Poor Patient-provider Communication Research Articles

LGBTQ Youth's Perceptions of Primary Care.

Despite published guidelines on the need to provide comprehensive care to lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) youth, there has been limited research related to the deliverance of primary health care to this population. The goals of this study were to learn about LGBTQ youth's experiences with their primary care physicians and to identify areas for improvement. Youth attending 1 of 5 community-based programs completed a written questionnaire and participated in a focus group discussion regarding experiences at primary care visits, including topics discussed, counselling received, and physician communication. Most of the youth did not feel their health care needs were well met. The majority acknowledged poor patient-provider communication, disrespect, and lack of discussions about important topics such as sexual and emotional health. Participants cited concerns about confidentiality and inappropriate comments as barriers to care. Youth expressed a strong desire to have physicians be more aware of their needs and concerns.

Colorectal Cancer Screening in Vulnerable Patients: Promoting Informed and Shared Decisions.

Low-income, low-literacy, limited English-proficient populations have low colorectal cancer (CRC) screening rates and experience poor patient-provider communication and decision-making processes around screening. The purpose of this study was to test the effect of a CRC screening decision aid on screening-related communication and decision making in primary care visits. RCT with data collected from patients at baseline and immediately after the provider encounter. Patients aged 50-75 years, due for CRC screening, were recruited from two safety net clinics in North Carolina and New Mexico (data collection, January 2014-September 2015; analysis, 2015). Participants viewed a CRC screening decision aid or a food safety (control) video immediately before their provider encounter. CRC screening-related knowledge, discussion, intent, test preferences, and test ordering. The study population (N=262) had a mean age of 58.3 years and was 66% female, 61% Latino, 17% non-Latino black, and 16% non-Latino white. Among Latino participants, 71% preferred Spanish. Compared with controls, intervention participants had greater screening-related knowledge (on average 4.6 vs 2.8 of six knowledge items correct, adjusted difference [AD]=1.8, 95% CI=1.5, 2.1) and were more likely to report screening discussion (71.0% vs 45.0%, AD=26.1%, 95% CI=14.3%, 38.0%) and high screening intent (93.1% vs 84.7%, AD=9.0%, 95% CI=2.0%, 16.0%). Intervention participants were more likely to indicate a specific screening test preference (93.1% vs 68.0%, AD=26.5%, 95% CI=17.2%, 35.8%) and to report having a test ordered (56.5% vs 32.1%, AD=25.8%, 95% CI=14.4%, 37.2%). Viewing a CRC screening decision aid before a primary care encounter improves knowledge and shared decision making around screening in a racially, ethnically, and linguistically diverse safety net clinic population. This study is registered at www.clinicaltrials.gov NCT02054598.

Transitioning from Pediatric to Adult Diabetes Care

Objective : The clinical transition from pediatric to adult diabetes care is often challenging for both young adults with type 1 diabetes (T1D) and the health care providers (HCPs) who care for this population. This study presents insights into the perceptions and needs of both patients with diabetes and HCPs during the clinical transition. Research Design and Methods : Two separate surveys were administered with questions specifically tailored to each audience. Perceptions of the transition phase for both patients with T1D and HCPs were analyzed for general trends and then compared to investigate similarities and differences between patient and provider needs. Results : Both patients and HCPs expressed concerns regarding poor patient-provider communication during transition and the barriers to independently managing diabetes self-care responsibilities (e.g. navigating insurance, ordering supplies, arranging healthcare appointments). Although 45% of HCPs reported screening transition age patients for mental health issues related to diabetes, only 9% of patients stated their provider offered this opportunity. Furthermore, patients reported facing a variety of challenges not discussed with their HCP including: sexual issues (28%), depression or anxiety (17%), and eating disorders (11%). Conclusions : Training in the assessment of young adult T1D needs and effective communication techniques may assist HCPs in working more effectively with young adults. Offering mental health screenings for transition age patients may open the conversation to discuss diabetes concerns such as depression, sexual challenges, and eating disorders not currently being addressed. Both patients and providers desire improved communication with more emphasis on independently managing diabetes responsibilities and adjusting to new life situations.

Why Educators Should Apply Theories and Models of Health Education and Health Promotion to Teach Communication Skills to Nursing and Medical Students.

Why medical and nursing students need education in communication skills? And how these skills should be thought? These are two important questions in medical education. Effective communication between health care providers and their clients is a crucial factor in patient-centered care. Identifying clients’ needs and taking appropriate actions to overcome these problems need appropriate communication skills (1). Providing effective communication skills to nursing and midwifery students and helping them to reflect this on both work and personal lives is one of the main goals of education (2). According to Simonson (3), 25 years ago, formal writing courses were not offered at about 86 of 101 (85%) responding American medical schools. Furthermore, regarding his professional commitment, he hoped that his residents as well as other medical students would benefit from “formal professional written and verbal communication” programs soon. After 25 years, thanks to very admirable efforts of educational policy makers, the number of medical schools that offer formal communication skills has been significantly increased; however, the number of patient complaints about physicians and nurses communication skills has been dramatically increased. For instance, in content analysis of 1216 complaints of patients by Montini et al., “poor provider-patient communication” contributed to 17% of complaints (4). In a study in Turkey, nursing students’ mean score of communication skills scale was 165.27, which showed a moderate level of these skills (2). Benbassat found that teaching interviewing skills to medical students had serious problems. First the students were faced with wide variability in interviewing styles and different role models, second clinical teachers were not usually specialists in patient interviewing and third there was no valid method for assessment of interviewing skills (5). It seems that the efficacy of our communication skills programs is still under question and as Simonson has recommended, it needs something more than theoretical teaching (3). For instance, role modeling, critical reflections and formative and summative evaluations should be integrated in teaching programs. The role of theories in designing and conducting medical and nursing education is well defined. Learning theories are popular within nursing education and many important notions such as self-monitoring and simulation design have been derived from these theories. Sociocultural theories have been largely overlooked in medical and nursing education (6). It is believed that theories and models in health education and health promotion (HEHP) should be used in planning, implementing and evaluation of any educational programs about communication skills to enhance the success rate of educational programs (7). In “effective training strategies for teaching communication skills to physicians: an overview of systematic reviews” (8), the methodological errors of studies were reported as one of the limitations of overview. Reporting such an error in many studies supports the idea of using theories and models of HEHP in teaching communication skills. Indeed, applying theories and models would decrease methodological errors of studies, which in turn, would allow instructional designers to access many valid and reliable educational strategies. Applying theories and models of HEHP in instructional designs regarding communication skills should be a crucial concern of educators; otherwise, their blind attempts to improve medical students’ communication skills would usually fail to succeed. Moreover, using different constructs of theories and models of HEHP lets educators recognize constructs which are the most important predictors of physicians’ successful communication behaviors. Consequently, designing educational programs based on highly predictive constructs would be the key to their success. Based on social, epidemiological, educational and administrative and policy assessment, performed in a recent Ph.D. dissertation in Tarbiat Modarres University, Precede–Proceed model was the effective model for planning interns’ physician-patient communication skills and for the most part, the items from interviews with 14 faculty members and 7 medical interns were matched with the constructs of Social Cognitive Theory. Based on confirmatory factor analysis (CFA), the most important predictors of successful communication behavior among interns were recognized and used to write lesson plans to train participants in the intervention group of the educational quasi-experimental study (IRCT2013021812511N1). Having a good grasp of theories and models of HEHP and practicing theories and models of HEHP in formal communication courses by educators and health leaders would improve the outcome measures of communication skills programs. For this reason, educators should appreciate that theories and models are for all health care administers, not just for students.

Patient Health Literacy and Perception of Provider Communication: Is there a Link?

Inadequate health literacy is a common problem that contributes to poor patient-provider communication. Health literacy screening and specific provider communication practices may be important in clinics where patients are at high risk for inadequate health literacy. This study assessed patients’ health literacy and their perception of provider communication practices in a primary care residency program clinic serving an urban multi-ethnic population. A convenience sample of 324 patients in an urban-based primary care practice was surveyed for health literacy and their perception of physician communication using validated instruments. Of the patients surveyed, 37% had inadequate health literacy. There was high internal consistency of our validated screening questions for health literacy (p < .0001). Overall, the patients surveyed rated the quality of their provider’s communication very highly. We found no statistically significant relationship between patients’ health literacy and their perception of provider communication, suggesting provider communication may be independent of patient understanding in this cohort. Effective communication from providers may compensate for lack of understanding with patients with inadequate health literacy in urban primary care practices.

Medication adherence in type 2 diabetes patients in Nigeria.

Medication adherence is a major universal factor influencing patient health outcomes, particularly in chronic diseases such as diabetes. Poor adherence to antidiabetes medication can cause therapeutic failure, leading to manifestation of diabetes-related complications, such as retinopathy, neuropathy, nephropathy, etc., reduced quality of life, and increased healthcare costs. To forestall these, likely predictors of medication nonadherence should be assessed and addressed appropriately. The purpose of this work was therefore to assess medication adherence among type 2 diabetes patients and to identify patient characteristics and probable factors associated with nonadherence. A descriptive, cross-sectional research design was used. The study was conducted on 360 ambulatory type 2 diabetes patients attending an endocrinology clinic between June 2012 and February 2013. The eight-item Modified Morisky Adherence Scale was used to assess medication adherence; sociodemographic information and respondents' opinion on the possible barrier(s) to medication adherence were also obtained. Data were analyzed using SPSS version 14.0 software (SPSS, Inc., Chicago, IL). Of the 303 patients included in the final analysis, 19.8% of respondents were judged to be highly adherent. Medium and low adherers were 30.0% and 50.2%, respectively. The median adherence score was 5.75 (interquartile range, 4.5-7.0). Adherence to medication correlated with low literacy level (P=0.008), forgetfulness (P=0.009), high cost of medication (P=0.014), limited access to care (P=0.001), complexity of regimen (P=0.001), poor patient-provider communication (P=0.000), lack of trust in the provider (P=0.046), and depression (P=0.031). No statistically significant relationship was found between patients' characteristics and medication adherence. Medication adherence was generally poor among the cohorts studied.

A qualitative examination of secondary prophylaxis in rheumatic heart disease: factors influencing adherence to secondary prophylaxis in Uganda.

Rheumatic heart disease (RHD) is the most common cause of heart disease among Ugandans age 15 to 49 years. Secondary prophylaxis with monthly injection of benzathine penicillin is effective in preventing recurrence of acute rheumatic fever and worsening of RHD, but adherence rates are poor in Uganda. This study sought to identify health behaviors, attitudes, and health care system factors that influence adherence to RHD secondary prophylaxis. We conducted 5 structured focus groups with 36 participants on monthly penicillin injections for RHD in Kamplala, Uganda. Transcripts were analyzed using qualitative description analysis and health behavior models. Most participants were female (64%), from an urban area (81%), and had family income less than US$1 daily (69%). Ages ranged from 14 to 58 years. Median prophylaxis duration was 1.42 years and 58% were adherent (≥80% of injections). Key facilitators include perceived worsening of disease with missing injections, personal motivation, a reminder system for injections, supportive family and friends, and a positive relationship with health care providers. Barriers to adherence include lack of resources for transportation and medications, fear of injection pain, poor patient-provider communication, and poor availability of clinics and providers able to give injections. We identified key facilitators and barriers to secondary prophylaxis for RHD from the patient perspective framed within the socioecological model. Our findings provide direction for intervention development to improve national RHD secondary prophylaxis.

Improved A1C and Lipid Profile in Patients Referred to Diabetes Education Programs in a Wide Health Care Network: A Retrospective Study.

Diabetes is a chronic disease characterized by high blood glucose levels and caused either by a deficiency of insulin or a defect in the way the body responds to insulin.1,2 The increased prevalence of type 2 diabetes is believed to be the consequence of an aging population, increased physical inactivity and obesity, and genetic factors.3,4 Diabetes is one of the leading causes of blindness and renal failure,5,6 and people with diabetes who have an increased A1C level and uncontrolled lipid levels have increased rates of morbidity and mortality. Complications usually fall into three main groups: acute metabolic abnormalities, microvascular anomalies, and long-term cardiovascular disorders specific to diabetes.7 The main treatment goals for diabetes are controlling blood glucose and cholesterol levels and maintaining a normal blood pressure.8 Tight control and management of blood glucose and blood pressure has been proven to prevent or delay complications of diabetes.9 Involving patients in their care through self-management is of utmost importance to achieving these goals. Yet, self-management is difficult to attain and maintain because of the complexity of the processes involved and the lack of motivation and skills on the part of some patients.10 Frequently reported barriers to self-management11,12 include knowledge deficits, poor patient-provider communication, low self-efficacy, limitations of time or resources, financial constraints, lack of individualized and coordinated care, and lifestyle differences among family members. An extensive review of 16 studies identified barriers from five different perspectives: psychosocial, socioeconomic, physical, environmental, and cultural.13 It is widely believed that educating patients about diabetes may be a mechanism to encourage and support them in assuming active responsibility for self-management. Based on this belief, several educational programs have been developed.14,15 Diabetes education, also known as diabetes …

A Metasynthesis of Patient-Provider Communication in Hospital for Patients with Severe Communication Disabilities: Informing New Translational Research

Poor patient–provider communication in hospital continues to be cited as a possible causal factor in preventable adverse events for patients with severe communication disabilities. Yet to date there are no reports of empirical interventions that investigate or demonstrate an improvement in communication in hospital for these patients. The aim of this review was to synthesize the findings of research into communication in hospital for people with severe communication disabilities arising from lifelong and acquired stable conditions including cerebral palsy, autism, intellectual disability, aphasia following stroke, but excluding progressive conditions and those solely related to sensory impairments of hearing or vision. Results revealed six core strategies suggested to improve communication in hospital: (a) develop services, systems, and policies that support improved communication, (b) devote enough time to communication, (c) ensure adequate access to communication tools (nurse call systems and communication aids), (d) access personally held written health information, (e) collaborate effectively with carers, spouses, and parents, and (f) increase the communicative competence of hospital staff. Currently there are no reports that trial or validate any of these strategies specifically in hospital settings. Observational and evaluative research is needed to investigate the ecological validity of strategies proposed to improve communication.

An unequal burden: Poor patient–provider communication and sickle cell disease

ObjectiveTo assess disparities in the quality of healthcare provider communication experienced by African-American adults with and without sickle cell disease (SCD) in the U.S. MethodsPoor provider communication was assessed by the Provider Communication subscale of the Consumer Assessment of Healthcare Plans and Systems survey. The SCD sample was obtained from participants in a multicenter observational study of healthcare experiences. The national African-American sample data was obtained from published national estimates. ResultsThe SCD sample was more likely than the national sample to report poor communication in 3 out of 4 communication domains: listening (22.3% vs. 11.5%, p<0.0001); showing respect (26.1% vs. 9.5%, p<0.0001); and spending enough time (38.3% vs. 16.2%, p<0.0001). Differences were consistent in young, but not old, patients and showed some variation by self-reported health status and education. ConclusionsThe communication difficulties experienced by persons with SCD do not appear reducible to their predominantly African-American race, but may result from more disease-specific factors. Practice implicationsHealthcare providers should take particular care in recognizing and demonstrating recommended communication skills with SCD patients as these patients may be particularly vulnerable to, and cognizant of, poor quality interactions.

The impact of depressive symptoms on patient–provider communication in HIV care

Persons with HIV who develop depression have worse medical adherence and outcomes. Poor patient–provider communication may play a role in these outcomes. This cross-sectional study evaluated the influence of patient depression on the quality of patient–provider communication. Patient–provider visits (n=406) at four HIV care sites were audio-recorded and coded with the Roter Interaction Analysis System (RIAS). Negative binomial and linear regressions using generalized estimating equations tested the association of depressive symptoms, as measured by the Center for Epidemiology Studies Depression scale (CES-D), with RIAS measures and postvisit patient-rated quality of care and provider-reported regard for his or her patient. The patients, averaged 45 years of age (range =20–77), were predominately male (n=286, 68.5%), of black race (n=250, 60%), and on antiretroviral medications (n=334, 80%). Women had greater mean CES-D depression scores (12.0) than men (10.6; p=0.03). There were no age, race, or education differences in depression scores. Visits with patients reporting severe depressive symptoms compared to those reporting none/mild depressive symptoms were longer and speech speed was slower. Patients with severe depressive symptoms did more emotional rapport building but less social rapport building, and their providers did more data gathering/counseling (ps<0.05). In postvisit questionnaires, providers reported lower levels of positive regard for, and rated more negatively patients reporting more depressive symptoms (p<0.01). In turn, patients reporting more depressive symptoms felt less respected and were less likely to report that their provider knows them as a person than none/mild depressive symptoms patients (ps<0.05). Greater psychosocial needs of patients presenting with depressive symptoms and limited time/resources to address these needs may partially contribute to providers' negative attitudes regarding their patients with depressive symptoms. These negative attitudes may ultimately serve to adversely impact patient–provider communication and quality of HIV care.

Perceptions of drug users regarding Hepatitis C screening and care: a qualitative study

BackgroundIllicit drug users have a high prevalence of HCV and represent the majority of newly infected persons in the U.S. Despite the availability of effective HCV treatment, few drug users have been evaluated or treated for HCV. Racial and ethnic minorities have a higher incidence and prevalence of HCV and higher HCV-related mortality. Factors contributing to poor engagement in care are incompletely understood.MethodsFourteen mixed-gender focus groups of either African American or Latino/a drug users (N = 95) discussed barriers to HCV testing and treatment. Themes were identified through content analysis of focus group discussions.ResultsMany drug users were tested for HCV in settings where they were receiving care. Outside of these settings, most were unaware of voluntary test sites. After testing HCV positive, drug users reported not receiving clear messages regarding the meaning of a positive HCV test, the impact of HCV infection, or appropriate next steps including HCV clinical evaluations. Many drug users perceived treatment as unimportant because they lacked symptoms, healthcare providers minimized the severity of the diagnosis, or providers did not recommend treatment. Mistrust of the motivations of healthcare providers was cited as a barrier to pursuing treatment. Social networks or social interactions were a source of HCV-related information and were influential in shaping drug users perceptions of treatment and its utility.ConclusionDrug users perceived a paucity of settings for self-initiated HCV testing and poor provider-patient communication at test sites and during medical encounters. Notably, drug users reported having an unclear understanding about the meaning of a positive HCV test, the health implications of HCV infection, the importance of clinical evaluations and monitoring, and of treatment options for HCV. Efforts to improve the delivery of clinical messages about HCV infection for drug users at test settings and clinical encounters are needed.

HPV Vaccine Status and BMI Correlation

Obese women are at increased risk of death from cervical cancer compared to non-obese women. Yet, research indicates a lower rate of cervical cancer screening among obese women, especially severely obese white women. Cited reasons for delaying screening include embarrassment, perceived weight stigma, lack of appropriately sized examination equipment and poor patient-provider communication. Parental acceptance of the Human Papillomavirus (HPV) vaccine for overweight adolescent females may decrease the incidence of cervical cancer among obese women in later years. This study seeks to determine the Human Papillomavirus (HPV) vaccination status of females, ages 11 to 21 years, in a university-based pediatric practice and to determine the correlation between HPV vaccine status and body mass index (BMI). Methods: We reviewed 800 randomly selected paper medical charts of females, ages 11 to 21 years, enrolled in a university-based pediatric practice as of October 31, 2008. Data collected included age, height, weight, BMI, race, insurance carrier, immunizations, sexually transmitted infections (STIs) and documentation of STI prevention counseling. Statistical analysis was performed to determine associations among risk factors and outcome variables. Results: 800 charts reviewed; 91 were incomplete due to missing documentation of immunizations. The remaining 709 charts included 338 (48.2%) African Americans; 302 (43.1%) Whites; 26 (3.7%) Hispanics; and 35 (5%) other. Approximately 28.2% had current HPV vaccine status. There was no correlation between HPV vaccination status and BMI (p >0.05).

Abstract PR07: Racial-ethnic disparities in patient-provider communication and overall perceptions of follow-up care quality among adult cancer survivors.

Abstract Purpose: Poor patient-provider communication (PPC) may contribute to racial-ethnic disparities in healthcare, and is critical to quality cancer survivorship care. Racial-ethnic differences in PPC have been noted among cancer survivors; however, previous studies have focused primarily on comparing White and African American patients and survivors recently diagnosed or treated for cancer. This study examined racial-ethnic differences in PPC and its association with perceived follow-up care quality among a diverse sample of long-term cancer survivors. Methods: Survivors of breast, prostate, colorectal, ovarian and endometrial cancers were recruited from Surveillance Epidemiology and End Results cancer registries in California to complete a mailed survey on cancer follow-up care. African American, Asian/Pacific Islander (Asian), Hispanic, and non-Hispanic White (White) cancer survivors were selected for this analysis if they had seen a doctor for cancer-related follow-up care in the past two years (n=1215). We conducted linear regression analyses to identify racial-ethnic differences in PPC (general follow-up care communication and explanation of medical tests). We used logistic regression models to examine the association between race-ethnicity and dichotomized perceived follow-up care quality outcomes: overall rating (very good/excellent vs. poor/fair/good) and receipt of desired help with symptoms/side effects (usually/always vs. never/sometimes). Finally, we added PPC to the adjusted logistic regression models to assess the effect of PPC on racial-ethnic differences in perceived follow-up care quality, adjusting for covariates (age, gender, education, insurance, comorbidities, cancer treatment modalities, cancer site, stage at diagnosis, number of provider visits for follow-up care, time since most recent follow-up care visit, duration of relationship with follow-up care provider, and whether it was the same provider seen for cancer treatment). Results: Of the 1215 survivors, 24% were African American, 22% were Asian, 13% were Hispanic, and 39% were White. Compared to White survivors, all minority survivors reported poorer explanation of medical tests (F=4.69, p=0.003), and Asian and Hispanic survivors reported poorer follow-up care communication (F=11.42, p&amp;lt;0.001). Asian survivors were also less likely to report receipt of desired help with symptoms/side effects (OR=0.46, 95%CI: 0.27-0.79), and both African American and Asian survivors were less likely to report high overall ratings of follow-up care quality (OR= 0.55, 95%CI: 0.38-0.79 and OR=0.43, 95%CI: 0.30-0.62, respectively) compared to White survivors. In fully adjusted models, including PPC, Asian survivors remained less likely to rate overall follow-up care quality as good/excellent (OR: 0.51, 95%CI: 0.28-0.93) compared to White survivors. No other significant racial-ethnic differences persisted. Conclusions: Both Asian and Hispanic survivors reported poorer PPC. For some survivors, PPC may help to explain disparities in perceived follow-up care quality; however, Asian survivors reported poorer overall ratings of follow-up care, despite controlling for covariates and PPC. Addressing PPC is important as poor communication may also affect survivors' ability to actively participate in follow-up care. This abstract is also presented as Poster A12. Citation Format: Nynikka R.A. Palmer, Neeraj K. Arora, Erin Kent, Laura Forsythe, Julia H. Rowland, Noreen Aziz, Kathryn E. Weaver. Racial-ethnic disparities in patient-provider communication and overall perceptions of follow-up care quality among adult cancer survivors. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr PR07.

Depressive Symptoms and Reduced Preventive Care Use in Older Adults

Depressive symptomatology is common in older adults and is associated with reduced adherence to recommended preventive care, but little is known as to why. Understanding how depressive symptoms may interfere with adherence can help to identify leverage points for interventions to increase preventive service use. This study examined perceived access to medical care as a possible mediator linking depressive symptomatology to reduced preventive service use in older adults. We analyzed data from 5465 respondents completing the 1993 and 2003/2004 waves of the Wisconsin Longitudinal Study. Depressive symptomatology was assessed using the Center for Epidemiologic Studies Depression Scale. Perceived access survey items were organized through factor analysis to represent key dimensions of access: availability/accessibility, affordability, acceptability, and accommodation. The primary outcome was the total number of 7 recommended preventive services that respondents received. Multivariate path analysis was used to estimate direct and indirect effects between depressive symptomatology, perceived access, and preventive service use. Older adults with depressive symptomatology received fewer recommended services. Depressive symptomatology reduced preventive service use by adversely affecting 2 dimensions of perceived access: (1) acceptability, pertaining to poor patient-provider trust and communication, and (2) accommodation, pertaining to inconveniently organized services. Depressive symptomatology may negatively alter older adults' perceptions of access and, in turn, negatively impact their preventive service use. In addition to treating depression, interventions designed to mitigate the impact of depression on the patient-provider relationship, and organizational changes to practice that better accommodate the needs of depressed patients, may increase adherence to preventive care guidelines in depressed older adults.

Unequal Treatment in the US

Despite interventions that have improved the overall health of the majority of Americans, racial and ethnic minorities have benefited less from these advances. Research has shown that multiple factors contribute to racial and ethnic disparities in health, health care, and cancer care. The Institute of Medicine Report, "Unequal Treatment" provides a detailed examination of racial/ethnic disparities in health care in the U.S., highlighting three clinical contributors--poor provider-patient communication, stereotyping in clinical decisionmaking, and patient mistrust. Although the findings and recommendations in "Unequal Treatment" are broad in scope, they provide a blueprint for how to address disparities in health care in general-as well as cancer care-and have direct implications for clinical practice, both nationally and internationally. We propose a patient-based approach to cross-cultural care as a model to improve communication with racial and ethnic minorities, and cross-cultural populations in general. We also highlight the importance of community based interventions, such as those that use health care navigators to promote cancer screening. If we hope to provide effective cancer care around the world, we must be attentive to the factors that impact minorities and vulnerable populations, and be prepared to address them.

140 Exploring Heart Failure-Related Emergency Department Visits and Hospitalizations From the Patient Perspective

Low-income African-Americans with heart failure represent a vulnerable population that has poor clinical outcomes despite high rates of emergency department (ED) visits and hospitalizations. The patient-level factors that contribute to these high rates of health service utilization have not been clearly defined. The purpose of this study is to identify, among low-income African-Americans, patient-perceived medical and social challenges that contribute to poor heart failure-related clinical outcomes, avoidable ED visits, and avoidable hospitalizations. Semi-structured interviews were conducted with a convenience sample of African-American patients who presented to a high volume, inner-city, county-owned, teaching ED in Los Angeles. Patients were eligible for the study if they were being admitted to the hospital for a chronic heart failure exacerbation. The patients were interviewed in the ED or inpatient medicine ward. The interview incorporated questions to examine patients' experiences and beliefs regarding heart failure-related quality of life, general heart failure knowledge, patient-provider interactions, medication adherence, self-management skills, and health system navigation. Two follow-up interviews were performed by telephone with each study participant at 7 days and 30 days following discharge. The follow-up interviews included additional questions regarding patient satisfaction, the quality and comprehension of hospital discharge instructions, ease of new medication regimen, and outpatient follow-up care. Audio files of the interviews were transcribed and organized using Atlas.ti software. Themes were coded using grounded theory methods. Theme saturation was pre-defined as the identification of recurrent themes in greater than 70% of the interviews. Preliminary interviews were conducted with 7 African-American patients with a hospital admission diagnosis of chronic heart failure. The patients consisted of 5 men and 2 women, whose age ranged from 47 to 65 years old. One patient had Medicare insurance and the remaining patients were uninsured. All of the patients had a New York Heart Association classification of 3. Five salient themes were consistently identified that were believed by the patients to contribute to poor health and increased use of hospital-based care: 1) Competing demands due to economic or social stressors which results in medication noncompliance, 2) Dietary challenges and lack of nutrition education, 3) Poor patient-provider communication and/or interactions, 4) Unwarranted judgment by health providers and/or family, and 5) Lack of social support to make and maintain healthy lifestyle changes. All of the patients stated that they had adequate access to health care providers and heart failure related information. African-Americans with heart failure represent a vulnerable population that is subject to poor health outcomes despite costly health service utilization. However, lack of access to medical care is not a patient-perceived contributor to poor health. This qualitative study suggests that social and community factors may have a greater than expected impact on health behaviors and outcomes. The results from this study will be used to develop a community-based intervention to decrease avoidable ED visits and hospitalizations among low-income African-Americans with heart failure.

Families Are Key in Improving Quality

From Family Voices, Inc, Lexington, MA (Ms Wells); and National Partnership for Women and Families Washington, DC (Ms Partridge) The opinions expressed herein are those of the authors and do not necessarily represent the views of the US Department of Health and Human Services, the Agency for Healthcare Research and Quality, or the Centers for Medicare & Medicaid Services. The authors have no conflicts of interest to disclose. Publication of this article was supported by the US Department of Health and Human Services or the Agency for Healthcare Research and Quality. Address correspondence to NoraWells, MSEd, Family Voices, Inc, c/o ERG, 110, Hartwell Avenue, Lexington,Massachusetts 02421 (e-mail: nwells@familyvoices.org).

New Hospital Standards Will Improve Communication

New Hospital Standards Will Improve Communication

Use of Communication Technologies to Cost-Effectively Increase the Availability of Interpretation Services in Healthcare Settings

Poor patient-provider communication due to limited English proficiency (LEP) costs healthcare providers and payers through lower patient use of preventive care, misdiagnosis, increased testing, poor patient compliance, and increased hospital and emergency room admissions. Scarcity of bilingual healthcare professionals and prohibitive interpretation costs hinder full implementation of language service despite federal and state laws requiring their provision. We review recent published literature and unpublished data documenting the use of telephonic and video interpretation methodologies to improve healthcare communication with LEP persons. For example, a cooperative of nine California public hospitals and their associated community clinics, psychiatric facilities, skilled nursing facilities, and public health departments have implemented shared video interpretation services with video/voice-over Internet Protocol call center technology that automatically routes requests for interpretation in 15 languages to a pool of 30 full-time interpreters and 4 trained bilingual staff. For organizations seeking to initiate or expand their language services, the Internet provides access to translated documents, promising practices, step-by-step guides, planning tools, and research briefs. Such recent technological advances make provision of language services-to respond to federal and state mandates and improve access and quality of care to LEP persons-more feasible than is widely believed. Increased government and foundation support, and collaboration among provider organizations themselves can catalyze these efforts.