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IIR 07-139 – HSR&D Study

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IIR 07-139
Racial Variations in Communication, Decision Making and Diabetes Outcomes
Charlene A Pope PhD MPH BSN
Ralph H. Johnson VA Medical Center, Charleston, SC
Charleston, SC
Funding Period: October 2008 - March 2014

BACKGROUND/RATIONALE:
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.

OBJECTIVE(S):
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.

METHODS:
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).

FINDINGS/RESULTS:
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.

IMPACT:
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.

PUBLICATIONS:

Journal Articles

  1. Davis BH, Pope C, Mason PR, Magwood G, Jenkins CM. "It's a wild thing, waiting to get me": stance analysis of African Americans with diabetes. The Diabetes educator. 2011 May 1; 37(3):409-18.
  2. Davis BH, Pope C. Institutionalized ghosting: policy contexts and language use in erasing the person with Alzheimer's. Language policy. 2010 Feb 1; 9(1):29-44.
  3. Jenkins C, Pope C, Magwood G, Vandemark L, Thomas V, Hill K, Linnen F, Beck LS, Zapka J. Expanding the chronic care framework to improve diabetes management: the REACH case study. Progress in community health partnerships : research, education, and action. 2010 Jan 1; 4(1):65-79.
  4. Francis-Baldesari C, Pope C. Using a social constructivist model of teaching to create a learning community. The Journal of nursing education. 2008 Mar 1; 47(3):143-4.
Journal Other

  1. Gilbert GE, Pope C. A brief introduction to evaluating the literature. [Editorial]. Journal of the National Medical Association. 2010 Jan 1; 102(1):65-7.
Book Chapters

  1. Pope CA, Roberson J. The comparison of shared decision making in monolingual and bilingual health encounters. In: Interpreter Mediated Healthcare Consultations. London, England: Equinox; 2014. Chapter 10. 288 p.
  2. Pope CA. Positioning and membership categorization in monoracial and interracial interactions of persons with dementia. In: Davis BH, Guendouzi J, editors. Pragmatics in Dementia Discourse. Cambridge, England: Cambridge Scholars Publishing; 2013. Chapter 3. 55-82 p.
Conference Presentations

  1. Pope CA. Task at hand habitus: The search for teamwork in the discourse of nurse to nurse shift handoff communication. Paper presented at: Advances in Qualitative Methods Annual Conference; 2014 Jun 24; Edmonton, Canada.
  2. Pope CA. Future Challenges for Medical Interpreters. Paper presented at: South East Medical Interpreters Association Annual Conference; 2014 Jun 6; Charleston, SC.
  3. Davis BH, Pope CA, Maclagan M. Proposition density in dementia conversations. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2013 Nov 1; New Orleans, LA.
  4. Pope CA. Health Disparities and Social Action: Setting Priorities. Paper presented at: Philippine Nurses Association of America South Central Regional Conference; 2013 Jan 26; Charleston, SC.
  5. Pope CA. Discourses of Prevention for Veterans with Chronic Disease in Primary Care: Cues for Health Promotion Planning. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2012 Oct 29; San Francisco, CA.
  6. Pope CA, North-Lee B. Dropped cues and missed referrals: talk of primary care providers and Veterans with poorly controlled diabetes. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 17; National Harbor, MD.
  7. Pope CA, Davis BH. Identification of health literacy practices in the communication of an adult education group. Paper presented at: Health Literacy Research Annual Conference; 2011 Oct 17; Chicago, IL.
  8. Pope CA. It's all about the question: choosing and using qualitative, quantitative and mixed methods research. Paper presented at: South Carolina Upstate Area Health Education Center Annual Symposium; 2010 Sep 24; Greenville, SC.
  9. Pope CA. Racial variations in cognitive mapping by Veterans living with diabetes. Poster session presented at: VA HSR&D Field-Based Equity Conference; 2010 Sep 13; Boston, MA.
  10. Pope CA. The VA Role in Broadening Approaches to Communication Research for Nursing. Paper presented at: Communication, Medicine and Ethics (COMET) Interdisciplinary Annual Conference; 2010 Jun 28; Boston, MA.
  11. Pope CA, North-Lee B, Davis B. Expanding explanatory models: The embodiment of agency and accountability in the talk of Veterans with diabetes. Paper presented at: Communication, Medicine and Ethics (COMET) Interdisciplinary Annual Conference; 2010 Jun 19; Boston, MA.
  12. Pope CA, Davis B. Carolinas Conversations Collections: A Gerontology Resource. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2009 Nov 22; Atlanta, GA.
  13. Pope CA. Building the Future by Hearing the Past. Paper presented at: Winston-Salem State University National Conference to End Health Disparities II; 2009 Nov 5; Winston-Salem, NC.
  14. Pope CA. Approaches to Health Disparities and Social Determinants of Health for Health Educators. Paper presented at: Healthcare Education Association Annual Meeting; 2009 Oct 8; Asheville, NC.
  15. Pope CA. Lame Jokes: co-constructed humor and societal inequalities in health encounters. Paper presented at: North American Workshop on Pragmatics; 2008 Oct 4; Toronto, Canada.


DRA: Health Systems, Diabetes and Related Disorders
DRE: none
Keywords: Attitudes/Beliefs, Communication -- doctor-patient, Culture, Decision-Making, Diabetes, Disparities, Outcomes, Patient-Provider Interaction
MeSH Terms: none

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