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ECV 04-296 – HSR&D Study

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ECV 04-296
Measuring Cross-Cultural Competence in VA Primary Care
Somnath Saha MD MPH
VA Portland Health Care System, Portland, OR
Portland, OR
Funding Period: October 2010 - September 2014

BACKGROUND/RATIONALE:
Despite a greater burden of illness from numerous conditions, African Americans receive health care that is lower in quantity and quality compared to the majority white population. These disparities have been documented within the VHA, where financial access barriers are minimized. Studies examining the quality of encounters with physicians provide evidence that racial barriers affect patient-provider interactions and may contribute to racial disparities in health care. Over the last decade, the desire to reduce provider contributions to racial disparities has led to widespread calls to train providers in "cultural competence" (CC). The primary goal of CC training is to equip clinicians with the knowledge, attitudes, and skills to address potential sources of disparities in healthcare quality, by improving their communication and relationships with patients from diverse backgrounds. CC training for healthcare trainees and providers has now become ubiquitous and consumes substantial time and resources, yet there is still little empirical evidence available to inform their content and evaluate their effectiveness.

OBJECTIVE(S):
The primary objective of this study was to determine which dimensions of healthcare provider CC, if any, are associated with better relationships and greater equity of care across racial/ethnic groups.

METHODS:
We previously developed a self-administered instrument for primary care providers (PCPs), consisting of 6 scales representing different CC dimensions: Perceived Cultural Aptitude, Perceived Cross-Cultural Efficacy, Awareness of Racial Disparities, Valuing Diverse Perspectives, Support for Accommodating Patient Diversity, and Patient-Centered Orientation. In the current study, 97 PCPs at 4 geographically diverse VA Medical Centers - Philadelphia, Greater Los Angeles, Jesse Brown (Chicago), and Michael E. DeBakey (Houston) - completed our CC instrument. We surveyed 1016 Veterans from participating PCPs' patient panels, and administered validated instruments to measure their global ratings of PCPs, their experience with PCPs' communication and interpersonal style, and their trust in the PCP. We tested associations to determine which CC dimensions were associated with higher ratings of PCPs among minority patients. For CC dimensions positively associated with minority patient ratings, we tested interactions between provider CC and patient race, to determine whether CC dimensions were associated with reduced disparity in outcome measures. We used GEE-based linear regression for all analyses, adjusting for clinic site and patients' age, and accounting for clustering of patients within providers.

FINDINGS/RESULTS:
Most of the 97 PCPs were white (49%) and Asian (27%), and most (68%) were women, while most of the 1016 Veterans identified primarily as African American (62%) or white (31%), and most (93%) were men. The provider CC dimension most consistently associated with higher minority patient ratings of providers was Valuing Diverse Perspectives (VDP). This 6-item scale evaluated providers' openness to diverse patient opinions and ideas, validation of diverse patient perspectives, and interest in engaging patients as partners. The scale had good internal consistency (Cronbach's alpha 0.87). PCPs scoring above the median on the VDP scale received significantly higher ratings from African American patients on communication quality (beta 0.15, 95% CI .002- 0.3, on a scale ranging from 0 to 6 with a mean score of 5.51) and interpersonal style (beta 0.11, 95% CI .02-0.2, on a scale ranging from 0 to 5 with a mean score of 4.67). Higher VDP was not significantly associated with white patients' ratings of providers. We found significant provider VDP-patient race interactions for all outcome measures. Ratings of low CC providers were significantly lower among African American compared to white patients on all outcome measures (global ratings of PCPs, communication quality, interpersonal style, and trust). Ratings of higher CC providers were not significantly different between white and African American patients on any of the outcome measures. These findings indicate that providers placing higher value on diverse patient perspectives deliver care that results in more racially equitable patient experience.

IMPACT:
Reducing racial disparities in health care has become a high priority for the VA. Understanding how to reduce disparities in health care quality and outcomes is critical to achieving the VHA's mission of maximizing the health of the Veteran population. CC training has been advocated and deployed in many healthcare settings including within the VA, but there has been limited evidence to guide the content of CC training or to measure outcomes of training that are likely to improve care and reduce disparities. Our results indicate that the providers' self-assessments on Valuing Diverse Perspectives, which aligns with the often-cited concept of "cultural humility," provide more equitable interpersonal care across patient race and ethnicity. Provider CC training that targets the principles captured in the VDP measure therefore holds the potential to improve equity in healthcare delivery. Our VDP scale also holds promise as a tool for evaluating the effectiveness of CC training that will result in more equitable patient care.

PUBLICATIONS:

Journal Articles

  1. Cuevas AG, O'Brien K, Saha S. African American experiences in healthcare: "I always feel like I'm getting skipped over". Health psychology : official journal of the Division of Health Psychology, American Psychological Association. 2016 Sep 1; 35(9):987-95.
  2. Flickinger TE, Saha S, Roter D, Korthuis PT, Sharp V, Cohn J, Moore RD, Ingersoll KS, Beach MC. Respecting patients is associated with more patient-centered communication behaviors in clinical encounters. Patient education and counseling. 2016 Feb 1; 99(2):250-5.
Conference Presentations

  1. Saha S, Gatchell MS, O M, Bates JT, Gordon HS, Long JA, Washington DL, Gerrity MS. Provider cultural competence and racial disparity in doctor-patient relationships. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  2. Saha S, Gatchell M, O’Neil MO, Bates J, Gordon H, Long J, Washington D. Clinician Cultural Competence and Racial Disparity in Doctor-patient Relationships. Paper presented at: American Academy on Communication in Healthcare Research and Teaching Forum; 2014 Oct 18; Orlando, FL.
  3. Saha S. Provider Cultural Competence and Racial Disparity in Doctor-Patient Relationships. Paper presented at: Communication in Healthcare International Annual Conference; 2014 Sep 29; Amsterdam, Netherlands.
  4. Saha S. Provider Cultural Competence and Racial Disparity in Doctor-Patient Relationships. Paper presented at: Communication, Medicine and Ethics Interdisciplinary Annual Conference; 2014 Jun 28; Lugano, Switzerland.
  5. Saha S. Implicit Race Bias, Stress, Mindfulness, and Disparities in the Quality of Diabetes Care. Poster session presented at: WELL-Med Annual Meeting; 2014 May 31; Alexandroupolis, Greece.
  6. Saha S, Gatchell MS, O’Neil M, Bates JT, Gordon HS, Long JA, Washington DL, Gerrity M. Provider cultural competence and racial disparity in doctor-patient relationships. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 25; San Diego, CA.


DRA: Health Systems, Diabetes and Related Disorders
DRE: Treatment - Observational, Technology Development and Assessment
Keywords: Cultural Competence, Ethnicity/Race, Patient-Provider Interaction, Quality of Care
MeSH Terms: none