Exploring theoretical mechanisms of community-engaged research: a multilevel cross-sectional national study of structural and relational practices in community-academic partnerships.

BACKGROUND: Community-Based Participatory Research (CBPR) is often used to address health inequities due to structural racism. However, much of the existing literature emphasizes relationships and synergy rather than structural components of CBPR. This study introduces and tests new theoretical mechanisms of the CBPR Conceptual Model to address this limitation. METHODS: Three-stage online cross-sectional survey administered from 2016 to 2018 with 165 community-engaged research projects identified through federal databases or training grants. Participants (N = 453) were principal investigators and project team members (both academic and community partners) who provided project-level details and perceived contexts, processes, and outcomes. Data were analyzed through structural equation modeling and fuzzy-set qualitative comparison analysis. RESULTS: Commitment to Collective Empowerment was a key mediating variable between context and intervention activities. Synergy and Community Engagement in Research Actions were mediating variables between context/partnership process and outcomes. Collective Empowerment was most strongly aligned with Synergy, while higher levels of Structural Governance and lower levels of Relationships were most consistent with higher Community Engagement in Research Actions. CONCLUSIONS: The CBPR Conceptual Model identifies key theoretical mechanisms for explaining health equity and health outcomes in community-academic partnerships. The scholarly literature's preoccupation with synergy and relationships overlooks two promising practices-Structural Governance and Collective Empowerment-that interact from contexts through mechanisms to influence outcomes. These results also expand expectations beyond a "one size fits all" for reliably producing positive outcomes.

Racial/Ethnic Disparities in Clinical Grading in Medical School.

Phenomenon: Performance during the clinical phase of medical school is associated with membership in the Alpha Omega Alpha Honor Medical Society, competitiveness for highly selective residency specialties, and career advancement. Although race/ethnicity has been found to be associated with clinical grades during medical school, it remains unclear whether other factors such as performance on standardized tests account for racial/ethnic differences in clinical grades. Identifying the root causes of grading disparities during the clinical phase of medical school is important because of its long-term impacts on the career advancement of students of color. Approach: To evaluate the association between race/ethnicity and clinical grading, we examined Medical Student Performance Evaluation (MSPE) summary words (Outstanding, Excellent, Very Good, Good) and 3rd-year clerkship grades among medical students at the University of Washington School of Medicine. The analysis included data from July 2010 to June 2015. Medical students were categorized as White, underrepresented minorities (URM), and non-URM minorities. Associations between MSPE summary words and clerkship grades with race/ethnicity were assessed using ordinal logistic regression models. Findings: Students who identified as White or female, students who were younger in age, and students with higher United States Medical Licensing Examination Step 1 scores or final clerkship written exam scores consistently received higher final clerkship grades. Non-URM minority students were more likely than White students (Adjusted Odds Ratio = 0.53), confidence interval [0.36, 0.76], p = .001, to receive a lower category MSPE summary word in analyses adjusting for student demographics (age, gender, maternal education), year, and United States Medical Licensing Examination Step 1 scores. Similarly, in four of six required clerkships, grading disparities (p < .05) were found to favor White students over either URM or non-URM minority students. In all analyses, after accounting for all available confounding variables, grading disparities favored White students. Insights: This single institution study is among the first to document racial/ethnic disparities in MSPE summary words and clerkship grades while accounting for clinical clerkship final written examinations. A national focus on grading disparities in medical school is needed to understand the scope of this problem and to identify causes and possible remedies.

Disparities in the Use of Internet and Telephone Medication Refills among Linguistically Diverse Patients.

BACKGROUND: Health systems are increasingly implementing remote telephone and Internet refill systems to enhance patient access to medication refills. Remote refill systems may provide an effective approach for improving medication non-adherence, but more research is needed among patients with limited English proficiency with poor access to remote refill systems. OBJECTIVE: To compare the use of remote medication refill systems among limited-English-proficiency (LEP) and English-proficient (EP) patients with chronic conditions. METHODS: Cross-sectional survey in six languages/dialects (English, Cantonese, Mandarin, Korean, Vietnamese, and Spanish) of 509 adults with diabetes, hypertension, or hyperlipidemia. Primary study outcomes were self-reported use of 1) Internet refills, 2) telephone refills, and 3) any remote refill system. LEP was measured by patient self-identification of a primary language other than English and a claims record of use of an interpreter. Other measures were age, gender, education, years in the U.S., insurance, health status, chronic conditions, and number of prescribed medications. Analyses included multivariable logistic regression weighted for survey non-response. RESULTS: Overall, 33.1 % of patients refilled their medications by telephone and 31.6 % by Internet. Among LEP patients (n = 328), 31.5 % refilled by telephone and 21.2 % by Internet, compared with 36.7 % by telephone and 52.7 % by Internet among EP patients (n = 181). Internet refill by language groups were as follows: English (52.7 %), Cantonese (34.9 %), Mandarin (17.4 %), Korean (16.7 %), Vietnamese (24.4 %), and Spanish (12.6 %). Compared to EP patients, LEP patients had lower use of any remote refill system (adjusted odds ratio [AOR] 0.18; p < 0.001), CONCLUSIONS: LEP patients are significantly less likely than EP patients to use any remote medication refill system. Increased reliance on current systems for remote medication refills may increase disparities in health outcomes affecting LEP patients with poor access to telephone and Internet medication refills.

Content validity of Patient-Reported Outcomes Measurement Information System (PROMIS) items in the context of HIV clinical care.

PURPOSE: To assess content validity and patient and provider prioritization of Patient-Reported Outcomes Measurement Information System (PROMIS) depression, anxiety, fatigue, and alcohol use items in the context of clinical care for people living with HIV (PLWH), and to develop and assess new items as needed. METHODS: We conducted concept elicitation interviews (n = 161), item pool matching, prioritization focus groups (n = 227 participants), and cognitive interviews (n = 48) with English-speaking (~75 %) and Spanish-speaking (~25 %) PLWH from clinical sites in Seattle, San Diego, Birmingham, and Boston. For each domain we also conducted item review and prioritization with two HIV provider panels of 3-8 members each. RESULTS: Among items most highly prioritized by PLWH and providers were those that included information regarding personal impacts of the concept being assessed, in addition to severity level. Items that addressed impact were considered most actionable for clinical care. We developed additional items addressing this. For depression we developed items related to suicide and other forms of self-harm, and for all domains we developed items addressing impacts PLWH and/or providers indicated were particularly relevant to clinical care. Across the 4 domains, 16 new items were retained for further psychometric testing. CONCLUSION: PLWH and providers had priorities for what they believed providers should know to provide optimal care for PLWH. Incorporation of these priorities into clinical assessments used in clinical care of PLWH may facilitate patient-centered care.

Latinos with diabetes and food insecurity in an agricultural community.

BACKGROUND: Latinos from agricultural communities have a high prevalence of food insecurity and are at increased risk of obesity and diabetes, yet little is known about the associations between food insecurity and diabetes outcomes. OBJECTIVE: To examine the associations between food insecurity and diabetes outcomes among rural Latinos. METHODS: Cross-sectional survey with medical chart abstraction of 250 Latinos with diabetes. Primary outcomes are the control of 3 intermediate diabetes outcomes (hemoglobin A1C ≤8.0%, LDL-cholesterol ≤100 mg/dL, and blood pressure ≤140/90 mm Hg), a composite of control of the 3, and receipt of 6 processes of care. Secondary outcomes are cost-related medication underuse and participation in self-care activities. RESULTS: Fifty-two percent of patients reported food insecurity and 1-in-4 reported cost-related medication underuse. Patients with food insecurity were more likely to report cost-related medication underuse [adjusted odds ratio (AOR)=2.49; 95% confidence intervals (CI), 1.30, 4.98; P=0.003], less likely to meet the composite measure for control of the 3 intermediate outcomes (AOR=0.24; 95% CI, 0.07, 0.84; P<0.05), and less likely to receive a dilated eye examination (AOR=0.37; 95% CI, 0.18, 0.77; P<0.05) and annual foot examinations (AOR=0.42; 95% CI, 0.20, 0.84; P<0.05) compared with those who were food secure. CONCLUSIONS: Among this rural Latino population, food insecurity was independently associated with not having control of the intermediate diabetes outcomes captured in the composite measure, not receiving dilated eye and foot examinations, and with self-reporting cost-related medication underuse.

Perceived health status and cardiometabolic risk among a sample of youth in Mexico.

PURPOSE: To examine differences in self-reported perceived mental and physical health status, as well as known cardiometabolic risk factors in a sample of normal weight, overweight, and obese Mexican youths. METHODS: Cross-sectional analysis of 164 youths aged 11-18 years recruited in Cuernavaca, Mexico. Participants completed a self-administered questionnaire that included measures of generic and weight-specific quality of life, perceived health, physical function, depressive symptoms, and body shape satisfaction. Height, weight, and waist circumference were measured, and body mass index (BMI) was determined. Fasting blood samples from participants yielded levels of glucose, triglycerides, and cholesterol (total, HDL, and LDL). RESULTS: Nearly 50 % of participants were female, 21 % had a normal BMI, 39 % were overweight, and 40 % were obese. Obese youths reported significantly lower measures of perceived health status (PHS) and showed an increase in cardiometabolic risk, compared with normal weight youths. Physical functioning, generic and weight-specific QoL were inversely associated with BMI, waist circumference, and glucose. Depressive symptoms were positively correlated with BMI, waist circumference, glucose levels, and HDL cholesterol. No correlation was found between PHS and cardiometabolic risk measures after controlling for BMI. CONCLUSIONS: In this sample of Mexican youths, obesity was associated with a significantly lower PHS and increased cardiometabolic risk.

Language concordance, interpersonal care, and diabetes self-care in rural Latino patients.

BACKGROUND: Interpersonal care (IPC) is increasingly emphasized as health care systems focus on implementing patient-centered care. Language barriers may be a particularly important influence on IPC ratings among rural Spanish-speaking Latinos. OBJECTIVE: To examine the associations between provider Spanish fluency and Spanish-speaking patients' ratings of IPC and between patient-provider language concordance and patient engagement in diabetes self-care activities. DESIGN: Cross-sectional survey combined with chart reviews. SETTING/PARTICIPANTS: Two hundred fifty Latino adults with diabetes receiving care at safety-net community health centers in two rural California counties. MAIN MEASURES: Using a validated questionnaire, we assessed patient ratings of IPC in three areas: communication, decision-making, and interpersonal style. Patient-provider language concordance was measured by physician self-reported fluency in Spanish. We measured participation in diabetes self-care activities by patient self-report. The survey response rate was 68%. KEY RESULTS: Patients with language-concordant providers had more favorable IPC ratings (20% to 41% of language-discordant patients had optimal scores for IPC scales vs. 35% to 69% of language-concordant patients, p < 0.05), except with respect to discrimination. Patients with language-concordant providers reported higher levels of participation in diabetic foot care (1.4 days vs. 0.7 days per week, p value 0.01) compared to patients with language discordance. There was no association between language concordance and participation in other self-care activities. CONCLUSION: This study provides evidence that language concordance is independently associated with high IPC scores in rural Latino adults with diabetes. Moreover, this study suggests that language concordance may contribute to improved participation diabetes self-care activities.

Measurement properties of the Adolescent Quality of Life Mental Health Scale (AQOL-MHS).

BACKGROUND: This article presents data on the psychometric properties of a new measure, the Adolescent Quality of Life Mental Health Scale (AQOL-MHS), designed to measure quality of life in clinical samples of Latino adolescents aged 12-18 years. Participants were recruited in Puerto Rico to have one of five prevalent mental health disorders. The initial instrument development was achieved through a grounded theory approach with the use of focus groups and in-depth interviews. METHODS: We conducted two stages of exploratory factor analyses (EFA) on 60 candidate items. The first stage was to establish the number of factors to extract, and the second was to improve the model by selecting the best items. A final EFA model retained 31 items and 3 factors labeled Emotional Regulation (11 items), Self-Concept (10 items) and Social Context (10 items). RESULTS: The instrument showed good internal consistency, test-retest reliability, and construct validity. The hypotheses-driven validity tests were all supportive of the AQOL-MHS. There was evidence for convergent validity and discriminant validity, and results for known-groups' validity were overwhelmingly supportive of the ability of the instrument to identify differences between groups. CONCLUSIONS: These preliminary findings support our conceptual model and the use of the AQOL-MHS domain and overall scores. We believe that this instrument will provide clinicians additional insight into the different aspects of quality of life that are important to adolescents with mental health problems. Therefore, we consider the AQOL-MHS a vital patient-centered outcome measure for assessment strategies in the prevention and treatment of this population.

Neighborhood perceptions and health-related outcomes among Latinos with diabetes from a rural agricultural community.

Little is known about how neighborhood perceptions are related to diabetes outcomes among Latinos living in rural agricultural communities. Our objective was to examine the association between perceived neighborhood problems and diabetes outcomes. This is a cross-sectional survey study with medical record reviews of a random sample of 250 adult Latinos with type 2 diabetes. The predictor was a rating of patient ratings of neighborhood problems (crime, trash and litter, lighting at night, and access to exercise facilities, transportation, and supermarkets). The primary outcomes were the control of three intermediate outcomes [LDL-cholesterol (LDL-c) < 100 mg/dl, AlC < 9.0 %, and blood pressure (BP) < 140/80 mmHg], and body mass index (BMI) < 30 kg/m(2). Secondary outcomes were participation in self-care activities (physical activity, healthy eating, medication adherence, foot checks, and glucose checks). We used regression analysis and adjusted for age, gender, education, income, years with diabetes, insulin use, depressive symptoms, and co-morbidities. Forty-eight percent of patients perceived at least one neighborhood problem and out of the six problem areas, crime was most commonly perceived as a problem. Perception of neighborhood problems was independently associated with not having a BP < 140/80 [Adjusted odds ratio (AOR) = 0.45; 95 % CI 0.22, 0.92], and BMI < 30 (AOR = 0.43; 95 % CI 0.24, 0.77), after controlling for covariates. Receipt of recommended processes of care was not associated with perception of neighborhood. Perception of neighborhood problems among low-income rural Latinos with diabetes was independently associated with a higher BMI and BP.

Risk factors for cardiovascular disease among Mexican-American adults in the United States and Mexico: a comparative study.

OBJECTIVE: To compare cardiovascular disease (CVD) risk factors in a cohort of Mexican health workers with representative samples of US-born and Mexico-born Mexican-Americans living in the US. MATERIALS AND METHODS: Data were obtained from the Mexican Health Worker Cohort Study (MHWCS) in Mexico and the National Health and Nutrition Examination Survey (NHANES) IV 1999-2006 in the US. Regression analyses were used to investigate CVD risk factors. RESULTS: In adjusted analyses, NHANES participants were more likely than MHWCS participants to have hypertension, high total cholesterol, diabetes, obesity, and abdominal obesity, and were less likely to have low HDL cholesterol and smoke. Less-educated men and women were more likely to have low HDL cholesterol, obesity, and abdominal obesity. CONCLUSIONS: In this binational study, men and women enrolled in the MHWCS appear to have fewer CVD risk factors than US-born and Mexico-born Mexican-American men and women living in the US.

The risk of developing invasive breast cancer in Hispanic women : a look across Hispanic subgroups.

BACKGROUND: Current evidence on breast cancer among US Hispanic women indicates a significant public health threat, although few studies have assessed the heterogeneity in breast cancer risk among Hispanics of different origin. METHODS: The 2000 and 2005 National Health Interview Survey Cancer Control Modules were used to examine the Breast Cancer Risk Assessment Tool (BCRAT) 5-year risk and lifetime risk of invasive breast cancer among Mexican/Mexican American, Puerto Rican, Cuban/Cuban American, Dominican (Republic), Central/South American, Other Hispanic, and non-Hispanic white (NHW) women ages 35 to 84 years. Multiple linear regression models were used to compare the BCRAT 5-year and lifetime breast cancer risk between 1) Hispanics and NHWs and 2) Hispanic subgroups. RESULTS: Hispanic women had significantly lower mean BCRAT 5-year and lifetime breast cancer risk compared with NHW women (P < .001). Among Hispanic subgroups, Cuban/Cuban Americans had a higher BCRAT 5-year risk (P < .05), whereas Dominicans had a higher lifetime risk (P < .001) compared with Mexican/Mexican Americans. Approximately 2.6% of Hispanic women were at high risk for breast cancer (BCRAT 5-year risk ≥1.67%), ranging from 1% of Central/South Americans to 3.7% of Puerto Ricans; few Hispanics (0.2%) had a lifetime risk ≥20%. CONCLUSIONS: The current findings indicate that Hispanic women have a significantly lower risk of breast cancer compared with NHW women, although the risk according to BCRAT differed significantly between specific Hispanic subgroups. We provide estimates of the number of US Hispanic women from six subgroups who may be eligible for prophylactic breast cancer chemoprevention. The authors concluded that future studies should further investigate the heterogeneity in breast cancer risk and risk factors between Hispanic women of different origins.

Evaluation of the Patient-Reported Outcomes Information System (PROMIS(®)) Spanish-language physical functioning items.

PURPOSE: To evaluate the equivalence of the PROMIS(®) physical functioning item bank by language of administration (English versus Spanish). METHODS: The PROMIS(®) wave 1 English-language physical functioning bank consists of 124 items, and 114 of these were translated into Spanish. ANALYSIS: Item frequencies, means and standard deviations, item-scale correlations, and internal consistency reliability were calculated. The IRT assumption of unidimensionality was evaluated by fitting a single-factor confirmatory factor analytic model. IRT threshold and discrimination parameters were estimated using Samejima's Graded Response Model. DIF by language of administration was evaluated. RESULTS: Item means ranged from 2.53 (SD = 1.36) to 4.62 (SD = 0.82). Coefficient alpha was 0.99, and item-rest correlations ranged from 0.41 to 0.89. A one-factor model fits the data well (CFI = 0.971, TLI = 0.970, and RMSEA = 0.052). The slope parameters ranged from 0.45 ("Are you able to run 10 miles?") to 4.50 ("Are you able to put on a shirt or blouse?"). The threshold parameters ranged from -1.92 ("How much do physical health problems now limit your usual physical activities (such as walking or climbing stairs)?") to 6.06 ("Are you able to run 10 miles?"). Fifty of the 114 items were flagged for DIF based on an R(2) of 0.02 or above criterion. The expected total score was higher for Spanish- than English-language respondents. CONCLUSIONS: English- and Spanish-speaking subjects with the same level of underlying physical function responded differently to 50 of 114 items. This study has important implications in the study of physical functioning among diverse populations.

Tobacco Use Patterns From Adolescence to Young Adulthood Among Latinx Youth From Rural Communities.

PURPOSE: To examine patterns in adolescent and young adult tobacco use, comparing Latinx foreign-born children and children of foreign-born parents (i.e., children of immigrants(COI)) to Latinx US-born children of US-born parents (i.e., children of nonimmigrants,(CONI)) and to CONI White youth who grew up in small and rural towns. METHODS: Data were from youth who lived in control communities that participated in a community-randomized trial of the Communities That Care prevention system. We compared Latinx CONI (n = 154) with Latinx COI (n = 316) and with non-Latinx White CONI (n = 918). We examined tobacco use in adolescence (any adolescent use, early onset, and chronic use) and young adulthood (any past-year tobacco use, any daily smoking, any nicotine dependence symptoms) with mixed-effects logistic regressions. RESULTS: In adolescence, Latinx CONI had a higher prevalence of any and chronic tobacco use relative to Latinx COI, and of any and early onset tobacco use relative to non-Latinx White CONI. In young adulthood, Latinx CONI were more likely to report tobacco use in the past year, any symptoms of nicotine dependence, and daily smoking relative to Latinx COI; and more likely to report daily smoking relative to non-Latinx White CONI. Generation differences in young adult tobacco use were explained by chronic tobacco use in adolescence. DISCUSSION: The study suggests targeting chronic tobacco use in adolescence to prevent disparities in tobacco outcomes among Latinx young adults from rural communities.

Patient-reported quality of pain treatment and use of interpreters in spanish-speaking patients hospitalized for obstetric and gynecological care.

BACKGROUND: Assessment and treatment of pain are based largely on patient's self reports. Patients with limited English proficiency (LEP) may have difficulties communicating their pain symptoms in the presence of language barriers. OBJECTIVE: To determine whether interpreter use was associated with quality of acute pain treatment among Latina patients with limited English proficiency. DESIGN: Secondary analysis of two cross-sectional surveys. PARTICIPANTS: One hundred and eighty-five Latino female patients hospitalized for obstetric and gynecological care who required interpreter services. Patients were classified into two groups according to interpreter availability ('Always' and 'Not Always' available). MAIN MEASURES: Quality of pain treatment was measured by patient report of 1) overall level of pain control during hospitalization; 2) timeliness of pain treatment; and 3) perceived provider helpfulness to treat pain. KEY RESULTS: Patients who always received interpreters were more likely to report higher levels of pain control (P=0.02), timely pain treatment (P=0.02), and greater perceived provider helpfulness to treat their pain (P=0.005), compared with patients who not always received interpreters. CONCLUSION: Use of interpreters by LEP patients was associated with better patient reports on quality of pain treatment, and may also improve clinical interactions related to pain.

Variation in documented care for unhealthy alcohol consumption across race/ethnicity in the Department of Veterans Affairs Healthcare System.

BACKGROUND: The VA Healthcare System has made progress implementing evidence-based care for unhealthy alcohol use, but whether there are differences in care across race/ethnicity is unclear. We describe alcohol-related care for 3 racial/ethnic groups among VA outpatients with unhealthy alcohol use. METHODS: This cross-sectional study utilized secondary quality improvement data collected for the VA Office of Quality and Performance (July 2006 to June 2007) to identify a sample of 9,194 black (n = 1,436), Hispanic (n = 500), and white (n = 7,258) VA outpatients who screened positive for unhealthy alcohol use (AUDIT-C score ≥4 men; ≥3 women). Alcohol-related care was defined as medical record documentation of brief intervention (advice or feedback) and/or referral (discussion of or scheduled). Logistic regression models estimated the prevalence of alcohol-related care among black, Hispanic, and white patients after adjustment for sociodemographic characteristics, alcohol use severity, other substance use, and mental health comorbidity. RESULTS: Among all eligible patients, 2,903 (32%) had documented alcohol-related care. Adjusted prevalences were 35.3% (95% CI 30.0 to 40.5) for black, 27.3% (95% CI 21.1 to 33.5) for Hispanic, and 28.9% (95% CI 25.5 to 32.3) for white patients. Differences in documented alcohol-related care between all racial/ethnic groups were significant (p-values all < 0.05). CONCLUSIONS: Among VA patients with unhealthy alcohol use, black patients had the highest, and Hispanic the lowest, prevalence of documented alcohol-related care. Future research should evaluate contextual and system-, provider-, or patient-level factors that may attenuate racial/ethnic differences in documented alcohol-related care, as well as whether differences in documented care are associated with differences in outcomes.

Early dropout from psychotherapy for depression with group- and network-model therapists.

Administrative data were used to examine early dropout among 16,451 health plan members calling to request psychotherapy for depression. Compared to members referred to group-model therapists, those referred to network-model therapists were more likely to drop out before the initial visit (OR 2.33, 95% CI 2.17-2.50) but less likely to drop out after the first visit (OR 0.45, 95% CI 0.43-0.48). These differences were unaffected by adjustment for neighborhood income and educational attainment, antidepressant use, or generosity of insurance coverage. Efforts to increase the effectiveness of psychotherapy may required different strategies in group- and network-model practice.

Brief online implicit bias education increases bias awareness among clinical teaching faculty.

PROBLEM AND PURPOSE: Healthcare provider implicit bias influences the learning environment and patient care. Bias awareness is one of the key elements to be included in implicit bias education. Research on education enhancing bias awareness is limited. Bias awareness can motivate behavior change. The objective was to evaluate whether exposure to a brief online course, Implicit Bias in the Clinical and Learning Environment, increased bias awareness. MATERIALS AND METHODS: The course included the history of racism in medicine, social determinants of health, implicit bias in healthcare, and strategies to reduce the impact of implicit bias in clinical care and teaching. A sample of U.S. academic family, internal, and emergency medicine providers were recruited into the study from August to December 2019. Measures of provider implicit and explicit bias, personal and practice characteristics, and pre-post-bias awareness measures were collected. RESULTS: Of 111 participants, 78 (70%) were female, 81 (73%) were White, and 63 (57%) were MDs. Providers held moderate implicit pro-White bias on the Race IAT (Cohen's d = 0.68) and strong implicit stereotypes associating males rather than females with 'career' on the Gender-Career IAT (Cohen's d = 1.15). Overall, providers held no explicit race bias (Cohen's d = 0.05). Providers reported moderate explicit male-career (Cohen's d = 0.68) and strong female-family stereotype (Cohen's d = 0.83). A statistically significant increase in bias awareness was found after exposure to the course (p = 0.03). Provider implicit and explicit biases and personal and practice characteristics were not associated with an increase in bias awareness. CONCLUSIONS: Implicit bias education is effective to increase providers' bias awareness regardless of strength of their implicit and explicit biases and personal and practice characteristics. Increasing bias awareness is one step of many toward creating a positive learning environment and a system of more equitable healthcare.

Health inequities and the inappropriate use of race in nephrology.

Chronic kidney disease is an important clinical condition beset with racial and ethnic disparities that are associated with social inequities. Many medical schools and health centres across the USA have raised concerns about the use of race - a socio-political construct that mediates the effect of structural racism - as a fixed, measurable biological variable in the assessment of kidney disease. We discuss the role of race and racism in medicine and outline many of the concerns that have been raised by the medical and social justice communities regarding the use of race in estimated glomerular filtration rate equations, including its relationship with structural racism and racial inequities. Although race can be used to identify populations who experience racism and subsequent differential treatment, ignoring the biological and social heterogeneity within any racial group and inferring innate individual-level attributes is methodologically flawed. Therefore, although more accurate measures for estimating kidney function are under investigation, we support the use of biomarkers for determining estimated glomerular filtration rate without adjustments for race. Clinicians have a duty to recognize and elucidate the nuances of racism and its effects on health and disease. Otherwise, we risk perpetuating historical racist concepts in medicine that exacerbate health inequities and impact marginalized patient populations.

Differential item functioning by survey language among older Hispanics enrolled in Medicare managed care: a new method for anchor item selection.

OBJECTIVE: To propose a permutation-based approach of anchor item detection and evaluate differential item functioning (DIF) related to language of administration (English vs. Spanish) for 9 questions assessing patients' perceptions of their providers from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare 2.0 survey. METHOD AND STUDY DESIGN: CAHPS 2.0 health plan survey data collected from 703 Hispanics who completed the survey in Spanish were matched on personal characteristics to 703 Hispanics that completed the survey in English. Steps to be followed for the detection of anchor items using the permutation tests are proposed and these tests in conjunction with item response theory were used for the identification of anchor items and DIF detection. RESULTS: Of the questions studied, 4 were selected as anchor items and 3 of the remaining questions were found to have DIF (P < 0.05). The 3 questions with DIF asked about seeing the doctor within 15 minutes of the appointment time, respect for what patients had to say, and provider spending enough time with patients. CONCLUSIONS: Failure to account for language differences in CAHPS survey items may result in misleading conclusions about disparities in health care experiences between Spanish and English speakers. Statistical adjustments are needed when using the items with DIF.

Do physicians with self-reported non-English fluency practice in linguistically disadvantaged communities?

BACKGROUND: Language concordance between physicians and patients may reduce barriers to care faced by patients with limited English proficiency (LEP). It is unclear whether physicians with fluency in non-English languages practice in areas with high concentrations of people with LEP. OBJECTIVE: To investigate whether physician non-English language fluency is associated with practicing in areas with high concentrations of people with LEP. DESIGN: Cross-sectional cohort study. PARTICIPANTS: A total of 61,138 practicing physicians no longer in training who participated in the California Medical Board Physician Licensure Survey from 2001-2007. MEASURES: Self-reported language fluency in Spanish and Asian languages. Physician practice ZIP code corresponding to: (1) high concentration of people with LEP and (2) high concentration of linguistically isolated households. METHODS: Practice location ZIP code was geocoded with geographic medical service study designations. We examined the unadjusted relationships between physician self-reported fluency in Spanish and selected Asian languages and practice location, stratified by race-ethnicity. We used staged logistic multiple variable regression models to isolate the effect of self-reported language fluency on practice location controlling for age, gender, race-ethnicity, medical specialty, and international medical graduate status. RESULTS: Physicians with self-reported fluency in Spanish or an Asian language were more likely to practice in linguistically designated areas in these respective languages compared to those without fluency. Physician fluency in an Asian language [adjusted odds ratio (AOR) = 1.77; 95% confidence intervals (CI): 1.63-1.92] was independently associated with practicing in areas with a high number of LEP Asian speakers. A similar pattern was found for Spanish language fluency (AOR = 1.77; 95% CI: 1.43-1.82) and areas with high numbers of LEP Spanish-speakers. Latino and Asian race-ethnicity had the strongest effect on corresponding practice location, and this association was attenuated by language fluency. CONCLUSIONS: Physicians who are fluent in Spanish or an Asian language are more likely to practice in geographic areas where their potential patients speak the corresponding language.