOSE

The purpose of this paper is to identify five quality improvement initiatives for healthcare system leaders, produced by such leaders themselves, and to provide some guidance on how these could be implemented.

DESIGN/METHODOLOGY/APPROACH

A multi-stage modified-Delphi process was used, blending the Delphi approach of iterative information collection, analysis and feedback, with the option for participants to revise their judgments.

FINDINGS

The process reached consensus on five initiatives: change information privacy laws; overhaul professional training and work in the workplace; use co-design methods; contract for value and outcomes across health and social care; and use data from across the public and private sectors to improve equity for vulnerable populations and the sickest people.

RESEARCH LIMITATIONS/IMPLICATIONS

Information could not be gathered from all participants at each stage of the modified-Delphi process, and the participants did not include patients and families, potentially limiting the scope and nature of input.

PRACTICAL IMPLICATIONS

The practical implications are a set of findings based on what leaders would bring to a decision-making table in an ideal world if given broad scope and capacity to make policy and organisational changes to improve healthcare systems.

ORIGINALITY/VALUE

This study adds to the literature a suite of recommendations for healthcare quality improvement, produced by a group of experienced healthcare system leaders from a range of contexts.

A web-based cultural competency training for medical students: a randomized trial

BACKGROUND

The objectives of this research were to compare a Web-based curriculum with a traditional lecture format on medical students' cultural competency attitudes using a standardized instrument and to examine the internal consistency of the standardized instrument.

METHODS

In 2010, we randomized all 180 1st-year medical students into a Web-based (intervention group) or a lecture-based (control group) cultural competency training. The main outcome was the overall score on the Health Belief Attitudes Survey (1 = lowest, 6 = highest). We examined internal consistency with factor analysis.

RESULTS

No differences were observed in the overall median scores between the intervention (median 5.2; 25th percentile [Q1] 4.9, 75th percentile [Q3] 5.5) and the control groups (median 5.3, Q1 4.9, Q3 5.6) (P = 0.77). The internal consistency of the 2 main subcomponents was good (Cronbach's alpha = 0.83) to acceptable (Cronbach's alpha = 0.69).

CONCLUSIONS

A Web-based and a lecture-based cultural competency training strategies were associated with equally high positive attitudes among 1st-year medical students. These findings warrant further evaluation of Web-based cultural competency educational interventions.

Applying best practices to designing patient education for patients with end-stage renal disease pursuing kidney transplant

Despite the known benefits of kidney transplant, less than 30% of the 615 000 patients living with end-stage renal disease (ESRD) in the United States have received a transplant. More than 100 000 people are presently on the transplant waiting list. Although the shortage of kidneys for transplant remains a critical factor in explaining lower transplant rates, another important and modifiable factor is patients' lack of comprehensive education about transplant. The purpose of this article is to provide an overview of known best practices from the broader literature that can be used as an evidence base to design improved education for ESRD patients pursuing a kidney transplant. Best practices in chronic disease education generally reveal that education that is individually tailored, understandable for patients with low health literacy, and culturally competent is most beneficial. Effective education helps patients navigate the complex health care process successfully. Recommendations for how to incorporate these best practices into transplant education design are described. Providing more ESRD patients with transplant education that encompasses these best practices may improve their ability to make informed health care decisions and increase the numbers of patients interested in pursuing transplant.

Preparing for patient-centered care: assessing nursing student knowledge, comfort, and cultural competence toward the Latino population

As the Latino population continues to grow throughout the United States, cultural competence training of nursing students at the baccalaureate level has become a priority. This study aimed to explore undergraduate nursing students' attitudes and beliefs toward Latino patients and their perceived readiness to provide care to Latino patients. A cross-sectional survey was conducted at four major nursing schools in the southeastern United States, which is the region that has seen the highest percentage of growth in the Latino population. Results from multivariable regression suggest that social interaction with Latino individuals and cultural immersion in a Spanish-speaking country predict student knowledge, cultural competence, and comfort with Latino patients. Direct influence by nursing programs, such as clinical experience, coursework, and language proficiency, are positively associated with the designed outcomes, but these relationships are not statistically significant. Our findings suggest that dosage of training matters. Implications for student recruitment, selection, and training are discussed.

Prioritizing health disparities in medical education to improve care

Despite yearly advances in life-saving and preventive medicine, as well as strategic approaches by governmental and social agencies and groups, significant disparities remain in health, health quality, and access to health care within the United States. The determinants of these disparities include baseline health status, race and ethnicity, culture, gender identity and expression, socioeconomic status, region or geography, sexual orientation, and age. In order to renew the commitment of the medical community to address health disparities, particularly at the medical school level, we must remind ourselves of the roles of doctors and medical schools as the gatekeepers and the value setters for medicine. Within those roles are responsibilities toward the social mission of working to eliminate health disparities. This effort will require partnerships with communities as well as with academic centers to actively develop and to implement diversity and inclusion strategies. Besides improving the diversity of trainees in the pipeline, access to health care can be improved, and awareness can be raised regarding population-based health inequalities.

Educational games for health professionals

BACKGROUND

The use of games as an educational strategy has the potential to improve health professionals' performance (e.g. adherence to standards of care) through improving their knowledge, skills and attitudes.

OBJECTIVES

The objective was to assess the effect of educational games on health professionals' performance, knowledge, skills, attitude and satisfaction, and on patient outcomes.

SEARCH METHODS

We searched the following databases in January 2012: MEDLINE, AMED, CINAHL, Cochrane Central Database of Controlled Trials, EMBASE, EPOC Register, ERIC, Proquest Dissertations & Theses Database, and PsycINFO. Related reviews were sought in DARE and the above named databases. Database searches identified 1546 citations. We also screened the reference lists of included studies in relevant reviews, contacted authors of relevant papers and reviews, and searched ISI Web of Science for papers citing studies included in the review. These search methods identified an additional 62 unique citations for a total of 1608 for this update.

SELECTION CRITERIA

We included randomized controlled trials (RCT), controlled clinical trials (CCT), controlled before and after (CBA) and interrupted time-series analysis (ITS). Study participants were qualified health professionals or in postgraduate training. The intervention was an educational game with "a form of competitive activity or sport played according to rules".

DATA COLLECTION AND ANALYSIS

Using a standardized data form we extracted data on methodological quality, participants, interventions and outcomes of interest that included patient outcomes, professional behavior (process of care outcomes), and professional's knowledge, skills, attitude and satisfaction.

MAIN RESULTS

The search strategy identified a total of 2079 unique citations. Out of 84 potentially eligible citations, we included two RCTs. The game evaluated in the first study used as a reinforcement technique, was based on the television game show "Family Feud" and focused on infection control. The study did not assess any patient or process of care outcomes. The group that was randomized to the game had statistically higher scores on the knowledge test (P = 0.02). The second study compared game-based learning ("Snakes and Ladders" board game) with traditional case-based learning of stroke prevention and management. The effect on knowledge was not statistically different between the two groups immediately and 3 months after the intervention. The level of reported enjoyment was higher in the game-based group.

AUTHORS' CONCLUSIONS

The findings of this systematic review neither confirm nor refute the utility of games as a teaching strategy for health professionals. There is a need for additional high-quality research to explore the impact of educational games on patient and performance outcomes.

Reasons for not meeting coronary artery disease targets of care in ambulatory practice

INTRODUCTION

Four targets of care: control of blood pressure, control of low-density lipoprotein cholesterol level, taking aspirin daily, and not using tobacco improve outcomes for patients with coronary artery disease (CAD). We sought to identify why, in a large multispecialty group, these targets were not being met in patients with CAD.

METHODS

We thus conducted a retrospective review of patient records in the group practice's CAD registry, which is updated quarterly.

RESULTS

Of a random selection of 14,973 patients in the CAD registry, 353 charts were consecutively reviewed until theoretic saturation was achieved-that is, until no new information was found. We could not find any evidence of CAD in 14 patients, and we considered that all four targets had been met for 169 patients. The most frequent reasons for not meeting all targets of care among the 170 remaining patients were 1) the patient was in for a visit and the care team failed to address an unmet target of care (n = 98), 2) the patient was asked to come back for follow-up care but did not (n = 28), and 3) the patient declined an intervention that was offered (n = 14). Blood pressure and low-density lipoprotein cholesterol levels were the targets that were most frequently out of range.

CONCLUSION

Giving the health care team access to tools with which they can identify the concurrent care needs of their patients could significantly increase the proportion of patients with CAD for whom care targets are met. Lists generated by these tools would also be significantly more accurate than lists generated from quarterly reports.

Racial and ethnic service use disparities among homeless adults with severe mental illnesses receiving ACT

OBJECTIVE

Case management-based interventions aimed at improving quality of care have the potential to narrow racial and ethnic disparities among people with chronic illnesses. The aim of this study was to assess the equity effects of assertive community treatment (ACT), an evidence-based case management intervention, among homeless adults with severe mental illness.

METHODS

This study used baseline, three-, and 12-month data for 6,829 black, Latino, and white adults who received ACT services through the ACCESS study (Access to Community Care and Effective Services and Support). Zero-inflated Poisson random regression models were used to estimate the adjusted probability of use of outpatient psychiatric services and, among service users, the intensity of use. Odds ratios and rate ratios (RRs) were computed to assess disparities at baseline and over time.

RESULTS

No disparities were found in probability of use at baseline or over time. Compared with white users, baseline intensity of use was lower for black users (RR=.89; 95% confidence interval [CI]=.83-.96) and Latino users (RR=.65; CI=.52-.81]). Intensity did not change over time for whites, but it did for black and Latino users. Intensity increased for blacks between baseline and three months (RR=1.11, CI=1.06-1.17]) and baseline and 12 months (RR=1.17, CI=1.11-1.22]). Intensity of use dropped for Latinos between baseline and three months (RR=.83, CI=.70-.98).

CONCLUSIONS

Receipt of ACT was associated with a reduction in service use disparities for blacks but not for Latinos. Findings suggest that ACT's equity effects differ depending on race-ethnicity.

What should we include in a cultural competence curriculum? An emerging formative evaluation process to foster curriculum development

PURPOSE

To identify, prioritize, and organize components of a cultural competence curriculum to address disparities in cardiovascular disease.

METHOD

In 2006, four separate nominal group technique sessions were conducted with medical students, residents, community physicians, and academic physicians to generate and prioritize a list of concepts (i.e., ideas) to include in a curriculum. Afterward, 45 educators and researchers organized and prioritized the concepts using a card-sorting exercise. Multidimensional scaling (MDS) and hierarchical cluster analysis produced homogeneous groupings of related concepts and generated a cognitive map. The main outcome measures were the number of cultural competence concepts, their relative ranks, and the cognitive map.

RESULTS

Thirty participants generated 61 concepts; 29 were identified by at least two participants. The cognitive map organized concepts into four clusters, interpreted as (1) patient's cultural background (e.g., information on cultures, habits, values), (2) provider and health care (e.g., clinical skills, awareness of one's bias, patient centeredness, professionalism), communication skills (e.g., history, stereotype avoidance, health disparities epidemiology), (3) cross-culture (e.g., idiomatic expressions, examples of effective communication), and (4) resources to manage cultural diversity (e.g., translator guides, instructions, community resources). The MDS two-dimensional solution demonstrated a good fit (stress = 0.07; R² = 0.97).

CONCLUSIONS

A novel, combined approach allowed stakeholders' inputs to identify and cognitively organize critical domains used to guide development of a cultural competence curriculum. Educators may use this approach to develop and organize educational content for their target audiences, especially in ill-defined areas like cultural competence.

Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research

BACKGROUND

Cultural competency training has been proposed as a way to improve patient outcomes. There is a need for evidence showing that these interventions reduce health disparities.

OBJECTIVE

The objective was to conduct a systematic review addressing the effects of cultural competency training on patient-centered outcomes; assess quality of studies and strength of effect; and propose a framework for future research.

DESIGN

The authors performed electronic searches in the MEDLINE/PubMed, ERIC, PsycINFO, CINAHL and Web of Science databases for original articles published in English between 1990 and 2010, and a bibliographic hand search. Studies that reported cultural competence educational interventions for health professionals and measured impact on patients and/or health care utilization as primary or secondary outcomes were included.

MEASUREMENTS

Four authors independently rated studies for quality using validated criteria and assessed the training effect on patient outcomes. Due to study heterogeneity, data were not pooled; instead, qualitative synthesis and analysis were conducted.

RESULTS

Seven studies met inclusion criteria. Three involved physicians, two involved mental health professionals and two involved multiple health professionals and students. Two were quasi-randomized, two were cluster randomized, and three were pre/post field studies. Study quality was low to moderate with none of high quality; most studies did not adequately control for potentially confounding variables. Effect size ranged from no effect to moderately beneficial (unable to assess in two studies). Three studies reported positive (beneficial) effects; none demonstrated a negative (harmful) effect.

CONCLUSION

There is limited research showing a positive relationship between cultural competency training and improved patient outcomes, but there remains a paucity of high quality research. Future work should address challenges limiting quality. We propose an algorithm to guide educators in designing and evaluating curricula, to rigorously demonstrate the impact on patient outcomes and health disparities.

Factors influencing the effectiveness of interventions to reduce racial and ethnic disparities in health care

Reducing racial and ethnic disparities in health care has become an important policy goal in the United States and other countries, but evidence to inform interventions to address disparities is limited. The objective of this study was to identify important dimensions of interventions to reduce health care disparities. We used qualitative research methods to examine interventions aimed at improving diabetes and/or cardiovascular care for patients from racial and ethnic minority groups within five health care organizations. We interviewed 36 key informants and conducted a thematic analysis to identify important features of these interventions. Key elements of interventions included two contextual factors (external accountability and alignment of incentives to reduce disparities) and four factors related to the organization or intervention itself (organizational commitment, population health focus, use of data to inform solutions, and a comprehensive approach to quality). Consideration of these elements could improve the design, implementation, and evaluation of future interventions to address racial and ethnic disparities in health care.

Eight years of building community partnerships and trust: the UCLA family medicine community-based participatory research experience

Acknowledging the growing disparities in health and health care that exist among immigrant families and minority populations in large urban communities, the UCLA Department of Family Medicine (DFM) sought a leadership role in the development of family medicine training and community-based participatory research (CBPR). Performing CBPR requires that academic medicine departments build sustainable and long-term community partnerships. The authors describe the eight-year (2000-2008) process of building sustainable community partnerships and trust between the UCLA DFM and the Sun Valley community, located in Los Angeles County.The authors used case studies of three research areas of concentration (asthma, diabetes prevention, and establishing access to primary care) to describe how they established community trust and sustained long-term community research partnerships. In preparing each case study, they used an iterative process to review qualitative data.Many lessons were common across their research concentration areas. They included the importance of (1) having clear and concrete community benefits, (2) supporting an academic-community champion, (3) political advocacy, (4) partnering with diverse organizations, (5) long-term academic commitment, and (6) medical student involvement. The authors found that establishing a long-term relationship and trust was a prerequisite to successfully initiate CBPR activities that included an asthma school-based screening program, community walking groups, and one of the largest school-based primary care clinics in the United States.Their eight-year experience in the Sun Valley community underscores how academic-community research partnerships can result in benefits of high value to communities and academic departments.

Educational games for health professionals

BACKGROUND

The use of games as an educational strategy has the potential to improve health professionals' performance (e.g. adherence to standards of care) through improving their knowledge, skills and attitudes.

OBJECTIVES

The objective was to assess the effect of educational games on health professionals' performance, knowledge, skills, attitude and satisfaction, and on patient outcomes.

SEARCH STRATEGY

We used a comprehensive search strategy including an electronic search of the following databases: DARE, EPOC register, CENTRAL, MEDLINE, EMBASE, CINAHL, AMED, ERIC, and Dissertation Abstracts Online (search date: January 2007). We also screened the reference list of included studies and relevant reviews, contact authors of relevant papers and reviews, and searched ISI Web of Science for papers citing studies included in the review

SELECTION CRITERIA

We included randomized controlled trials (RCT), controlled clinical trials (CCT), controlled before and after (CBA) and interrupted time-series analysis (ITS). Study participants were qualified health professionals or in postgraduate training. The intervention was an educational game with "a form of competitive activity or sport played according to rules".

DATA COLLECTION AND ANALYSIS

Using a standardized data form we extracted data on methodological quality, participants, interventions and outcomes of interest that included patient outcomes, professional behaviour (process of care outcomes), and professional's knowledge, skills, attitude and satisfaction.

MAIN RESULTS

The search strategy identified 1156 citations. Out of 55 potentially eligible citations, we included one RCT. The methodological quality was fair. The game, used as a reinforcement technique, was based on the television game show "Family Feud" and focused on infection control. The study did not assess any patient or process of care outcomes. The group that was randomized to the game had statistically higher scores on the knowledge test (P = 0.02).

AUTHORS' CONCLUSIONS

The findings of this systematic review do not confirm nor refute the utility of games as a teaching strategy for health professionals. There is a need for additional high-quality research to explore the impact of educational games on patient and performance outcomes.

Ethics of complementary and alternative medicine use in children

Complementary and alternative medicine (CAM) has enjoyed tremendous public interest in North America in recent years. CAM is used most often by those who have serious, chronic, or recurrent illness, sometimes for symptom control and sometimes to combat the primary disease. Others use CAM to promote wellness or as a prophylaxis. CAM therapies are increasingly being offered in conventional medical settings and at various other centers and institutes. The relevant ethical commitments or values that must be considered are social commitment to public welfare, nonmaleficence, respect for patient autonomy/consumer choice, recognition of medical pluralism, and public accountability. This article explores the major ethical principles involved in pediatric CAM use and how they affect clinical care and research.

Interpersonal processes of care survey: patient-reported measures for diverse groups

OBJECTIVE

To create a patient-reported, multidimensional physician/patient interpersonal processes of care (IPC) instrument appropriate for patients from diverse racial/ethnic groups that allows reliable, valid, and unbiased comparisons across these groups. DATA SOURCE/DATA COLLECTION: Data were collected by telephone interview. The survey was administered in English and Spanish to adult general medicine patients, stratified by race/ethnicity and language (African Americans, English-speaking Latinos, Spanish-speaking Latinos, non-Latino whites) (N=1,664).

STUDY DESIGN/METHODS

In this cross-sectional study, items were designed to be appropriate for diverse ethnic groups based on focus groups, our prior framework, literature, and cognitive interviews. Multitrait scaling and confirmatory factor analysis were used to examine measurement invariance; we identified scales that allowed meaningful quantitative comparisons across four race/ethnic/language groups.

PRINCIPAL FINDINGS

The final instrument assesses several subdomains of communication, patient-centered decision making, and interpersonal style. It includes 29 items representing 12 first-order and seven second-order factors with equivalent meaning (metric invariance) across groups; 18 items (seven factors) allowed unbiased mean comparison across groups (scalar invariance). Final scales exhibited moderate to high reliability.

CONCLUSIONS

The IPC survey can be used to describe disparities in interpersonal care, predict patient outcomes, and examine outcomes of quality improvement efforts to reduce health care disparities.

A program to reduce the disparity in the rate of biennial lipid profiles between African-American and white Medicare beneficiaries with diabetes mellitus in New York City

The burden of diabetes is more severe for minority populations than for the white population in the United States. Analysis of Medicare fee-for-service claims data revealed a significant disparity regarding screening for lipids between white and African-American Medicare beneficiaries with diabetes as measured by the biennial lipid profile indicator in New York State and the disparity was even greater in New York City. Thus IPRO, the Medicare New York State Quality Improvement Organization, launched a multifaceted quality improvement project to reduce the disparity, targeting African-American Medicare beneficiaries with diabetes in New York City and the providers who serve them. There was an absolute increase of 16.7% in the proportion of African-American beneficiaries with diabetes receiving a biennial lipid profile in the intervention areas and the disparity reduced by 9.8% between African-American and all eligible white beneficiaries in the intervention areas. Although it was not feasible to determine the direct impact of selected interventions on reducing the disparity, the interventions collectively appeared to be effective.

"That never would have occurred to me": a qualitative study of medical students' views of a cultural competence curriculum

BACKGROUND

The evidence is mixed regarding the efficacy of cultural competence curricula in developing learners' knowledge, attitudes and skills. More research is needed to better understand both the strengths and shortcomings of existing curricula from the perspective of learners in order to improve training.

METHODS

We conducted three focus groups with medical students in their first year of clinical training to assess their perceptions of the cultural competence curriculum at a public university school of medicine.

RESULTS

Students evaluated the informal curriculum as a more important source of learning about cultural competence than the formal curriculum. In terms of bias in both self and others, the cultural competence curriculum increased awareness, but was less effective in teaching specific interventional skills. Students also noted that the cultural competence curriculum did not always sufficiently help them find a balance between group-specific knowledge and respect for individual differences. Despite some concerns as to whether political correctness characterized the cultural competence curriculum, it was also seen as a way to rehumanize the medical education experience.

CONCLUSION

Future research needs to pay attention to issues such as perceived relevance, stereotyping, and political correctness in developing cross-cultural training programs.

Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions

BACKGROUND

Despite awareness of inequities in health care quality, little is known about strategies that could improve the quality of healthcare for ethnic minority populations. We conducted a systematic literature review and analysis to synthesize the findings of controlled studies evaluating interventions targeted at health care providers to improve health care quality or reduce disparities in care for racial/ethnic minorities.

METHODS

We performed electronic and hand searches from 1980 through June 2003 to identify randomized controlled trials or concurrent controlled trials. Reviewers abstracted data from studies to determine study characteristics, results, and quality. We graded the strength of the evidence as excellent, good, fair or poor using predetermined criteria. The main outcome measures were evidence of effectiveness and cost of strategies to improve health care quality or reduce disparities in care for racial/ethnic minorities.

RESULTS

Twenty-seven studies met criteria for review. Almost all (n = 26) took place in the primary care setting, and most (n = 19) focused on improving provision of preventive services. Only two studies were designed specifically to meet the needs of racial/ethnic minority patients. All 10 studies that used a provider reminder system for provision of standardized services (mostly preventive) reported favorable outcomes. The following quality improvement strategies demonstrated favorable results but were used in a small number of studies: bypassing the physician to offer preventive services directly to patients (2 of 2 studies favorable), provider education alone (2 of 2 studies favorable), use of a structured questionnaire to assess adolescent health behaviors (1 of 1 study favorable), and use of remote simultaneous translation (1 of 1 study favorable). Interventions employing more than one main strategy were used in 9 studies with inconsistent results. There were limited data on the costs of these strategies, as only one study reported cost data.

CONCLUSION

There are several promising strategies that may improve health care quality for racial/ethnic minorities, but a lack of studies specifically targeting disease areas and processes of care for which disparities have been previously documented. Further research and funding is needed to evaluate strategies designed to reduce disparities in health care quality for racial/ethnic minorities.

Physician notification of their diabetes patients' limited health literacy. A randomized, controlled trial

BACKGROUND

Many patients with chronic disease have limited health literacy (HL). Because physicians have difficulty identifying these patients, some experts recommend instituting screening programs in clinical settings. It is unclear if notifying physicians of patients' limited HL improves care processes or outcomes.

OBJECTIVE

To determine whether notifying physicians of their patients' limited HL affects physician behavior, physician satisfaction, or patient self-efficacy.

DESIGN

We screened all patients for limited HL and randomized physicians to be notified if their patients had limited HL skills.

PARTICIPANTS

Sixty-three primary care physicians affiliated with a public hospital and 182 diabetic patients with limited HL.

MEASUREMENTS

After their visit, physicians reported their management strategies, satisfaction, perceived effectiveness, and attitudes toward HL screening. We also assessed patients' self-efficacy, feelings regarding HL screening's usefulness, and glycemic control.

RESULTS

Intervention physicians were more likely than control physicians to use management strategies recommended for patients with limited HL (OR 3.2, P=.04). However, intervention physicians felt less satisfied with their visits (81% vs 93%, P=.01) and marginally less effective (38% vs 53%, P=.10). Intervention and control patients' post-visit self-efficacy scores were similar (12.6 vs 12.9, P=.6). Sixty-four percent of intervention physicians and 96% of patients felt HL screening was useful.

CONCLUSIONS

Physicians are responsive to receiving notification of their patients' limited HL, and patients support the potential utility of HL screening. However, instituting screening programs without specific training and/or system-wide support for physicians and patients is unlikely to be a powerful tool in improving diabetes outcomes.

Physician notification of their diabetes patients' limited health literacy. A randomized, controlled trial

BACKGROUND

Many patients with chronic disease have limited health literacy (HL). Because physicians have difficulty identifying these patients, some experts recommend instituting screening programs in clinical settings. It is unclear if notifying physicians of patients' limited HL improves care processes or outcomes.

OBJECTIVE

To determine whether notifying physicians of their patients' limited HL affects physician behavior, physician satisfaction, or patient self-efficacy.

DESIGN

We screened all patients for limited HL and randomized physicians to be notified if their patients had limited HL skills.

PARTICIPANTS

Sixty-three primary care physicians affiliated with a public hospital and 182 diabetic patients with limited HL.

MEASUREMENTS

After their visit, physicians reported their management strategies, satisfaction, perceived effectiveness, and attitudes toward HL screening. We also assessed patients' self-efficacy, feelings regarding HL screening's usefulness, and glycemic control.

RESULTS

Intervention physicians were more likely than control physicians to use management strategies recommended for patients with limited HL (OR 3.2, P=.04). However, intervention physicians felt less satisfied with their visits (81% vs 93%, P=.01) and marginally less effective (38% vs 53%, P=.10). Intervention and control patients' post-visit self-efficacy scores were similar (12.6 vs 12.9, P=.6). Sixty-four percent of intervention physicians and 96% of patients felt HL screening was useful.

CONCLUSIONS

Physicians are responsive to receiving notification of their patients' limited HL, and patients support the potential utility of HL screening. However, instituting screening programs without specific training and/or system-wide support for physicians and patients is unlikely to be a powerful tool in improving diabetes outcomes.