Psychometric evaluation of a cultural competency assessment instrument for health professionals.

BACKGROUND: Few valid and reliable measures exist for health care professionals interested in determining their levels of cultural and linguistic competence. OBJECTIVE: To evaluate the measurement properties of the Cultural Competence Health Practitioner Assessment (CCHPA-129). METHODS: The CCHPA-129 is a 129-item web-based instrument, developed by the National Center for Cultural Competence. Responses on the CCHPA -129 were examined using factor analysis; Rasch modeling; and differential item functioning across race, ethnicity, sex, and profession. SUBJECTS: A total of 2504 practitioners, including 1864 nurses (RN/LPN/BSN); 341 clinicians (PA/NP); and 299 physicians (MD/DO), who completed the CCHPA-129 online between 2005 and 2008. RESULTS: Three factors representing domains of Knowledge, Adapting Practice, and Promoting Health for culturally and linguistically diverse populations accounted for 46% of the variance. Among Knowledge factor items, 53% (23/43) fit the Rasch model, item difficulties ranged from -1.01 logits (least difficult) to +1.11 logits (most difficult), separation index (SI) 13.82, and Cronbach's α 0.92. Forty-seven percent (21/44) Adapting Practice factor items fit the model, item difficulties -0.07 to +1.11 logits, SI 11.59, Cronbach's α 0.88; and 58% (23/39). Promoting Health factor items fit the model, item difficulties -1.01 to +1.38 logits, SI 22.64, Cronbach's α 0.92. Early evidence of validity was established by known groups having statistically different scores. CONCLUSIONS: The 67-item CCHPA-67 is psychometrically sound. This shorted instrument can be used to establish associations between practitioners' cultural and linguistic competence and health outcomes as well as to evaluate interventions to increase practitioners' cultural and linguistic competence.

Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

BACKGROUND: Antihypertensive drugs with favorable metabolic effects are advocated for first-line therapy in hypertensive patients with metabolic/cardiometabolic syndrome (MetS). We compared outcomes by race in hypertensive individuals with and without MetS treated with a thiazide-type diuretic (chlorthalidone), a calcium channel blocker (amlodipine besylate), an alpha-blocker (doxazosin mesylate), or an angiotensin-converting enzyme inhibitor (lisinopril). METHODS: A subgroup analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double-blind hypertension treatment trial of 42 418 participants. We defined MetS as hypertension plus at least 2 of the following: fasting serum glucose level of at least 100 mg/dL, body mass index (calculated as weight in kilograms divided by height in meters squared) of at least 30, fasting triglyceride levels of at least 150 mg/dL, and high-density lipoprotein cholesterol levels of less than 40 mg/dL in men or less than 50 mg/dL in women. RESULTS: Significantly higher rates of heart failure were consistent across all treatment comparisons in those with MetS. Relative risks (RRs) were 1.50 (95% confidence interval, 1.18-1.90), 1.49 (1.17-1.90), and 1.88 (1.42-2.47) in black participants and 1.25 (1.06-1.47), 1.20 (1.01-1.41), and 1.82 (1.51-2.19) in nonblack participants for amlodipine, lisinopril, and doxazosin comparisons with chlorthalidone, respectively. Higher rates for combined cardiovascular disease were observed with lisinopril-chlorthalidone (RRs, 1.24 [1.09-1.40] and 1.10 [1.02-1.19], respectively) and doxazosin-chlorthalidone comparisons (RRs, 1.37 [1.19-1.58] and 1.18 [1.08-1.30], respectively) in black and nonblack participants with MetS. Higher rates of stroke were seen in black participants only (RR, 1.37 [1.07-1.76] for the lisinopril-chlorthalidone comparison, and RR, 1.49 [1.09-2.03] for the doxazosin-chlorthalidone comparison). Black patients with MetS also had higher rates of end-stage renal disease (RR, 1.70 [1.13-2.55]) with lisinopril compared with chlorthalidone. CONCLUSIONS: The ALLHAT findings fail to support the preference for calcium channel blockers, alpha-blockers, or angiotensin-converting enzyme inhibitors compared with thiazide-type diuretics in patients with the MetS, despite their more favorable metabolic profiles. This was particularly true for black participants.

The association of how time is spent during outpatient visits and patient satisfaction: are there racial differences?

Both satisfaction with the physician and how time is spent in the patient-physician outpatient visit have been shown to differ between African-American and Caucasian patients. This study uses structural equation modeling to examine racial differences in the association between time use during the outpatient visit and patient satisfaction. This cross-sectional study employed direct observation of outpatient visits and surveys of 2,502 adult African-American and Caucasian outpatients visiting 138 primary care physicians in 84 family practices in Northeast Ohio. Patient satisfaction was measured using the Medical Outcome Study (MOS) nine-item Visit Rating Scale. Time use was assessed with the Davis Observation Code, which was used to classify every 20 seconds of a visit into 20 behavioral categories. No difference was found between African-American and Caucasian patients in the association between patient satisfaction with a physician and the time the physician spent chatting, planning treatment, providing health education, structuring the interaction, assessing health knowledge or answering patient questions. Patients were generally satisfied with their physicians, and no racial differences between Caucasians and African Americans were observed. Despite racial differences in how physicians spend time in the outpatient visit encounter, these differences are not associated with racial differences in patient satisfaction. Efforts to understand disparities in satisfaction should address areas other than how physicians allocate time in the physician-patient encounter.

Missed Opportunities for the Diagnosis of Colorectal Cancer.

OBJECTIVE: To examine patient and medical characteristics which predict a missed diagnostic opportunity (MDO) for colorectal cancer (CRC). METHODS: The sample consisted of 252 patients diagnosed with Stages 1-4 CRC who were diagnosed in the prior six months, had experienced symptoms prior to diagnosis, and were not diagnosed through routine screening. Systematic review of all medical records prior to patients' diagnosis was conducted. An MDO was defined as a clinical encounter where, even in the presence of presumptive CRC symptoms, the CRC diagnostic process is not started. RESULTS: 92 patients (36.5%) experienced an MDO. Almost 80% of alternate diagnoses were other GI-GU diseases, including hemorrhoids and diverticulitis. Stomach pain, anemia, and constipation were the most common symptoms experienced by the MDO group. These symptoms, and weight loss and vomiting, were more likely to be noted in the charts of the MDO patients (P < 0.04). Independent risk factors for MDO included age (<50) [OR = 2.29 (1.14-4.60), P = 0.02] and female sex [OR = 2.19 (1.16-4.16), P = 0.03]. Each additional physician seen, more than doubled the MDO risk [OR = 2.05 (1.53-2.74), P < 0.001]. CONCLUSIONS: Females, younger patients, and those consulting more physicians were all more likely to experience an MDO. Continued increased training of physicians to enhance knowledge of who is vulnerable to CRC is needed in addition to an increased focus to adherence to screening recommendations.

Doctor, what's wrong with me? Factors that delay the diagnosis of colorectal cancer.

OBJECTIVE: To examine the influence of patient and physician communication factors on diagnostic delay (DD). METHODS: 242 patients diagnosed with colorectal cancer (CRC) in the past 6 months who experienced symptoms prior to diagnosis were administered a 2-h semi-structured qualitative interview to assess communication with health care provider and ease of access to care, among other factors. Patient-provided information was verified via review of medical records. RESULTS: The factors associated with DD>2 months included lower income (OR=0.56, p=0.03), having regular physician prior to receiving a cancer diagnosis (OR=2.52, p=0.03), having a physician who used temporizing communication strategies during the consultation (OR=2.41, p=0.02), receiving an initial alternate diagnosis (OR=3.36, p=0.02), experiencing referral delay (OR=3.61, p=<0.001), and experiencing follow-up delay of any kind (OR=3.32, p=0.01). CONCLUSION: Excellent communication skills that appropriately probe for relevant social and economic patient information, assist patients in distinguishing and elaborating on symptoms, and provide clear rationale and instructions for future steps, will speed along the diagnosis process and could be the difference between early and late stage CRC. PRACTICE IMPLICATIONS: Increased understanding of physician communication and practice styles that contribute to DD could have a positive impact on decreasing the morbidity and mortality from this disease.

The advantages and challenges of unannounced standardized patient methodology to assess healthcare communication.

OBJECTIVE: This paper provides an overview of the implementation of using unannounced standardized patients (USPs) to conduct health communication research in clinical settings. METHODS: Certain types of health communication situations are difficult to capture because of their rarity or unpredictable nature. In primary care the real reasons for a visit are frequently unknown until the consultation is well under way. Therefore, it is logistically difficult for communication studies to capture many real-time communications between patients and their physicians. Although the USP methodology is ideal for capturing these communication behaviors, challenges to using this method include developing collaborative relationships with clinical practices, logistical issues such as safeguarding the identity of the USP, training USPs and creating their identities, maintaining fidelity to the role, and analyzing the resultant data. RESULTS: This paper discusses the challenges and solutions to USP implementation. We provide an example of how to implement a USP study using an on-going study being conducted in primary care practices. CONCLUSION: This paper explores the advantages and challenges as well as strategies to overcome obstacles to implementing a USP study. PRACTICE IMPLICATIONS: Despite the challenges, USP methodology can contribute much to our understanding of health communication and practice.

Recruiting minority primary care practices into practice-based research.

BACKGROUND: A potentially fruitful strategy for increasing enrollment of minority patients in research is to engage minority clinicians. However, little attention has been paid to unique challenges and effective strategies for engaging practices with minority physicians. OBJECTIVE: The objective of this study was to provide a model for recruiting community-based primary care practices with minority physicians into research studies. RESEARCH DESIGN: Practices were recruited using a 3-step process that included telephone contact, on-site meetings, and follow-up discussions. Strategies used to recruit 18 New Jersey community-based primary care practices with minority physicians for a quality improvement intervention study were assessed. RESULTS: Twelve of 18 practices (67%) were successfully recruited into the study. Effective recruitment strategies included building rapport using a multiethnic/multidisciplinary team led by a minority physician recruiter and stressing study benefits for the practice. We attempted to match recruiters and key practice members by race, underrepresented minority status of the lead recruiter, gender, career stage, experience in urban practice, and experience in clinical instruction. Practices that were successfully recruited had more characteristics in common between recruiters and key practice members than unsuccessfully recruited practices (mean number of characteristic matches = 3.75 vs. 1.83, P = 0.020). Study benefits cited by participants as motivators for participation included a general desire to provide good patient care by understanding their practices' strengths and challenges (92%) and improving their practice (85%). CONCLUSIONS: Our experience suggests that a staged, tailored, and iterative recruitment process emphasizing communication and relationship building can be successful in recruiting community-based primary care minority physicians into practice-based research.