HSR&D Home » Research » IIR 07-139 – HSR&D Study
Racial Variations in Communication, Decision Making and Diabetes Outcomes
Charlene A Pope, PhD MPH BSN
Ralph H. Johnson VA Medical Center, Charleston, SC
Funding Period: October 2008 - March 2014
Despite equity in access and services, VA studies identify racial disparities for Black Americans in the process and quality of diabetes care, adherence with treatment regimens, and patient satisfaction with services. Though effective patient-provider communication contributes to better diabetes outcomes, it is unclear how communication contributes to racial disparities in the process of care. Systematic comparisons of communication and decision making in patient-provider interactions to diabetes outcomes will provide evidence for targeted, culturally tailored interventions.
1. Determine the association between patient-centered communication (FHCS tool) and shared decision-making (OPTION tool) in relation to glycemic control (A1Cs) and potential racial disparities.
2. Identify patterns of communication, shared decision making, and beliefs and attitudes in a sample of patient-provider pairs that represent patients with optimal, intermediate and poor glycemic control.
3. Identify speaking practices by qualitative discourse analysis as predictors of glycemic control to propose elements for a targeted intervention.
This mixed methods study recorded 107 patients with Type 2 diabetes (65 Blacks and 42 Whites) communicating with providers during Primary Care visits as part of a cohort of 179 Veterans consented to study racial disparities in care. A quantitative analysis examined variations in glycemic control by race. The transcriptions of recorded visits were scored and ranked for quality of communication, empathy, and shared decision making during health encounters, using two validated and reliable instruments, the Four Habits Coding Scheme (FHCS) and the OPTION Scale for shared decision making. Subsequently, t-tests examined communication and shared decision making for differences in relation to race and glycemic control.
Data associated with the 60 Veterans (30 Black and 30 White) sorted and categorized with best, moderate, and least effective glycemic control were separated for closer investigation and intervention mapping. A qualitative discourse analysis on this sub-set compared their patterns of communication and decision making, cultural models of diabetes, and examples of communication practices with their providers. Finally, resulting patterns were used to map key elements for a future institutional, patient-provider, and community outreach intervention for future testing (Integration of Mixed Methods).
Cognitive mapping interviews preliminary to initial recordings identified limited understanding of diabetes, assumptions about health services and approaches to self-management. A manuscript in revision sums up the mechanical approach to self-care, narrow focus on medication-taking, and areas of differing understanding arising from specific provider communication practices and the lack of teach back in recorded interviews.
Overall analysis of the entire cohort demonstrated a racial disparity in glycemic control with mean A1cs of 9.3 for Blacks (95% CI: 8.8-9.8) and 8.4 for Whites (95% CI: 7.8-9.0 ), which was statistically significant (p = 0.03).
The communication quality in Primary Care diabetes discussions was measured using the FHCS overall score and a sub-score for empathy. There was no racial disparity in communication, with a mean of 11 for Blacks (95% CI: 9.7-12.3) and 10.4 for Whites (95% CI: 8.4-12.4), which was not significantly different (p =0.62) or empathy, with 1.0 for Blacks 9 (95% CI: 0.64-1.4) and 1.4 for Whites (95% CI: 0.89-2.41), which was not significant (p =0.13). However, in comparisons of expected FHCS scores outside the VA, a mean of 60 out of a possible 115 has been described previously (Krupat et al. 2006) in comparison to the 10.8 mean in this VA facility for this study.
In measuring shared decision making in the diabetes encounters, this analysis found a mean score of 7.0 for Blacks (95% CI: 5.9-8.6) and 6.2 for Whites (95% CI: 4.2-8.2), which was not significantly different (p=0.52). By contrast, shared decision making scores in a reported study outside the VA as a comparative benchmark (Pellerin et al. 2011) reported a mean score of 24. The overall low mean VA scores in communication quality and shared decision making for both Blacks and Whites obviate the identification of racial disparities in these two components of care, while identifying areas needing intervention and change.
Transcriptions of visits with Veterans who had the highest, lowest and mid-level A1cs in interaction with their providers identified particular communication patterns that represent potential best practices and areas for improvement. For example, providers speaking with Veterans with the best glycemic control were more likely to use open-ended questions, affirmations in relation to successes, offer more details in explanations, provide more opportunity for information exchange, and pick up psychosocial cues or information about Veteran social contexts affecting health or disease.
The overall impact of this project was:
To propose areas to improve quality of care and outcomes and reduce disparities for Black and White veterans with Type 2 diabetes mellitus.
In the interim since the completion of data collection and analysis for this study, the VA National Center for Health Promotion and Disease Prevention has initiated the Patient Education: TEACH for Success Program that addresses many of the communication practices identified as contributing to low overall communication scores in this study. A number of Primary Care providers have been offered the opportunity for training in motivational interviewing at this facility. Findings can be used as evidence to enrich the TEACH for Success Program or offer a supplement focused specifically on diabetes management as an intervention for testing for impact on glycemic control and impact on racial disparities.
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DRA: Health Systems, Diabetes and Other Endocrine Disorders
Keywords: Communication -- doctor-patient, Diabetes, Outcomes
MeSH Terms: none