Lenny López

How do black-serving hospitals perform on patient safety indicators? Implications for national public reporting and pay-for-performance.

Background:There is increasing policy interest in public reporting and tying financial incentives to metrics of patient safety. How black-serving hospitals fare on these measures will have important implications for disparities in care. Objectives:To determine how black-serving hospitals perform on patient safety indicators (PSIs). Research Design:We used national Medicare data to calculate the performance of hospitals on 11 medical and surgical PSIs. We designated US hospitals in the top decile of proportion of hospitalized patients who are black as “black-serving.” We calculated overall and race-specific rates and examined the relationship between being a black-serving hospital and PSI rates. Subjects:Medicare fee-for-service enrollees discharged from 4488 acute-care US hospitals. Results:Black-serving hospitals performed worse than other hospitals on 6 of 11 PSIs. For example, black-serving hospitals had nearly twice the rate of postoperative pulmonary embolism or deep venous thrombosis (19.4 vs. 11.5 per 1000 discharges, P < 0.001). Adjusting for hospital characteristics had moderate effects. In race-specific analyses, we found that both white and black patients generally had higher rates of potential safety events in black-serving hospitals than they did in non–black-serving hospitals. Conclusions:Hospitals that disproportionately care for black patients have higher rates of potential safety events among both black and white patients than other hospitals. Current efforts to penalize hospitals with high PSI rates will have a greater effect on hospitals that disproportionately care for black patients.

Lifestyle modification counseling for hypertensive patients: results from the National Health and Nutrition Examination Survey 1999-2004.

BACKGROUND Lifestyle modification is recommended for all patients with the diagnosis of hypertension. METHODS We examined 3,497 adult hypertensive participants (representing 42 million Americans), from the National Health and Nutrition Examination Survey (NHANES) 1999-2004. We analyzed the rate, demographic, and clinical factors of participants who reported receiving lifestyle counseling and their adherence. RESULTS Of the 3,497 participants with hypertension, 84% reported receiving lifestyle modification counseling. After adjustment for demographic and clinical characteristics, non-Hispanic blacks were more likely to report receiving counseling (odds ratio (OR), 2.5; P < 0.001) when compared to whites. Men (OR, 1.5; P = 0.02) reported receiving counseling more often than women as well as those with Medicare insurance (OR, 1.5; P = 0.02) compared to the privately insured. Participants who were hypercholesterolemic (OR, 1.7; P < 0.001), diabetic (OR, 3.5; P < 0.001), overweight (OR, 1.5; P < 0.001), or obese (OR 3.0; P < 0.001) reported receiving lifestyle counseling more often than those without these conditions. Of those receiving counseling, 88% reported adhering to those recommendations. After adjustment for demographic and clinical characteristics, only non-Hispanic blacks (OR, 2.8; P < 0.001) and those aged >60 (OR, 1.9; P = 0.04) were more likely to report adhering when advised. CONCLUSIONS High cardiovascular risk hypertensive patients had high rates of lifestyle counseling. However, gaps exist in lifestyle counseling for young and low cardiovascular risk hypertensive patients. In addition, differences in rates of adherence exist especially in those with high cardiovascular risk comorbid conditions. Future work is needed to increase adherence to lifestyle counseling for all hypertensive patients.

Hospitalists and the Quality of Care in Hospitals

BACKGROUND Little is known about the link between hospitalists and performance on hospital-level quality indicators. METHODS From October 1, 2005, through September 31, 2006, we linked the Hospital Quality Alliance (HQA) data to the American Hospital Association data on the presence of hospitalists. Main outcome measures included composite measurements of hospital-level quality of care for 3 conditions (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) and 2 dimensions of care (treatment and diagnosis, as well as counseling and prevention). We fitted a series of logistic regression models to examine the relationship between hospitalists and overall quality of care for each condition, controlling for all other hospital characteristics. RESULTS Of 3619 hospitals reporting HQA data, 1461 (40.4%) had hospitalists. Hospitals with hospitalists tended to be large, private, not-for-profit, teaching institutions located in the southern United States. The mean unadjusted composite scores were higher for hospitals with hospitalists vs those with no hospitalists for all 3 conditions (93% vs 86% for AMI, 82% vs 72% for CHF, and 75% vs 71% for pneumonia) and both dimensions of care (87% vs 77% for treatment and diagnosis and 75% vs 66% for counseling and prevention) (P < .001 for all comparisons). After multivariable adjustment, hospitals with hospitalists continued to perform significantly better than those without hospitalists across all composite scores except for CHF. CONCLUSION Hospitals with hospitalists were associated with better performance on HQA indicators for AMI, pneumonia, and the domains of overall disease treatment and diagnosis, as well as counseling and prevention.

Closing the Gap: Eliminating Health Care Disparities among Latinos with Diabetes Using Health Information Technology Tools and Patient Navigators

Latinos have higher rates of diabetes and diabetes-related complications compared to non-Latinos. Clinical diabetes self-management tools that rely on innovative health information technology (HIT) may not be widely used by Latinos, particularly those that have low literacy or numeracy, low income, and/or limited English proficiency. Prior work has shown that tailored diabetes self-management educational interventions are feasible and effective in improving diabetes knowledge and physiological measures among Latinos, especially those interventions that utilize tailored coaching and navigator programs. In this article, we discuss the role of HIT for diabetes management in Latinos and describe a novel “eNavigator” role that we are developing to increase HIT adoption and thereby reduce health care disparities.

The longitudinal impact of patient navigation on equity in colorectal cancer screening in a large primary care network.

The long‐term effects of interventions to improve colorectal (CRC) screening in vulnerable populations are uncertain. The authors evaluated the impact of patient navigation (PN) on the equity of CRC prevention over a 5‐year period.

Cardiovascular Risk Score, Cognitive Decline, and Dementia in Older Mexican Americans: The Role of Sex and Education

Background The purpose of this study was to examine the associations of cardiovascular disease (CVD) risk with cognitive decline and incidence of dementia and cognitive impairment but not dementia (CIND) and the role of education as a modifier of these effects. Methods and Results One thousand one hundred sixteen Mexican American elderly were followed annually in the Sacramento Area Latino Study on Aging. Our sex‐specific 10‐year CVD risk score included baseline age, systolic blood pressure, total cholesterol, high‐density lipoprotein, smoking, body mass index, and diabetes. From adjusted linear mixed models, errors on the Modified Mini–Mental State Exam (3MSE) were annually 0.41% lower for women at the 25th percentile of CVD risk, 0.11% higher at the 50th percentile, and 0.83% higher at the 75th percentile (P value of CVDrisk×time <0.01). In men, 3MSE errors were annually 1.76% lower at the 25th percentile of CVD risk, 0.96% lower at the 50th percentile, and 0.12% higher at the 75th percentile (P value of CVDrisk×time <0.01). From adjusted linear mixed models, the annual decrease in the Spanish and English Verbal Learning Test score was 0.09 points for women at the 25th percentile of CVD risk, 0.10 points at the 50th percentile, and 0.12 points at the 75th percentile (P value of CVDrisk×time=0.02). From adjusted Cox models in women, compared with having <6 years of education, having 12+ years of education was associated with a 76% lower hazard of dementia/CIND (95% CI, 0.08 to 0.71) at the 25th percentile of CVD risk and with a 45% lower hazard (95% CI, 0.28 to 1.07) at the 75th percentile (P value of CVDrisk×education=0.05). Conclusions CVD risk score may provide a useful tool for identifying individuals at risk for cognitive decline and dementia.

Personal Characteristics Associated with Resident Physicians’ Self Perceptions of Preparedness to Deliver Cross-Cultural Care

BACKGROUNDRecent reports from the Institute of Medicine emphasize patient-centered care and cross-cultural training as a means of improving the quality of medical care and eliminating racial and ethnic disparities.OBJECTIVETo determine whether, controlling for training received in medical school or during residency, resident physician socio-cultural characteristics influence self-perceived preparedness and skill in delivering cross-cultural care.DESIGNNational survey of resident physicians.PARTICIPANTSA probability sample of residents in seven specialties in their final year of training at US academic health centers.MEASUREMENTNine resident characteristics were analyzed. Differences in preparedness and skill were assessed using the χ2 statistic and multivariate logistic regression.RESULTSFifty-eight percent (2047/3500) of residents responded. The most important factor associated with improved perceived skill level in performing selected tasks or services believed to be useful in treating culturally diverse patients was having received cross-cultural skills training during residency (OR range 1.71–4.22). Compared with white residents, African American physicians felt more prepared to deal with patients with distrust in the US healthcare system (OR 1.63) and with racial or ethnic minorities (OR 1.61), Latinos reported feeling more prepared to deal with new immigrants (OR 1.88) and Asians reported feeling more prepared to deal with patients with health beliefs at odds with Western medicine (1.43).CONCLUSIONSCross-cultural care skills training is associated with increased self-perceived preparedness to care for diverse patient populations providing support for the importance of such training in graduate medical education. In addition, selected resident characteristics are associated with being more or less prepared for different aspects of cross-cultural care. This underscores the need to both include medical residents from diverse backgrounds in all training programs and tailor such programs to individual resident needs in order to maximize the chances that such training is likely to have an impact on the quality of care.

Association of Acculturation and Country of Origin with Self-Reported Hypertension and Diabetes in a Heterogeneous Hispanic Population

BackgroundHispanics are the fasting growing population in the U.S. and disproportionately suffer from chronic diseases such as hypertension and diabetes. Little is known about the complex interplay between acculturation and chronic disease prevalence in the growing and increasingly diverse Hispanic population. We explored the association between diabetes and hypertension prevalence among distinct U.S. Hispanic subgroups by country of origin and by degree of acculturation.MethodsWe examined the adult participants in the 2001, 2003, 2005, and 2007 California Health Interview Survey (CHIS). Using weighted logistic regression stratified by nativity, we measured the association between country of origin and self-reported hypertension and diabetes adjusting for participants’ demographics, insurance status, socio-economic status and degree of acculturation measured by citizenship, English language proficiency and the number of years of residence in the U.S.ResultsThere were 33,633 self-identified Hispanics (foreign-born: 19,988; U.S.-born: 13,645). After multivariable adjustment, we found significant heterogeneity in self-reported hypertension and diabetes prevalence among Hispanic subgroups. Increasing years of U.S. residence was associated with increased disease prevalence. Among all foreign-born subgroups, only Mexicans reported lower odds of hypertension after adjustment for socioeconomic and acculturation factors. Both U.S.-born and foreign-born Mexicans had higher rates of diabetes as compared to non-Hispanic whites.ConclusionsWe found significant heterogeneity among Hispanics in self-reported rates of hypertension and diabetes by acculturation and country of origin. Our findings highlight the importance of disaggregation of Hispanics by country of origin and acculturation factors whenever possible.

Perspective: creating an ethical workplace: reverberations of resident work hours reform.

Medical professionals are a community of highly educated individuals with a commitment to a core set of ideals and principles. This community provides both technical and ethical socialization. The development of ethical physicians is highly linked to experiences in the training period. Moral traits are situation-sensitive psychological and behavioral dispositions. The consequence of long duty hours on the moral development of physicians is less understood. The clinical environment of medical training programs can be so intense as to lead to conditions that may actually deprofessionalize trainees. The dynamic relationship between individual character traits and the situational dependence of their expression suggests that a systems approach will help promote and nurture moral development. Ethical behavior can be supported by systems that make it more difficult to veer from the ideal. Work hours limits are a structural change that will help preserve public safety by preventing physicians from taking the moral shortcuts that can occur with increasing work and time pressures. Work hours rules are beneficial but insufficient to optimize an ethical work and training environment. Additional measures need to be put in place to ensure that ethical tensions are not created between the patients well-being and the residents adherence to work hours rules. The ethical ideals of physician autonomy, selflessness, and accountability to the patient must be protected through the judicious and flexible use of work hours limits, physician extenders, census caps, nonteaching services, and high-quality handoffs.

Identifying and Preventing Medical Errors in Patients With Limited English Proficiency: Key Findings and Tools for the Field

Abstract: Since the 1999 Institute of Medicine (IOM) report To Err is Human, progress has been made in patient safety, but few efforts have focused on safety in patients with limited English proficiency (LEP). This article describes the development, content, and testing of two new evidence‐based Agency for Healthcare Research and Quality (AHRQ) tools for LEP patient safety. In the content development phase, a comprehensive mixed‐methods approach was used to identify common causes of errors for LEP patients, high‐risk scenarios, and evidence‐based strategies to address them. Based on our findings, Improving Patient Safety Systems for Limited English Proficient Patients: A Guide for Hospitals contains recommendations to improve detection and prevention of medical errors across diverse populations, and TeamSTEPPS Enhancing Safety for Patients with Limited English Proficiency Module trains staff to improve safety through team communication and incorporating interpreters in the care process. The Hospital Guide was validated with leaders in quality and safety at diverse hospitals, and the TeamSTEPPS LEP module was field‐tested in varied settings within three hospitals. Both tools were found to be implementable, acceptable to their audiences, and conducive to learning. Further research on the impact of the combined use of the guide and module would shed light on their value as a multifaceted intervention.