Transcript Assessing Culturally Competent Diabetes Care with

Assessing Culturally Competent
Diabetes Care with Unannounced
Standardized Patients
Kutob RM, Bormanis J, Crago M, Senf J, Gordon P.
Shisslak C.
Randa M. Kutob, MD, MPH
John Bormanis , PhD
Department of Family and
Community Medicine
University of Arizona, College of
Medicine
[email protected]
[email protected]
The Problem
More effective diabetes care is
desperately needed
and
The provider-patient relationship is a
key point of intervention.
Scope of the Problem
Diabetes and Pre-diabetes
18.8 million with diabetes
7.0 million undiagnosed
+79.0 million w/pre-diabetes
______________________
= 104.8 million!!!!
Diagnosed Diabetes
Undiagnosed
Diabetes
Prediabetes
Those Unaffected
Centers for Disease Control and Prevention. National Diabetes Fact Sheet: national
estimates and general information on diabetes and prediabetes in the United
States, 2011. Atlanta, GA: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, 2011.
Diabetes Disparities
• African Americans, American Indians, and
Hispanic/Latinos have higher rates of diabetes (CDC,
2011)
• African Americans have a 2–4 times higher rate of renal
disease, blindness, and amputations.(Peek, 2007)
• U.S. Latinos have a higher rate renal disease and
retinopathy. (Peek, 2007)
• African Americans, American Indians, and
Hispanic/Latinos have higher diabetes-related death
rates (AHRQ, 2003)
Reinke, 2012
The Medical Office Visit
Kleinman, 1980
Kutob, Senf, Harris, 2009
Medical Culture
Unannounced
Standardized Patient (SPs)
Study
What would a culturally competent physician do during the
office visit, and which of these behaviors could be
measured by an outside observer?
Standardized Patients
(SPs)
• Trained “fake” patients
• Used extensively in medical education
o Objective Structured Clinical Examination
• Typically students know that they are being
evaluated by a SP
• In our study physicians did not know.
Study Design Overview
• Unannounced SPs were sent to the offices of family and
internal medicine physicians
o 4 University-based clinics
o 1 Community-based clinic
• All physicians were consented. Study was approved by
the University of Arizona Institutional Review Board.
The Standardized Patient
Checklist
• Developed by experts in anthropology, endocrinology,
cultural competence, family medicine, internal medicine,
Objective Structured Clinical Examination (OSCE)
development, pediatrics, ethnic minority health care, and
research methodology
• For an adult SP with a chief complaint of diabetes
• The checklist included items modeled on Kleinman’s
cross-cultural office visit
7 Subscales, 41 dichotomous
Items
•
•
•
•
•
•
•
Explanatory Model Elicitation
Cultural Knowledge
Non-judgmental behavior
Sharing the Biomedical Model
Patient Empowerment
Diabetes Specific Behaviors
Arizona Clinical Interview Rating Scale
Explanatory Model
Elicitation
• Asked the patient’s view of illness
• Asked the patient’s view of illness treatment
• Asked about patient’s use of other medical/traditional
providers
• Asked about family support
• Asked about community support
• Asked abut gender role in family and how this influences
care
Cultural Knowledge
• Indicated knowledge when asked, “Is it true that Mexican
Americans have higher rates of diabetes?”
• Addressed health beliefs regarding fatalism
• Indicated knowledge when asked, “I have been eating
nopalitos. Have you heard of those.”
• MD addressed health beliefs, before patient brought up
• MD brought up higher rates of diabetes in Mexican
Americans before SP asked.
• MD brought up nopalitos before MD asked
Non-judgmental Behavior
•
•
•
•
Did not threaten insulin if did not take medications
Did not condemn use of alternative treatments
Did not condemn use of alternative healers
Was non-judgmental in response to elevated hemoglobin
A1c
• Did not threaten complications if did not take
medications
Sharing the Biomedical
Model
Shared knowledge about…
• The treatment of diabetes
• The benefits of exercise
• The benefits of weight control/diet
• The benefits of glycemic control
• The pathophysiology of diabetes
• Prevention of diabetes complications
Patient Empowerment
• Asked about patient’s fears about diabetes
• Asked patient to set her own goals
• Asked about barriers to care
Diabetes Specific
Behaviors
•
•
•
•
•
Ordered hemoglobin A1c
Ordered urinary microalbumin
Made appropriate referral to ophthalmology
Performed monofilament test
Put patient on aspirin
The Arizona Clinical
Interviewing Scale
• Repeated questions only to verify/clarify
• Used no medical terms unless defined immediately
without being asked
• Made sure patient understood future plans
• Avoided use of leading/multiple/why questions
• Avoided giving premature assessment and plan
• Avoided verbal/nonverbal judgment cues/reactions
• Used appropriate body contact
• Was aware of patient’s “space”
• Patient was comfortable with eye contact
• Gave nonverbal positive reinforcement
The Clinical Scenario
• Mexican American woman who did not have health
insurance
• Recently diagnosed with diabetes
• Just moved from a different state
• Needed to establish care with a new physician
• Little understanding of diabetes
• Had a glucometer, but not using it
• Symptomatic
• She thought hemoglobin A1c value was 11
The SPs Explanatory
Model
• Derived from qualitative studies in Mexican American
populations
• Diabetes ran in her family, and she felt that there was no
cure and that it could not be controlled.
• Her spouse and other family members were supportive.
• She had consulted her grandmother, a curandera.
• She was eating nopalitos.
Table 1. Demographics/Characteristics, N=27
Mean Age
Gender Female/Male
Female
Male
Race/Ethnicity
White, non-Hispanic
Asian/Pacific Islander
Other
Hispanic/Latino
Training
Attending
PGY 2
PGY 3
Specialty
Family Medicine
Internal Medicine
35.8±8.7 years
(range, 27-55)
70.4% (19)
29.6% (8)
63.0% (17)
18.5% (5)
11.1% (3)
7.4% (2)
37.0% (10)
37.0% (10)
25.9% (7)
70.4% (19)
29.6% (8)
Table 1. Demographics/Characteristics, N=27
Prior Cultural Competence Training
<1 hour
14.8% (4)
1-3 hours
11.1% (3)
4-6 hours
22.2% (6)
7-10 hours
14.8% (4)
>10 hours
37.0% (10)
Patient Panels Race/Ethnicity (mean %)
White, non-Hispanic
43.4%
Hispanic/Latino
38.5%
African American
8.6%
Asian/Pacific Islander
5.7%
American Indian
2.9%
Other
1.7%
Conversational Spanish
None
14.8% (4)
Poor
11.1% (3)
Fair
40.7%(11)
Good
22.2% (6)
Excellent
11.1% (3)
Table 2. Individual Item Responses, N=27
Subscales and Items
Percentage
of “Yes”
Responses
(n)
Subscale 1: Explanatory Model Elicitation
Asked patient’s view of illness
81.5% (22)
Asked patient’s view of illness treatment
81.5% (22)
Asked about patient’s use of other medical/traditional
providers
Asked about family support
70.4% (19)
Asked about community support
48.1% (13)
Asked about gender role in family and how this
influences care
Subscale 1 Total Score
44.4% (12)
51.9% (14)
63.0%
Table 2. Individual Item Responses, N=27
Subscale 2: Cultural Knowledge
Indicated knowledge when asked, “Is it true that Mexican
Americans have higher rates of diabetes?”
Addressed health beliefs regarding fatalism
Indicated knowledge when asked, “I have been eating
nopalitos. Have you heard of those?”
MD addressed health beliefs, before patient brought up
MD brought up higher rates of diabetes in Mexican
Americans, before SP asked.
MD brought up nopalitos, before SP asked
Subscale 2 Total Score
96.3% (26)
74.1% (20)
70.4% (19)
33.3% (9)
0% (0)
0% (0)
45.7%
Table 2. Individual Item Responses, N=27
Subscale 3: Non-Judgmental Behavior
Did not threaten insulin if did not take medications
Did not condemn use of alternative treatments
Did not condemn use of alternative healers
Was non-judgmental in response to elevated hemoglobinA1c
Did not threaten complications if did not take medications
Subscale 3 Total Score
85.2% (23)
85.2% (23)
85.2% (23)
85.2% (23)
81.5% (22)
84.4%
Subscale 4: Sharing Biomedical Model
Shared knowledge about…
the treatment of diabetes
the benefits of exercise
the benefits of weight control/diet
the benefits of glycemic control
the pathophysiology of diabetes
prevention of diabetes complications
Subscale 4 Total Score
96.3% (26)
88.9% (24)
81.5% (22)
81.5% (22)
74.1% (20)
66.7% (18)
81.5%
Table 2. Individual Item Responses, N=27
Subscale 5: Patient Empowerment
Asked about patients fears about diabetes
Asked patient to set her own goals
Asked about barriers to care
Subscale 5 Total Score
63.0% (17)
63.0% (17)
51.9% (14)
59.3%
Subscale 6: Diabetes Specific Behaviors
Ordered hemoglobin A1c
Ordered urinary microalbumin
Made appropriate referral to ophthalmology
Performed monofilament test
Put patient on aspirin
Subscale 6 Total Score
66.7% (18)
63.0% (17)
44.4% (12)
14.8% (4)
11.1% (3)
40.0%
Table 2. Individual Item Responses, N=27
Subscales and Items
Subscale 7: Arizona Clinical Interview Rating Scale (ACIR)
General Communication:
Repeated questions only to verify/clarify
Used no medical terms unless defined immediately without
being asked
Made sure patient understood future plans
Avoided use of leading/multiple/why questions
Avoided giving premature assessment and plan
Avoid verbal/nonverbal judgment cues/reactions
Nonverbal communication:
Used appropriate body contact
Was aware of patient’s “space”
Patient was comfortable with eye contact
Gave nonverbal positive reinforcement
Subscale 7 Total Score
Percentage
of “Yes”
Responses
(n)
96.3% (26)
96.3% (26)
96.3% (26)
92.6% (25)
92.6% (25)
88.9% (24)
100% (27)
100% (27)
100% (27)
96.3% (26)
95.9%
Total Score
• 70.7±11.0%, with a range of 43.9 to 90.2%
• No significant differences by any demographic or other
characteristics.
Correlations
• Non-Judgmental Behavior and Sharing the Biomedical
Model, Spearman’s rho= -.403, p=.037.
• Sharing the Biomedical Model and Patient
Empowerment, rho=.717, p<.001.
• Explanatory Model Elicitation and Diabetes-Specific
Behaviors subscale, rho=.466, p=.014.
• The item, “Asked patient’s view of illness treatment” was
associated with higher levels of cross-cultural training,
p=.032.
Limitations
• Small study
• One time visit only
• Many university-based physicians with high levels of
cultural competence training
Conclusions
• Providers asked about explanatory models
• Providers asked about social support less frequently
• How providers deliver the message (the biomedical
model) is important!
• Medical student and resident training in motivational
interviewing
Conclusions
Our results suggest that culturally competent care and
good diabetes care are intertwined.
Acknowledgements
• The authors would like to thank Dr. John Harris, Jr. for
his contributions to the design of this research project.
• This research was supported by a grant from the
National Institute of Diabetes and Digestive and Kidney
Diseases (R41 DK62569).
• Dr. Kutob’s time also supported by the Arizona Area
Health Education Centers’ Clinical Outcomes and
Comparative Effectiveness Research Fellowship.