Karen A. Robinson

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.

Cystic Fibrosis Pulmonary Guidelines: Treatment of Pulmonary Exacerbations

The natural history of cystic fibrosis lung disease is one of chronic progression with intermittent episodes of acute worsening of symptoms frequently called acute pulmonary exacerbations These exacerbations typically warrant medical intervention. It is important that appropriate therapies are recommended on the basis of available evidence of efficacy and safety. The Cystic Fibrosis Foundation therefore established a committee to define the key questions related to pulmonary exacerbations, review the clinical evidence using an evidence-based methodology, and provide recommendations to clinicians. It is hoped that these guidelines will be helpful to clinicians in the treatment of individuals with cystic fibrosis.

Clinical Care Guidelines for Cystic Fibrosis–Related Diabetes: A position statement of the American Diabetes Association and a clinical practice guideline of the Cystic Fibrosis Foundation, endorsed by the Pediatric Endocrine Society

Cystic fibrosis–related diabetes (CFRD) is the most common comorbidity in people with cystic fibrosis (CF), occurring in ∼20% of adolescents and 40–50% of adults (1). While it shares features of type 1 and type 2 diabetes, CFRD is a distinct clinical entity. It is primarily caused by insulin insufficiency, although fluctuating levels of insulin resistance related to acute and chronic illness also play a role. The additional diagnosis of CFRD has a negative impact on pulmonary function and survival in CF, and this risk disproportionately affects women (2–4). In contrast to patients with other types of diabetes, there are no documented cases of death from atherosclerotic vascular disease in patients with CFRD, despite the fact that some now live into their sixth and seventh decades. These guidelines are the result of a joint effort between the Cystic Fibrosis Foundation (CFF), the American Diabetes Association (ADA), and the Pediatric Endocrine Society (PES). They are intended for use by CF patients, their care partners, and health care professionals and include recommendations for screening, diagnosis, and medical management of CFRD. This report focuses on aspects of care unique to CFRD. A comprehensive summary of recommendations for all people with diabetes can be found in the ADA Standards of Medical Care, published annually in the January supplement to Diabetes Care (5). In 2009, CFF in collaboration with ADA and PES convened a committee of CF and diabetes experts to update clinical care guidelines for CFRD. Investigators at Johns Hopkins University conducted evidence reviews on relevant clinical questions identified by the guidelines committee. The reviews were provided to the committee to use in developing recommendations. Where possible, the evidence for each recommendation was considered and graded by the committee using the ADA (5) and the U.S. Preventive Services Task Force (USPSTF) (6 …

Prevalence and Incidence of Endocrine and Metabolic Disorders in the United States: A Comprehensive Review

CONTEXT There has not been a comprehensive compilation of data regarding the epidemiology of all endocrine and metabolic disorders in the United States. EVIDENCE ACQUISITION We included 54 disorders with clinical and public health significance. We identified population-based studies that provided U.S. prevalence and/or incidence data by searching PubMed in December 2007 for English-language reports, hand-searching reference lists of six textbooks of endocrinology, obtaining additional resources from identified experts in each subspecialty, and searching epidemiological databases and web sites of relevant organizations. When available, we selected articles with data from 1998 or later. Otherwise, we selected the article with the most recent data, broadest geographical coverage, and most stratifications by sex, ethnicity, and/or age. Ultimately, we abstracted data from 70 articles and 40 cohorts. EVIDENCE SYNTHESIS Endocrine disorders with U.S. prevalence estimates of at least 5% in adults included diabetes mellitus, impaired fasting glucose, impaired glucose tolerance, obesity, metabolic syndrome, osteoporosis, osteopenia, mild-moderate hypovitaminosis D, erectile dysfunction, dyslipidemia, and thyroiditis. Erectile dysfunction and osteopenia/osteoporosis had the highest incidence in males and females, respectively. The least prevalent conditions, affecting less than 1% of the U.S. population, were diabetes mellitus in children and pituitary adenoma. Conditions with the lowest incidence were adrenocortical carcinoma, pheochromocytoma, and pituitary adenomas. Certain disorders, such as hyperparathyroidism and thyroid disorders, were more common in females. As expected, the prevalence of diabetes mellitus was highest among ethnic minorities. Sparse data were available on pituitary, adrenal, and gonadal disorders. CONCLUSIONS The current review shows high prevalence and incidence of common endocrine and metabolic disorders. Defining the epidemiology of these conditions will provide clues to risk factors and identify areas to allocate public health and research resources.

Cystic Fibrosis Foundation Evidence-Based Guidelines for Management of Infants with Cystic Fibrosis

Newborn screening for cystic fibrosis (CF) offers the opportunity for early medical and nutritional intervention that can lead to improved outcomes. Management of the asymptomatic infant diagnosed with CF through newborn screening, prenatal diagnosis, or sibling screening is different from treatment of the symptomatically diagnosed individual. The focus of management is on maintaining health by preventing nutritional and respiratory complications. The CF Foundation convened a committee to develop recommendations based on a systematic review of the evidence and expert opinion. These guidelines encompass monitoring and treatment recommendations for infants diagnosed with CF and are intended to help guide families, primary care providers, and specialty care centers in the care of infants with CF.

Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations

Background: Although children are at the greatest risk for medication errors, little is known about the overall epidemiology of these errors, where the gaps are in our knowledge, and to what extent national medication error reduction strategies focus on children. Objective: To synthesise peer reviewed knowledge on children’s medication errors and on recommendations to improve paediatric medication safety by a systematic literature review. Data sources: PubMed, Embase and Cinahl from 1 January 2000 to 30 April 2005, and 11 national entities that have disseminated recommendations to improve medication safety. Study selection: Inclusion criteria were peer reviewed original data in English language. Studies that did not separately report paediatric data were excluded. Data extraction: Two reviewers screened articles for eligibility and for data extraction, and screened all national medication error reduction strategies for relevance to children. Data synthesis: From 358 articles identified, 31 were included for data extraction. The definition of medication error was non-uniform across the studies. Dispensing and administering errors were the most poorly and non-uniformly evaluated. Overall, the distributional epidemiological estimates of the relative percentages of paediatric error types were: prescribing 3–37%, dispensing 5–58%, administering 72–75%, and documentation 17–21%. 26 unique recommendations for strategies to reduce medication errors were identified; none were based on paediatric evidence. Conclusions: Medication errors occur across the entire spectrum of prescribing, dispensing, and administering, are common, and have a myriad of non-evidence based potential reduction strategies. Further research in this area needs a firmer standardisation for items such as dose ranges and definitions of medication errors, broader scope beyond inpatient prescribing errors, and prioritisation of implementation of medication error reduction strategies.

Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome

Dizziness is the third most common major medical symptom reported in general medical clinics[1][1] and accounts for about 3%–5% of visits across care settings.[2][2] In the United States, this translates to 10 million ambulatory visits per year because of dizziness,[3][3] with roughly 25% of these

Development of the Cochrane Collaboration’s Central Register of Controlled Clinical Trials

The Cochrane Collaboration has established a centralized database of controlled trials and other studies of health care interventions (called CENTRAL) that serves as the best available resource for all those preparing and maintaining systematic reviews or otherwise searching for trials. CENTRAL is available on The Cochrane Library. This article describes the history and methods of CENTRAL’s development and the results of an analysis of the current composition of CENTRAL. As of September 2000, CENTRAL contained almost 300,000 citations to reports of trials, contributed mainly by Cochrane Groups and Centers around the world. Development of CENTRAL has been an ambitious, scholarly undertaking and has resulted in a valuable resource: CENTRAL includes citations to controlled trials that may not be indexed in MEDLINE, EMBASE, or other bibliographic databases; citations published internationally in many languages; and citations that are available only in conference proceedings or other hard-to-access sources.

Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions

BackgroundDespite 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.MethodsWe 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.ResultsTwenty-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.ConclusionThere 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.

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.