Kevin Grumbach

Effects of Limited English Proficiency and Physician Language on Health Care Comprehension

AbstractOBJECTIVE: To determine the effect of limited English proficiency on medical comprehension in the presence and absence of language-concordant physicians. DESIGN, SETTING, AND PARTICIPANTS: A telephone survey of 1,200 Californians was conducted in 11 languages. The survey included 4 items on medical comprehension: problems understanding a medical situation, confusion about medication use, trouble understanding labels on medication, and bad reactions to medications. Respondents were also asked about English proficiency and whether their physicians spoke their native language. MEASUREMENTS AND MAIN RESULTS: We analyzed the relationship between English proficiency and medical comprehension using multivariate logistic regression. We also performed a stratified analysis to explore the effect of physician language concordance on comprehension. Forty-nine percent of the 1,200 respondents were defined as limited English proficient (LEP). Limited English-proficient respondents were more likely than English-proficient respondents to report problems understanding a medical situation (adjusted odds ratio [AOR] 3.2/confidence interval [CI] 2.1, 4.8), trouble understanding labels (AOR 1.5/CI 1.0, 2.3), and bad reactions (AOR 2.3/CI 1.3, 4.4). Among respondents with language-concordant physicians, LEP respondents were more likely to have problems understanding a medical situation (AOR 2.2/CI 1.2, 3.9). Among those with language-discordant physicians, LEP respondents were more likely to report problems understanding a medical situation (AOR 9.4/CI 3.7, 23.8), trouble understanding labels (AOR 4.2/CI 1.7, 10.3), and bad medication reactions (AOR 4.1/CI 1.2, 14.7). CONCLUSION: Limited English proficiency is a barrier to medical comprehension and increases the risk of adverse medication reactions. Access to language-concordant physicians substantially mitigates but does not eliminate language barriers.

Physician Language Ability and Cultural Competence: An Exploratory Study of Communication with Spanish-speaking Patients

AbstractOBJECTIVE: We studied physician-patient dyads to determine how physician self-rated Spanish-language ability and cultural competence affect Spanish-speaking patients’ reports of interpersonal processes of care. SETTING/PARTICIPANTS: Questionnaire study of 116 Spanish-speaking patients with diabetes and 48 primary care physicians (PCPs) at a public hospital with interpreter services. MEASURES: Primary care physicians rated their Spanish ability on a 5-point scale and cultural competence by rating: 1) their understanding of the health-related cultural beliefs of their Spanish-speaking patients; and 2) their effectiveness with Latino patients, each on a 4-point scale. We assessed patients’ experiences using the interpersonal processes of care (IPC) in diverse populations instrument. Primary care physician responses were dichotomized, as were IPC scale scores (optimal vs nonoptimal). We analyzed the relationship between language and two cultural competence items and IPC, and a summary scale and IPC, using multivariate models to adjust for known confounders of communication. RESULTS: Greater language fluency was strongly associated with optimal IPC scores in the domain of elicitation of and responsiveness to patients, problems and concerns [Adjusted Odds Ratio [AOR], 5.25; 95% confidence interval [CI], 1.59 to 17.27]. Higher score on a language-culture summary scale was associated with three IPC domains — elicitation/responsiveness (AOR, 6.34; 95% CI, 2.1 to 19.3), explanation of condition (AOR, 2.7; 95% CI, 1.0 to 7.34), and patient empowerment (AOR, 3.13; 95% CI, 1.2 to 8.19)—and not associated with two more-technical communication domains. CONCLUSION: Physician self-rated language ability and cultural competence are independently associated with patients’ reports of interpersonal process of care in patient-centered domains. Our study provides empiric support for the importance of language and cultural competence in the primary care of Spanish-speaking patients.

Primary care and receipt of preventive services

OBJECTIVE: To examine whether health insurance, a regular place of care, and optimal primary care are independently associated with receiving preventive care services.DESIGN: A cross-sectional telephone survey.SETTING: Population based.PARTICIPANTS: Probability sample of 3,846 English-speaking and Spanish-speaking women between the ages of 18 and 64 in urban California.INTERVENTIONS: Women were asked about their demographic characteristics, financial status, health insurance status, need for ongoing care, regular place of care, and receipt of blood pressure screening, clinical breast examinations, mammograms, and Pap smears. Women who reported a regular place of care were asked about four components of primary care: availability, continuity, comprehensiveness, and communication.MEASUREMENTS AND MAIN RESULTS: In multivariate analyses that controlled for differences in demographics, financial status, and need for ongoing care, having a regular place of care was the most important factor associated with receiving preventive care services (p<.0001). Having health insurance (p<.001) and receiving optimal primary care from the regular place of care (p<.01) further significantly increased the likelihood of receiving preventive care services.CONCLUSION: A regular source of care is the single most important factor associated with the receipt of preventive services, but optimal primary care from a regular place increases the likelihood that women will receive preventive care.

Who is Caring for the Underserved? A Comparison of Primary Care Physicians and Nonphysician Clinicians in California and Washington

PURPOSE: Little is known about whether different types of physician and nonphysician primary care clinicians vary in their propensity to care for underserved populations. The objective of this study was to compare the geographic distribution and patient populations of physician and nonphysician primary care clinicians. METHODS: This study was a cross-sectional analysis of 1998 administrative and survey data on primary care clinicians (family physicians, general internists, general pediatricians, nurse practitioners, physician assistants, and certified nurse-midwives) in California and Washington. For geographic analysis, main outcome measures were practice in a rural area, a vulnerable population area (communities with high proportions of minorities or low-income residents), or a health professions shortage area (HPSA). For patient population analysis, outcomes were the proportions of Medicaid, uninsured, and minority patients in the practice. RESULTS: Physician assistants ranked first or second in each state in the proportion of their members practicing in rural areas and HPSAs, and in California physician assistants also had the greatest proportion of their members working in vulnerable populations areas (P < .001). Compared with primary care physicians overall, nurse practitioners and certified nurse-midwives also tended to have a greater proportion of their members in rural areas and HPSAs (P < .001). Family physicians were much more likely than other primary care physicians to work in rural areas and HPSAs (P < .001). Compared with physicians, nonphysician clinicians in California had a substantially greater proportion of Medicaid, uninsured, and minority patients (P < .001). CONCLUSIONS: Nonphysician primary care clinicians and family physicians have a greater propensity to care for underserved populations than do primary care physicians in other specialties. Achieving a more equitable pattern of service to needy populations will require ongoing, active commitment by policy makers, educational institutions, and the professions to a mission of public service and to incentives that support and promote care to the underserved.

Congestive heart failure hospitalizations and survival in California: patterns according to race/ethnicity.

BACKGROUND Congestive heart failure (CHF) disproportionately affects African Americans, but data are limited concerning CHF hospitalization patterns among Hispanic and Asian populations, the 2 fastest growing ethnic groups in the United States, and race/ethnic patterns of rehospitalization and survival among patients with CHF are unknown. We conducted a study to assess rates of CHF hospitalization, readmission, and survival among diverse populations in California. METHODS AND RESULTS We used 2 study designs. First, we calculated the population-based incidence of CHF hospitalization in California in 1991. Next we conducted a retrospective cohort study that identified patients initially hospitalized for CHF in 1991 or 1992 and followed these patients for 12 months after their index hospitalization to determine their likelihood of rehospitalization or death. Data were analyzed with Cox proportional hazards models. African Americans had the highest rate of CHF hospitalization. Age-adjusted hospitalization rates were comparable among whites, Latinos, and Asian women and all lower than those in African American, whereas Asian men had the lowest rates. On adjusted analyses, African Americans were more likely than whites and Asians to be rehospitalized (relative risk 1.07; 95% confidence interval 1.04 to 1.10). However, they were less likely to die within the 12-month follow-up period (relative risk 0.86; 95% confidence interval 0.82 to 0.90). Whites, conversely, had the highest posthospitalization mortality rates. CONCLUSIONS These findings demonstrate important racial-ethnic differences in CHF morbidity and mortality rates. The disparate findings of higher hospitalization and rehospitalization rates and lower mortality rates among African Americans than whites may represent differences in the underlying pathophysiology of CHF in these groups or differences in access to quality care. Further studies are needed to explain these seemingly paradoxical outcomes.

Shared Decision Making and the Experience of Partnership in Primary Care

PURPOSE Communication has been researched either as a set of behaviors or as a facet of the patient-physician relationship, often leading to conflicting results. To determine the relationship between these perspectives, we examined shared decision making (SDM) and the subjective experience of partnership for patients and physicians in primary care. METHODS From a convenience sample of experienced primary care physicians in 3 clinics, we recruited a stratified sample of 18 English- or Spanish-speaking patients. Direct observation of visits was followed by videotape-triggered stimulated recall sessions with patients and physicians. We coded decision moments for objective evidence of SDM, using a structured instrument. We classified patients’ and physicians’ subjective experience of partnership as positive or negative by a consensus analysis of stimulated recall sessions. We combined results from these 2 analyses to generate 4 archetypes of engagements and used grounded theory to identify themes associated with each archetype. RESULTS The 18 visits yielded 125 decisions, 62 (50%) of which demonstrated SDM. Eighty-two decisions were discussed in stimulated recall and available for combined analysis, resulting in 4 archetypes of engagement in decision making: full engagement (SDM present, subjective experience positive)—22%; simulated engagement (SDM present, subjective experience negative)—38%; assumed engagement (SDM absent, subjective experience positive)—21%; and nonengagement (SDM absent, subjective experience negative)—19%. Thematic analysis revealed that both relationship factors (eg, trust, power) and communication behavior influenced subjective experience of partnership. CONCLUSIONS Combining direct observation and assessment of the subjective experience of partnership suggests that communication behavior does not ensure an experience of collaboration, and a positive subjective experience of partnership does not reflect full communication. Attempts to enhance patient-physician partnership must attend to both effective communication style and affective relationship dynamics.

The effect of health insurance on medical care utilization and implications for insurance expansion: a review of the literature.

Both the costs and benefits associated with extending health insurance coverage depend on the extent and exact ways in which health insurance affects the utilization of medical care. We review the literature relating to such effects with the goal of informing researchers interested in simulating the impact of policy initiatives aimed at achieving universal coverage. Overall, this literature is quite consistent in finding significant effects of insurance on all types of utilization. Insurance coverage increases outpatient utilization by roughly 1 visit per year for children and between 1 and 2 visits for adults. For both children and adults, these visits are associated with an increased receipt of preventive care. Insurance coverage also increases inpatient utilization for children and adults; for children, there is some evidence that insurance coverage reduces ambulatory care sensitive hospital admissions.

Effect of Physician and Patient Gender Concordance on Patient Satisfaction and Preventive Care Practices

AbstractOBJECTIVE: To explore the role of the gender of the patient and the gender of the physician in explaining differences in patient satisfaction and patient-reported primary care practice. DESIGN: Cross-sectional mailed survey [response rate of 71%]. SETTING: A large group-model Health Maintenance Organization (HMO) in northern California. PATIENTS/PARTICIPANTS: Random sample of HMO members aged 35 to 85 years with a primary care physician. The respondents (N=10,205) were divided into four dyads: female patients of female doctors; male patients of female doctors; female patients of male doctors; and male patients of male doctors. Patients were also stratified on the basis of whether they had chosen their physician or had been assigned. MEASUREMENTS AND MAIN RESULTS: Among patients who chose their physician, females who chose female doctors were the least satisfied of the four groups of patients for four of five measures of satisfaction. Male patients of female physicians were the most satisfied. Preventive care and health promotion practices were comparable for male and female physicians. Female patients were more likely to have chosen their physician than males, and were much more likely to have chosen female physicians. These differences were not seen among patients who had been assigned to their physicians and were not due to differences in any of the measured aspects of health values or beliefs. CONCLUSIONS: Our study revealed differences in patient satisfaction related to the gender of the patient and of the physician. While our study cannot determine the reasons for these differences, the results suggest that patients who choose their physician may have different expectations, and the difficulty of fulfilling these expectations may present particular challenges for female physicians.

The 10 Building Blocks of High-Performing Primary Care

Our experiences studying exemplar primary care practices, and our work assisting other practices to become more patient centered, led to a formulation of the essential elements of primary care, which we call the 10 building blocks of high-performing primary care. The building blocks include 4 foundational elements—engaged leadership, data-driven improvement, empanelment, and team-based care—that assist the implementation of the other 6 building blocks—patient-team partnership, population management, continuity of care, prompt access to care, comprehensiveness and care coordination, and a template of the future. The building blocks, which represent a synthesis of the innovative thinking that is transforming primary care in the United States, are both a description of existing high-performing practices and a model for improvement.

A lifeline for primary care.

A bold federal initiative to revitalize primary care is urgently needed as part of health care reform legislation. Drs. Thomas Bodenheimer, Kevin Grumbach, and Robert Berenson address three interrelated issues: physician payment, practice infrastructure and organization, and the training pipeline.