Clinical Trials in Pancreatitis: Opportunities and Challenges in the Design and Conduct of Patient-Focused Clinical Trials in Recurrent Acute and Chronic Pancreatitis: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop.

ABSTRACT: Recurrent acute pancreatitis and chronic pancreatitis represent high morbidity diseases, which are frequently associated with chronic abdominal pain, pancreatic insufficiencies, and reduced quality of life. Currently, there are no therapies to reverse or delay disease progression, and clinical trials are needed to investigate potential interventions that would address this important gap. This conference report provides details regarding information shared during a National Institute of Diabetes and Digestive and Kidney Diseases-sponsored workshop on Clinical Trials in Pancreatitis that sought to clearly delineate the current gaps and opportunities related to the design and conduct of patient-focused trials in recurrent acute pancreatitis and chronic pancreatitis. Key stakeholders including representatives from patient advocacy organizations, physician investigators (including clinical trialists), the US Food and Drug Administration, and the National Institutes of Health convened to discuss challenges and opportunities with particular emphasis on lessons learned from trials in participants with other painful conditions, as well as the value of incorporating the patient perspective throughout all stages of trials.

Is Telemetry Monitoring Useful in Patients Admitted With Suspected Acute Coronary Syndrome?

Patients with a chief complaint of chest pain are frequently monitored by telemetry for evaluation of acute coronary syndrome (ACS). However, there is insufficient evidence to support this practice in younger patients without coronary artery disease (CAD). The objective is to assess outcomes of patients younger than 50 years of age and monitored by telemetry. Consecutive medical records of patients admitted for chest pain between January 1, 2009, and June 30, 2010, were reviewed. Patients were excluded who had a CAD history, an abnormal initial troponin, or an abnormal initial electrocardiogram. The remaining patients' charts were evaluated for adverse events such as death, dysrhythmias, ST-elevation myocardial infarction, or upgrade to a higher level of care. Ultimately, 814 patients were selected for study. No study participants suffered a significant adverse event. When being evaluated for ACS, patients younger than 50 without a history of CAD may not benefit from telemetry monitoring.

Fit for purpose: perspectives on rapid reviews from end-user interviews.

BACKGROUND: There is increasing demand for rapid reviews and timely evidence synthesis. The goal of this project was to understand end-user perspectives on the utility and limitations of rapid products including evidence inventories, rapid responses, and rapid reviews. METHODS: Interviews were conducted with key informants representing: guideline developers (n = 3), health care providers/health system organizations (n = 3), research funders (n = 1), and payers/health insurers (n = 1). We elicited perspectives on important characteristics of systematic reviews, acceptable methods to streamline reviews, and uses of rapid products. We analyzed content of the interview transcripts and identified themes and subthemes. RESULTS: Key informants identified the following as critical features of evidence reviews: (1) originating from a reliable source (i.e., conducted by experienced reviewers from an established research organization), (2) addressing clinically relevant questions, and (3) trusted relationship between the user and producer. Key informants expressed strong preference for the following review methods and characteristics: use of evidence tables, quality rating of studies, assessments of total evidence quality/strength, and use of summary tables for results and conclusions. Most acceptable trade-offs to increase efficiencies were limiting the literature search (e.g., limiting search dates or language) and performing single screening of citations and full texts for relevance. Key informants perceived rapid products (particularly evidence inventories and rapid responses) as useful interim products to inform downstream investigation (e.g., whether to proceed with a full review or guideline, direction for future research). Most key informants indicated that evidence analysis/synthesis and quality/strength of evidence assessments were important for decision-making. They reported that rapid reviews in particular were useful for guideline development on narrow topics, policy decisions when a quick turn-around is needed, decision-making for practicing clinicians in nuanced clinical settings, and decisions about coverage by payers/health insurers. Rapid reviews may be more relevant within specific clinical settings or health systems; whereas, broad/national guidelines often need a traditional systematic review. CONCLUSIONS: Key informants interviewed in our study indicated that evidence inventories, rapid responses, and rapid reviews have utility in specific decisions and contexts. They indicated that the credibility of the review producer, relevance of key questions, and close working relationship between the end-user and producer are critical for any rapid product. Our findings are limited by the sample size which may have been too small to reach saturation for the themes described.

Professional challenges of non-U.S.-born international medical graduates and recommendations for support during residency training.

PURPOSE: Despite a long history of international medical graduates (IMGs) coming to the United States for residencies, little research has been done to find systematic ways in which residency programs can support IMGs during this vulnerable transition. The authors interviewed a diverse group of IMGs to identify challenges that might be eased by targeted interventions provided within the structure of residency training. METHOD: In a qualitative study conducted between March 2008 and April 2009, the authors contacted 27 non-U.S.-born IMGs with the goal of conducting qualitative interviews with a purposeful sample. The authors conducted in-person, in-depth interviews using a standardized interview guide with potential probes. All participants were primary care practitioners in New York, New Jersey, or Connecticut. RESULTS: A total of 25 IMGs (93%) participated. Interviews and subsequent analysis produced four themes that highlight challenges faced by IMGs: (1) Respondents must simultaneously navigate dual learning curves as immigrants and as residents, (2) IMGs face insensitivity and isolation in the workplace, (3) IMGs' migration has personal and global costs, and (4) IMGs face specific needs as they prepare to complete their residency training. The authors used these themes to inform recommendations to residency directors who train IMGs. CONCLUSIONS: Residency is a period in which key elements of professional identity and behavior are established. IMGs are a significant and growing segment of the physician workforce. Understanding particular challenges faced by this group can inform efforts to strengthen support for them during postgraduate training.

Hospital-wide reduction in central line-associated bloodstream infections: a tale of two small community hospitals.

Despite increasing awareness of central line-associated bloodstream infections (CLABSIs) in general wards, published strategies come from intensive care units (ICUs) of large tertiary care centers. After implementing a central line insertion checklist, two community hospitals experienced an 86% reduction in CLABSI rates in ICUs and a 57% reduction in non-ICU settings over 36 months.

Professional experiences of international medical graduates practicing primary care in the United States.

BACKGROUND: International medical graduates (IMGs) comprise approximately 25% of the US physician workforce, with significant representation in primary care and care of vulnerable populations. Despite the central role of IMGs in the US healthcare system, understanding of their professional experiences is limited. OBJECTIVE: To characterize the professional experiences of non-US born IMGs from limited-resource nations practicing primary care in the US. DESIGN: Qualitative study based on in-depth in-person interviews. PARTICIPANTS: Purposeful sample of IMGs (n = 25) diverse in country of origin, length of practice in the US, specialty (internal medicine, family medicine and pediatrics), age and gender. Participants were currently practicing primary care physicians in New York, New Jersey or Connecticut. APPROACH: A standardized interview guide was used to explore professional experiences of IMGs. KEY RESULTS: Four recurrent and unifying themes characterize these experiences: 1) IMGs experience both overt and subtle forms of workplace bias and discrimination; 2) IMGs recognize professional limitations as part of "the deal"; 3) IMGs describe challenges in the transition to the culture and practice of medicine in the US; 4) IMGs bring unique skills and advantages to the workplace. CONCLUSIONS: Our data reveal that IMGs face workplace challenges throughout their careers. Despite diversity in professional background and demographic characteristics, IMGs in our study reported common experiences in the transition to and practice of medicine in the US. Findings suggest that both workforce and workplace interventions are needed to enable IMG physicians to sustain their essential and growing role in the US healthcare system. Finally, commonalities with experiences of other minority groups within the US healthcare system suggest that optimizing IMGs' experiences may also improve the experiences of an increasingly diverse healthcare workforce.

Patient factors associated with following a relocated primary care provider among older adults.

OBJECTIVES: To use a natural experiment to identify patient factors associated with the decision to follow one's primary care provider (PCP) to a more distant location after the closure of a medical practice. STUDY DESIGN: Case-control study. METHODS: Eight months after the closure of a practice in Dundalk, Maryland, we randomly selected 140 patients older than 60 years from each of the following groups: those who followed their PCP (continuity group) and those who transferred to a closer clinic (proximity group). We designed a survey instrument to collect information about demographics, duration of the patient-PCP relationship, transportation, self-assessed driving proficiency, and patients' estimates of the distance in miles and the driving time in minutes from their homes to both practices. Chi2 tests and logistic regression analyses were used to determine differences between the groups. RESULTS: The response rate to the survey was 64%. More than 85% of patients in both groups had been with their original PCP for longer than 2 years. In multivariable analysis, the following 3 factors were associated with being a patient in the proximity group: living alone (adjusted odds ratio [OR], 3.14; 95% confidence interval [CI], 1.35-7.26), having greater physical disability (physical component summary score <40; OR, 2.14; 95% CI, 1.04-4.39), and perceiving that travel time from home to the farther clinic would require at least 10 minutes longer than the MapQuest estimate (OR, 4.08; 95% CI, 1.97-8.43). CONCLUSION: Older patients who live alone and are weaker seem to be more likely to forgo continuity with their PCP for the sake of convenience when a barrier to access occurs such as relocation of the physician to a more distant office.

Similarities and differences between international medical graduates and U.S. medical graduates at six Maryland community-based internal medicine residency training programs.

PURPOSE: Approximately 25% of practicing physicians in the United States are graduates of medical schools in other countries; they are called international medical graduates (IMGs). Their transition into the U.S. health care system may be difficult and challenging. This study sought to identify the similarities and differences between IMGs and U.S. medical graduates (USMGs) working together in residency training programs. METHOD: In 2006, the authors conducted a cross-sectional survey study of house officers (interns and residents) at six internal medicine (IM) community-based residency programs in Baltimore, Maryland. The survey asked about demographics, relocation for residency training, practice experience, and career plans and included four previously validated instruments: the Iowa Fatigue Scale, Cohen's Perceived Stress Scale, Rosenberg's Self-Esteem Scale, and the Personal Growth Scale. RESULTS: Of 225 potential house officers, 176 (78%) responded. In multivariable modeling, independent characteristics that differentiated IMGs from USMGs were that IMGs had (1) a native language other than English (odds ratio [OR] 18.3, 95% CI: 5.8-57.3), (2) less debt (<$50K) upon graduation from medical school (OR 7.3, 2.5-21.2), and (3) experiences practicing medicine before residency training (OR 41.02, 1.6-1017). With modeling to control for these three differences, the authors found IMGs to have lower fatigue (OR 2.7; 1.2-6.0), higher self-esteem (OR 3.0; 1.2-7.5), and greater personal growth scores (OR 3.6; 1.6-8.2). CONCLUSIONS: Differences exist between the IMGs and USMGs who are working together in community-based IM residency training programs. Considering such differences may help educators and program directors trying to support and train this diverse cadre of trainees.

Influence of diabetes and hyperglycemia on duration of stay in patients hospitalized with congestive heart failure.

OBJECTIVE: To analyze the influence of diabetes and hyperglycemia on duration of stay in patients hospitalized with congestive heart failure (CHF). METHODS: We conducted a retrospective review of data for patients admitted during a 6-month period with CHF to a community teaching hospital in Baltimore, Maryland. Patients were divided into diabetic and nondiabetic groups, and patients with diabetes were stratified by mean fasting plasma glucose levels into the following groups: <110 mg/dL, 110 to 180 mg/dL, and >180 mg/dL. The primary outcome was duration of hospitalization. Other variables included sex, age, ejection fraction, admission glucose, brain natriuretic peptide, creatinine, and other comorbidities. RESULTS: The study cohort consisted of 142 patients, 49% of whom had diabetes. The duration of hospitalization was 3.23 days in the patients with diabetes versus 3.11 days in those without diabetes (P = .875). Patients with diabetes were significantly younger (71.8 versus 76.6 years; P = .027) and had a higher baseline mean creatinine level (1.4 versus 1.2 mg/dL; P = .010). Patients with diabetes in the 110 to 180 mg/dL blood glucose group had shorter hospitalizations than did those in the <110 mg/dL group (2.94 versus 3.41 days; P = .259). Only 9 patients had blood glucose levels >180 mg/dL, and these patients had the longest hospitalizations (mean duration, 3.78 days). CONCLUSION: The prevalence of diabetes was higher in our study than in previously published studies of patients with CHF. Although patients with diabetes did not have significantly longer hospitalizations than those without diabetes, they were significantly younger and had higher baseline creatinine values. Hyperglycemia was an infrequent phenomenon among patients without diabetes. The patients with diabetes in the 110 to 180 mg/dL blood glucose group had shorter hospitalizations than did those in the <110 mg/dL group, although this difference did not reach statistical significance. Many of the initial studies of tight glucose control were conducted in the surgical intensive care unit, but recently published evidence has raised doubt about applying these results to medical patients. We conclude that there may be no significant benefit in terms of duration of hospitalization in assigning patients with diabetes who have CHF exacerbations to tight glucose control regimens. A more liberal approach of maintaining glucose levels at 110 to 180 mg/dL may be acceptable.

A model intensive course in geriatric teaching for non-geriatrician educators.

INTRODUCTION: Because of the aging demographics nearly all medical specialties require faculty who are competent to teach geriatric care principles to learners, yet many non-geriatrician physician faculty members report they are not prepared for this role. AIMS: To determine the impact of a new educational intervention designed to improve the self-efficacy and ability of non-geriatrician clinician-educators to teach geriatric medicine principles to medical students and residents. DESCRIPTION: Forty-two non-geriatrician clinician-educator faculty from 17 academic centers self-selected to participate in a 3-day on-site interactive intensive course designed to increase knowledge of specific geriatric medicine principles and to enhance teaching efficacy followed by up to a year of mentorship by geriatrics faculty after participants return to their home institutions. On average, 24% of their faculty time was spent teaching and 57% of their clinical practices involved patients aged over 65 years. Half of all participants were in General Internal Medicine, and the remaining were from diverse areas of medicine. EVALUATION: Tests of geriatrics medical knowledge and attitudes were high at baseline and did not significantly change after the intervention. Self-rated knowledge about specific geriatric syndromes, self-efficacy to teach geriatrics, and reported value for learning about geriatrics all improved significantly after the intervention. A quarter of the participants reported they had achieved at least one of their self-selected 6-month teaching goals. DISCUSSION: An intensive 3-day on-site course was effective in improving self-reported knowledge, value, and confidence for teaching geriatrics principles but not in changing standardized tests of geriatrics knowledge and attitudes in a diverse group of clinician-educator faculty. This intervention was somewhat associated with new teaching behaviors 6 months after the intervention. Longer-term investigations are underway to determine the sustainability of the effect and to determine which factors predict the faculty who most benefit from this innovative model.

The closure of a medical practice forces older patients to make difficult decisions: a qualitative study of a natural experiment.

OBJECTIVE: The closure of a primary care practice and the relocation of the physicians and staff to a new office forced patients to decide whether to follow their primary care physicians (PCP) or to transfer their care elsewhere. This study explores the perspectives of the older patients affected by this change. DESIGN: Qualitative study. SETTING AND PARTICIPANTS: Two lists of patients older than 60 years from the original office were generated: (1) those who had followed their PCPs to the further practice and (2) those who chose new PCPs at an affiliated nearby clinic. One hundred forty patients from each of the two lists were randomly selected for study. MEASUREMENT: Eight months after the clinic's closure, patients responded to an open-ended question asking patients to describe the transition. Using content analysis, two investigators independently coded all of the written responses. RESULTS: Over 85% of patients in both groups had been with their original PCP for longer than 2 years. Patients that elected to transition their care to a new PCP within their community were older (75 vs 70 years) and more likely to be living alone (38% vs 18%), both p < 0.01. There was still considerable frustration associated with the clinic's closure. Patients from both groups had variable levels of satisfaction with their new primary care arrangements. Patients who moved to the near clinic, now seeing a new physician, commented on being satisfied with the proximity of the site. On the other hand, these patients also expressed longing for the previous arrangement (the building, the staff, and especially their prior physician). Patients who transferred their care to the further clinic indicated a profound loyalty to their PCP and an appreciation of the added features at the new site. Yet, many patients still described being upset with the difficulties associated with the further distance. CONCLUSION: The closing of this practice was difficult for this cohort of older patients. Patients' decisions were considerably influenced by whether they imagined that convenience or their established relationship with their PCP was of a higher priority to them.

Long-term follow-up of a 10-month programme in curriculum development for medical educators: a cohort study.

CONTEXT: There is an ongoing need for curriculum development (CD) in medical education. However, only a minority of medical teaching institutions provide faculty development in CD. This study evaluates the long-term impact of a longitudinal programme in curriculum development. METHODS: We surveyed eight cohorts of participants (n = 64) and non-participants (n = 64) from 1988 to 1996 at baseline and at 6-13 years after completion of a 10-month, one half-day per week programme offered annually, which included a mentored CD project, workshops on CD steps, a final paper and a presentation. RESULTS: Fifty-eight participants (91%) and 50 non-participants (78%) returned completed follow-up surveys. In analyses, controlling for background characteristics and baseline self-rated proficiencies, participants were more likely than non-participants at follow-up to report having developed and implemented curricula in the past 5 years (65.5% versus 43.7%; odds ratio [OR] 2.41, 95% confidence interval [CI] 1.03-5.66), to report having performed needs assessment when planning a curriculum (86.1% versus 58.8%; OR 5.59, 95% CI 1.20-25.92), and to rate themselves highly in developing (OR 3.57, 95% CI 1.36-9.39), implementing (OR 3.04, 95% CI 1.16-7.93) and evaluating (OR 2.74, 95% CI 1.10-6.84) curricula. At follow-up, 86.2% of participants reported that the CD programme had made a moderate or great impact on their professional careers. Responses to an open-ended question on the impact confirmed continued involvement in CD work, confidence in CD skills, application of CD skills and knowledge beyond CD, improved time management, and lasting relationships formed because of the programme. CONCLUSIONS: Our results suggest that a longitudinal faculty development programme that engages and supports faculty in real CD work can have long-lasting impact.

Self-administered instruments to measure cultural competence of health professionals: a systematic review.

BACKGROUND: Tools that measure knowledge, attitudes, and skills reflecting cultural competence of health professionals have not been comprehensively identified, described, or critiqued. SUMMARY: We systematically reviewed English-language articles published from 1980 through June 2003 that evaluated the effectiveness of cultural competence curricula targeted at health professionals by using at least one self-administered tool. We abstracted information about targeted providers, evaluation methods, curricular content, and the psychometric properties of each tool. We included 45 articles in our review. A total of 45 unique instruments (32 learner self-assessments, 13 written exams) were used in the 45 articles. One third (15/45) of the tools had demonstrated either validity or reliability, and only 13% (6/45) had demonstrated both reliability and validity. CONCLUSIONS: Most studies of cultural competence training used self-administered tools that have not been validated. The results of cultural competence training could be interpreted more accurately if validated tools were used.

A ten-month program in curriculum development for medical educators: 16 years of experience.

BACKGROUND: Despite increased demand for new curricula in medical education, most academic medical centers have few faculty with training in curriculum development. OBJECTIVE: To describe and evaluate a longitudinal mentored faculty development program in curriculum development. DESIGN: A 10-month curriculum development program operating one half-day per week of each academic year from 1987 through 2003. The program was designed to provide participants with the knowledge, attitudes, skills, and experience to design, implement, evaluate, and disseminate curricula in medical education using a 6-step model. PARTICIPANTS: One-hundred thirty-eight faculty and fellows from Johns Hopkins and other institutions and 63 matched nonparticipants. MEASUREMENTS: Pre- and post-surveys from participants and nonparticipants assessed skills in curriculum development, implementation, and evaluation, as well as enjoyment in curriculum development and evaluation. Participants rated program quality, educational methods, and facilitation in a post-program survey. RESULTS: Sixty-four curricula were produced addressing gaps in undergraduate, graduate, or postgraduate medical education. At least 54 curricula (84%) were implemented. Participant self-reported skills in curricular development, implementation, and evaluation improved from baseline (p < .0001), whereas no improvement occurred in the comparison group. In multivariable analyses, participants rated their skills and enjoyment at the end of the program significantly higher than nonparticipants (all p < .05). Eighty percent of participants felt that they would use the 6-step model again, and 80% would recommend the program highly to others. CONCLUSIONS: This model for training in curriculum development has long-term sustainability and is associated with participant satisfaction, improvement in self-rated skills, and implementation of curricula on important topics.

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.

The role of cultural diversity climate in recruitment, promotion, and retention of faculty in academic medicine.

BACKGROUND: Ethnic diversity among physicians may be linked to improved access and quality of care for minorities. Academic medical institutions are challenged to increase representation of ethnic minorities among health professionals. OBJECTIVES: To explore the perceptions of physician faculty regarding the following: (1) the institution's cultural diversity climate and (2) facilitators and barriers to success and professional satisfaction in academic medicine within this context. DESIGN: Qualitative study using focus groups and semi-structured interviews. PARTICIPANTS: Nontenured physicians in the tenure track at the Johns Hopkins University School of Medicine. APPROACH: Focus groups and interviews were audio-taped, transcribed verbatim, and reviewed for thematic content in a 3-stage independent review/adjudication process. RESULTS: Study participants included 29 faculty representing 9 clinical departments, 4 career tracks, and 4 ethnic groups. In defining cultural diversity, faculty noted visible (race/ethnicity, foreign-born status, gender) and invisible (religion, sexual orientation) dimensions. They believe visible dimensions provoke bias and cumulative advantages or disadvantages in the workplace. Minority and foreign-born faculty report ethnicity-based disparities in recruitment and subtle manifestations of bias in the promotion process. Minority and majority faculty agree that ethnic differences in prior educational opportunities lead to disparities in exposure to career options, and qualifications for and subsequent recruitment to training programs and faculty positions. Minority faculty also describe structural barriers (poor retention efforts, lack of mentorship) that hinder their success and professional satisfaction after recruitment. To effectively manage the diversity climate, our faculty recommended 4 strategies for improving the psychological climate and structural diversity of the institution. CONCLUSIONS: Soliciting input from faculty provides tangible ideas regarding interventions to improve an institution's diversity climate.

Challenges in systematic reviews of educational intervention studies.

Educators have recognized the need to apply evidence-based approaches to medical training. To do so, medical educators must have access to reliable evidence on the impact of educational interventions. This paper describes 5 methodologic challenges to performing systematic reviews of educational interventions for health care professionals: finding reports of medical education interventions, assessing quality of study designs, assessing the scope of interventions, assessing the evaluation of interventions, and synthesizing the results of educational interventions. We offer suggestions for addressing these challenges and make recommendations for reporting, reviewing, and appraising interventions in medical education.

A systematic review of the methodological rigor of studies evaluating cultural competence training of health professionals.

PURPOSE: To systematically examine the methodological rigor of studies using cultural competence training as a strategy to improve minority health care quality. To the authors' knowledge, no prior studies of this type have been conducted. METHOD: As part of a systematic review, the authors appraised the methodological rigor of studies published in English from 1980 to 2003 that evaluate cultural competence training, and determined whether selected study characteristics were associated with better study quality as defined by five domains (representativeness, intervention description, bias and confounding, outcome assessment, and analytic approach). RESULTS: Among 64 eligible articles, most studies (no. = 59) were published recently (1990-2003) in education (no. = 26) and nursing (no. = 14) journals. Targeted learners were mostly nurses (no. = 32) and physicians (no. = 19). Study designs included randomized or concurrent controlled trials (no. = 10), pretest/posttest (no. = 22), posttest only (no. = 27), and qualitative evaluation (no. = 5). Curricular content, teaching strategies, and evaluation methods varied. Most studies reported provider outcomes. Twenty-one articles adequately described provider representativeness, 21 completely described curricular interventions, eight had adequate comparison groups, 27 used objective evaluations, three blinded outcome assessors, 14 reported the number or reason for noninclusion of data, and 15 reported magnitude differences and variability indexes. Studies targeted at physicians more often described providers and interventions. Most trials completely described targeted providers, had adequate comparison groups, and reported objective evaluations. Study quality did not differ over time, by journal type, or by the presence or absence of reported funding. CONCLUSIONS: Lack of methodological rigor limits the evidence for the impact of cultural competence training on minority health care quality. More attention should be paid to the proper design, evaluation, and reporting of these training programs.

Cultural competence: a systematic review of health care provider educational interventions.

OBJECTIVE: We sought to synthesize the findings of studies evaluating interventions to improve the cultural competence of health professionals. DESIGN: This was a systematic literature review and analysis. METHODS: We performed electronic and hand searches from 1980 through June 2003 to identify studies that evaluated interventions designed to improve the cultural competence of health professionals. We abstracted and synthesized data from studies that had both a before- and an after-intervention evaluation or had a control group for comparison and graded the strength of the evidence as excellent, good, fair, or poor using predetermined criteria. MAIN OUTCOME MEASURES: We sought evidence of the effectiveness and costs of cultural competence training of health professionals. RESULTS: Thirty-four studies were included in our review. There is excellent evidence that cultural competence training improves the knowledge of health professionals (17 of 19 studies demonstrated a beneficial effect), and good evidence that cultural competence training improves the attitudes and skills of health professionals (21 of 25 studies evaluating attitudes demonstrated a beneficial effect and 14 of 14 studies evaluating skills demonstrated a beneficial effect). There is good evidence that cultural competence training impacts patient satisfaction (3 of 3 studies demonstrated a beneficial effect), poor evidence that cultural competence training impacts patient adherence (although the one study designed to do this demonstrated a beneficial effect), and no studies that have evaluated patient health status outcomes. There is poor evidence to determine the costs of cultural competence training (5 studies included incomplete estimates of costs). CONCLUSIONS: Cultural competence training shows promise as a strategy for improving the knowledge, attitudes, and skills of health professionals. However, evidence that it improves patient adherence to therapy, health outcomes, and equity of services across racial and ethnic groups is lacking. Future research should focus on these outcomes and should determine which teaching methods and content are most effective.