Transcript Washington, DC Making the Case - UW Family Medicine & Community Health

Cultural Competency in Clinical Settings:
Improving the Care of Diverse Patients
Denice Cora-Bramble, MD, MBA
Professor of Pediatrics, George Washington University
Executive Director
Goldberg Center for Community Pediatric Health
Children’s National Medical Center
Overview
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Case study
Definitions
Making the case for culturally competent care
Clinical applications of culturally competent care
Applying quality improvement methodology to
ameliorate health disparities: conceptual
framework and example
• Conducting research in and with communities of
color
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Case Study
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Clinical Case #1: When is it Abuse?
• 18 mos old Laotian child presents with 2d
h/o vomiting and diarrhea without fever
• Physical exam was positive for patterned
skin discoloration streaking diagonally
across child’s abdomen
• Mother had similar findings on forehead
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Discussion
• Differential diagnosis?
• Treatment?
• Referrals?
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Differential Diagnosis
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Bruises secondary to coagulopathy
Vasculitis
Child abuse
Traditional practices such as coining and
cupping
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Southeast Asian
Cultural Perspectives
• Traditional practices incorporates ritual
healing, herbalism and dermabrasive
techniques
• Coining – shamans or healers repeatedly
rubbing a coin over patient’s skin
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Definitions
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Cultural Competence:
Practical Definitions
“The ability of health care providers and
health care organizations to understand
and respond effectively to the cultural and
linguistic needs brought by patients to the
health care encounter.”
US DHHS, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in
Health Care Final Report, 2001
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Cultural Competence:
Practical Definitions
“The ability of individuals to establish
effective interpersonal and working
relationships that supersede cultural
differences.”
Cooper LA, Roter DL: Patient-Provider Communication. The Effect of Race and Ethnicity on Process and
Outcomes of Health Care. In: Smedley DB, et al, eds. Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care. Washington, DC: National Academy Press; 2003:552-93
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Making the Case for Culturally
Competent Care
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Making the Case for Culturally
Competent Care
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Demographic changes
Business of medicine
Quality of care
Health disparities
Federal and state laws
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Making the Case:
Demographic Changes
Estimates of US Population 2000 to 2050
(U.S. Census Bureau)
100%
90%
Percent of Population
80%
70%
69.4
65.1
57.5
61.3
53.7
50.1
60%
.White alone, not Hispanic
50%
.All other races
.Hispanic (of any race)
.Asian Alone
40%
30%
12.6
20%
10%
15.5
20.1
17.8
22.3
24.4
4.1
6.2
4.7
7.1
5.3
2.5
3.8
3.0
4.6
3.5
5.4
12.7
13.1
13.5
13.9
14.3
14.6
2000
2010
2020
2030
2040
2050
8.0
0%
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Year
.Black alone
Making the Case:
Business of Medicine
Business Imperative - “Enhancing quality of
care, expanding markets, maximizing
retention rates, customizing care and
containing costs…”
Kaiser Permanente
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Making the Case:
Quality of Care
Importance of equity: no variations in the
quality of care according to patients’
personal characteristics, including race
and ethnicity
Institute of Medicine. Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, DC:
National Academies Press, 2001
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Cultural Competence and
Health Care Quality
Emerging data, with one 2004 study
providing some of the strongest available
evidence: policies that promote cultural
competence are associated with higher
quality of care
Lieu T et al.: Cultural Competence Policies and Other Predictors of
Asthma Care Quality for Medicaid-Insured Children. Pediatrics; 114(1) 2004
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Making the Case:
Health Disparities
“Evidence of racial and ethnic disparities in
healthcare is, with few exceptions,
remarkably consistent across a range of
illnesses and healthcare services.”
IOM Report: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, 2003
Washington, D.C.
Racial/Ethnic Disparities in
Cardiac Care (1984-2001)
11 studies find no racial/ethnic
differences in care (14%)
14%
Total = 81 studies
Racial/Ethnic Differences
in Cardiac Care: The
Weight of the Evidence.
Kaiser Family
Foundation, 2002
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2 studies find the racial/ethnic minority group more
likely than whites to receive appropriate care (2%)
2%
84% (68 studies) find racial/ethnic
differences in care
84%
Understanding Health
Disparities
• Contributing risk factors
– Race
– Income
– Insurance status
– Language & culture
– Unknown factors?
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Making the Case:
Federal and State Laws
• Title VI of the Civil Rights Act of 1964
Requires that all entities receiving Federal
financial assistance, including health care
organizations, take steps to ensure that LEP
persons have meaningful access to the health
care services they provide
• New Jersey: first state to mandate cultural
competence training as part of medical
licensure requirement
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Case Study
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Clinical Case #2: “Jose”
7 y.o. Latino male presents with
recurrent episodes of wheezing.
Patient has been prescribed Albuterol
and Flovent inhalers but mother uses
only the Albuterol MDI during acute
exacerbations. PMI positive for several
asthma related hospitalizations in the
last year.
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Discussion
• Next step?
• What else do you want to know?
• Therapeutic approach?
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Pediatric Asthma
• Most common chronic disease of
childhood
• Affects approximately 4.8 million children
in US
• One of the most common reasons for
pediatric hospital admissions
• Disproportionate burden of asthma related
morbidity and mortality among
racial/ethnic minority children
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Sociocultural Determinants
of Health
• Parental and child health beliefs
• Knowledge of asthma and asthma
management
• Competition with other basic life needs
• Environmental factors
– Can parents afford to control the
environmental triggers?
Mansour M et al.:Barriers to Asthma Care in Urban Children: Parent Perspectives.
Pediatrics; 106(3);512-519
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Sociocultural Determinants
of Health
• Racial and ethnic differences in health
beliefs and concepts of disease
• Differences in beliefs about the value of
prevention
• Fears about steroids
• Lack of regularity in the life of the family
Lieu T et al.: Ethnic Variation in Asthma Status and Management Practices Among Children in Managed
Medicaid; Pediatrics 109(5); 857-865; 2002
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Understanding Pediatric
Asthma Disparities
While the control and treatment for asthma
is primarily based on medications, some
parents have strong personal and cultural
beliefs against the use of medications
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Belief Systems and Asthma
• 60% of Dominican mothers believed that
their child did not have asthma in absence
of symptoms
• 88% thought that medicines are overused
in the US
• 72% did not use prescribed medicines but
substituted traditional practices instead
Bearison DJ et al.: Medical Management of Asthma and Folk Medicine in a Hispanic
Community. J Pediatr Psychol; 24(4);385-392;2002
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Traditional Practices Used in
the Treatment of Asthma
• Ethnomedical therapies
– Prayer
– Vicks VapoRub or “alcanfor”
– “Siete jarabes”
– “Agua maravilla”
– “Te de manzanilla”
Pachter L et al.: Ethnomedical (Folk) Remedies for Childhood Asthma in a Mainland Puerto
Rican Community. Arch Pediatr Adolesc Med, Vol149(9);982-988;1995
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Obtaining a Complete
Cultural History
• Have you consulted anyone else about
this problem? Traditional healers?
• Is your child taking any other medicines
or home remedies?
• Was your child prescribed medicine that
s/he is not taking?
• What do you think caused the disease?
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Applying Quality Improvement
Methodology
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Applying Quality Improvement
Methodology
• Equity identified by IOM as one of six
quality aims, in addition to safety,
effectiveness, patient centeredness,
timeliness and efficiency
Institute of Medicine. Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, DC:
National Academies Press, 2001
• Few interventions have used quality
improvement methodologies as a tool to
achieve equity in care and thereby reduce
health disparities
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Applying Quality Improvement
Methodology
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Two successful quality improvement
interventions that targeted at-risk, poor,
racial and ethnic minority children
Reduced disparities in two important
child health quality domains:
1. Immunization compliance rates
2. Comprehensive preventive services
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Target Outcome
Improvement in Goldberg
Center immunization rates*
for children 19-35 months old
to upper quartile of national
benchmarks
*4:3:1:3:3:1 series :4DPT:3IPV:1MMR:3Hib:3HepB:1Var
Rationale: Immunization rates can be a proxy
measure for child health status and adequacy of
preventive care
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Immunization Related
Health Disparities
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Children at risk for under-vaccination: children
who are poor, African American, from a single
parent household, and that live in inner cities
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Minority children’s immunization compliance
rate can be as much as 20 to 30 percentage
points below those of children living in
suburban areas
McCaskill QE, Livingood W, Crawford PM, Dekle AM, Hou T, Wood DL. Immunization levels among inner city
children enrolled in subsidized childcare. Journal of Health Care for the Poor and Underserved.
2008;19:596-610.
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Poverty as a Barrier
Children in families with incomes below the poverty level are less likely than are those
with families with incomes at or above the poverty level to receive the combined series
vaccination (4:3:1:3) (78 percent and 84 percent, respectively, in 2006).
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Improvement Methodology:
Identified Best Practices
CNMC Provider Level
• Immunization
compliance record
• “Standing”
immunization orders
• Eliminating “missed
opportunities”
• Provider and staff
training
• Data tracking
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Patient Level
• Patient education
• Patient recalls and
reminders
Community Level
• Active collaboration
with DOH Immunization
Program
• MCO’s: Patient
outreach referrals
Outcomes: Immunizations
Pre-Intervention
Post-Intervention
CNMC Compliance rate:
75%
Goldberg Center- NIS
ranking: Third quartile
88%
Top 5%
DC – NIS State ranking: #17
#6
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Outcomes: Goldberg Center
Immunization Rates
90%
88%
85%
84%
Target
80%
75%
75%
70%
65%
Goldberg Center
2006
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2007
2008
Research and Communities of
Color
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Impact of Culture on Research
“Cultures”
• Race/ethnicity
Study participants
Researchers
• Interdisciplinary collaborations
• Communities
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Impact of Culture on Research:
Participation of Minorities
Are there differences in rates of
participation of minorities in research
studies?
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Differential Participation
• Distrust
• Negative experiences
• Fewer studies conducted in minority-serving
institutions
• Ineffective communication of research staff
• Complex study medicine regimens
• Complicated record-keeping requirements
• Lack of feedback
• Ineffective informed consent procedures
El-Khorazaty M, Johnson A, Kiely M et al.: Recruitment and Retention of Low-Income Minority Women in a
Behavioral Intervention to Reduce Smoking, Depression, and Intimate Partner Violence During Pregnancy.
BMC Pub Health; 2007.7:233
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Differential Participation
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Fear of being used as “guinea pigs”
Lack of awareness of clinical trials
Influences of family and friends
Work schedules
Transportation and child care barriers
Literacy and language barriers
Priorities
El-Khorazaty M, Johnson A, Kiely M et al.: Recruitment and Retention of Low-Income Minority Women in a
Behavioral Intervention to Reduce Smoking, Depression, and Intimate Partner Violence During Pregnancy.
BMC Pub Health; 2007.7:233
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Counterargument?
• A 2006 study by Wendler et al. suggests that
differences in participation of minorities in
research is small
• Where differences did occur, minorities were
more willing than non-minorities to participate in
research
• Lack of participation may be due to failure to
invite minorities and to overcome barriers
(transportation, childcare, study location)
Wendler D, Kington R, Madans J et al.: Are Racial and Ethnic Minorities Less Willing to Participate in Health
Research?; PLoS Med 2006,3:0001-0010.
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Interdisciplinary Cultures
• Cultural differences exist between and within
disciplines
• Each interdisciplinary team member must:
– value diversity
– develop the capacity for self-assessment
– work towards understanding the disciplinary
cultures
– be sensitive to interactive dynamics
Reich SM, Reich JA: Cultural Competence in Interdisciplinary Collaborations: A Method for Respecting
Diversity in Research Partnership. Am J Community Psychol;2006. Sepr:38(1-2):51-62
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Culture of the Community
• Human subjects, study participants or
partners?
• Asset-based community model
• Community-based participatory research
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Final Thoughts
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Final Thoughts
“But culture in all its richness, does not
simply explain health behaviors, nor does
sensitivity to culture solve health
disparities. Rather, culture works
dynamically, in conjunction with economic
and social factors, to affect health
behaviors and to alleviate or exacerbate
health disparities.”
Gregg J, et al: Loosing Culture on the Way to Competence: The Use and Misuse of Culture in Medical
Education. Academic Medicine;2006;81(6);542-547
Washington, D.C.
Contact Information
Denice Cora-Bramble, MD, MBA
Executive Director
Goldberg Center for Community Pediatric
Health
Children’s National Medical Center
(202) 476-5857
[email protected]
Washington, D.C.