1

Science of CME web page: www.primeinc.org/scienceofcme1

Stroke affects roughly 795,000 Americans each year and is a leading cause of mortality and permanent disability in the United States. 1 The burden of stroke varies across the US, with Southeastern states having some of the highest prevalence rates in the nation, particularly in the states known as the “Stroke Belt” (Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia).2 Additionally, black patients have a stroke risk that is nearly twice that of white patients and tend to have strokes that are more severe and lead to greater mortality.1, 3

According to an Institute of Medicine Report (IOM), Unequal Treatment, clinicians’ stereotypes, biases, and clinical uncertainty play a role in racial and ethnic disparities and alter how stroke risk factors and other health conditions are diagnosed and managed.4 Patients’ perceptions about their health and their level of trust in their healthcare provider were also cited as factors contributing to disparities. The IOM advocated intervention that enhances physician cultural competence as a means to reduce disparities and potentially improve outcomes in cardiovascular and other important diseases. The Centers for Disease Control and Prevention (CDC) has also called for improved physician cultural competence within their framework for eliminating cardiovascular health disparities.5 Currently, studies are lacking that characterize practicing physicians’ preparedness for culturally appropriate care delivery.

The American Heart Association and CE Outcomes, LLC conducted 3 surveys separately assessing perceptions of physicians, office staff, and patients in the 10 states comprising the Stroke Belt. The physician sample included primary care (family medicine, internal medicine) and cardiology specialties.

The physician survey (Poster A) found that 18% of physicians in the Stroke Belt consider multicultural training and sociocultural issues in patient interactions to be of little importance (1-2 on a 5-point scale). Additionally, nearly a quarter of the surveyed physicians have no previous training in cultural diversity. More than 75% of the physicians had limited knowledge of the National Standards on Culturally and Linguistically Appropriate Services (CLAS), a set of standards designed to help ensure that culturally diverse patients receive effective healthcare. 6

Almost all physician offices are compliant with the CLAS Standard 1, culturally-appropriate healthcare delivery. However, only two-thirds of offices are compliant with Standard 2 (culturally diverse and representative staff and leadership), and just over one-quarter are compliant with Standard 3 (staff should receive ongoing education and training in culturally and linguistically appropriate service delivery).

The patient survey (Poster B) showed that a majority of patients were never asked by their doctors if they sought

Assessing Culturally Competent Care in the Stroke Belt

by Greg Salinas, PhDDirector of Research and Assessment Services, CE Outcomes, LLC

CE Outcomes, LLC

2

Assessing Culturally Competent Care in the Stroke Belt

Science of CME web page: www.primeinc.org/scienceofcme

advice from or wished to include family members when making healthcare decisions. However, 90% said that they were satisfied with their care and trusted their physicians.

Key aspects of culturally-appropriate, patient-centered care are often under-utilized, which may be overlooked by both patients and physicians as opportunities to improve healthcare quality. Findings from these surveys may suggest that physicians may have substantial room to improve cultural competence, which may be a viable strategy in the reduction of disparities in cardiovascular outcomes.

References 1. Lloyd-Jones D, Adams R, Carnethon M, et al., Heart disease and stroke statistics--2009 update: a report from the

American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009. 119: e21-181.

2. Howard G, Labarthe DR, Hu J, et al., Regional differences in African Americans’ high risk for stroke: the remarkable burden of stroke for Southern African Americans. Ann Epidemiol 2007. 17: 689-96.

3. Stansbury JP, Jia H, Williams LS, et al., Ethnic disparities in stroke: epidemiology, acute care, and postacute outcomes. Stroke 2005. 36: 374-86.

4. Smedley B, Stith A, Nelson AE, et al., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2003.

5. Mensah GA, Eliminating disparities in cardiovascular health: six strategic imperatives and a framework for action. Circulation 2005. 111: 1332-6.

6. National Standards for Culturally and Linguistically Appropriate Services in Health Care - Final Report. 2001, U.S. Department of Health and Human Services, Office of Minority Health: Washington, DC.

Background

Methods

Conclusions

Jill A. Foster1, Gregory D. Salinas1, Andrew Sanchez1, Marc DesLauriers1, Linda Casebeer1, Clyde W. Yancy2

1CE Outcomes LLC, Birmingham, AL, 2Baylor University Medical Center, Dallas, TX

The CDC and others advocate improved physician cultural competence to reduce disparities in cardiovascular (CV) health [1]. Clinical interventions to prevent and manage cardiovascular disease typically entail recommendations for long-term lifestyle change and pharmacotherapy. Patients may be more receptive and able to implement these recommendations when they have an effective therapeutic alliance with their physician [2]. Physician cultural competence facilitates the therapeutic alliance by enabling clinicians to better engage and communicate with patients. The ability to provide culturally appropriate, patient-centered care becomes particularly important when patients and physicians have different racial, ethnic or cultural backgrounds.

This study sought to better understand elements of cultural competence at both the physician and physician office level that could be targeted to improve cardiovascular health and reduce stroke in minority populations. In designing the study, particular emphasis was placed on understanding aspects of cultural competence that were relevant to stroke prevention among African Americans in the southeastern US (“Stroke Belt” region) [3].

This study invited family medicine (and internal medicine physicians, cardiologists and neurologists practicing in 10 southeastern states (Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia) to complete a survey exploring aspects of physician cultural competence in spring 2008. Items used in the survey were derived from the Clinical Cultural Competence Questionnaire (CCCQ) [4], an instrument developed by UMDNJ’s Center For Healthy Families and Cultural Diversity. Participants self-assessed their attitudes, prior training and perceived knowledge and skills in cross-cultural healthcare using 5-point rating scales. They were also asked demographicquestions about themselves and the types of patients seen in their practice.

To explore cultural competence at the practice level, office managers of physician respondents were invited to complete a separate survey assessing their practice’s compliance with Culturally and Linguistically Appropriate Services (CLAS) Standards 1, 2 and 3 [5]. These three CLAS standards form the Culturally Competent Care subgroup and are highly relevant to the ambulatory practice setting. Survey items were drawn from the CLAS Standards Pre-Assessment Tool developed by the Oklahoma Foundation for Medical Quality. Practices wereconsidered in compliance with a standard if they reported that they currently do at least 50% of behaviors considered indicative of that standard.

SpecialtyPrimary care (family physician/general internist) 73.0%Specialist (cardiologist/neurologist) 26.9%Caucasian/white 70.2% Asian 12.6%African American/black 7.4%Hispanic/Latino 4.7%Other/multiple ethnicity 4.7%

Ethnicity

Less than 10 9.0%10-20 36.9%More than 20 54.1%

Male 76.8%Female 23.2%

Years sincegraduation

Gender

Physician Demographics

Med School United States 79.0%International 21.0%

0 20 40 60 80 100

Physician Training and Attitudes

0 20 40 60 80 100

0 20 40 60 80 100

0 20 40 60 80 100

0 20 40 60 80 100

Previous training in cultural diversity

B

A

W

0 20 40 60 80 100

0 20 40 60 80 100

Importance of multicultural

healthcare training

Importance of sociocultural issues in

patient interactions

Aware of own racial, ethnic, or cultural

identity

0 20 40 60 80 100

Greeting patients inculturally-sensitive manner

Eliciting patient perspectiveabout health and illness

Eliciting information about folkremedies and alternative healing

Performing a culturally-sensitivephysical examination

Prescribing a culturally-sensitivetreatment plan

Providing culturally-sensitivepatient education and counseling

Assessing health literacy

Working with medical interpreters

Dealing with cross-cultural conflicts relating to dx or tx

Apologizing for cross-cultural misunderstandings or errors

Providing culturally-sensitiveclinical preventive services

Providing culturally-sensitiveend of life care

Dealing with cross-culturaladherence problems

Dealing with cross-culturalethical conflicts

0 1 2 3 4 5

Key Points

BAW

BAW

BAW

BAW

BAW

BAW

BAW

BAW

BAW

BAW

BAW

BAW

BAW

BAW

Physician Skill (self-assessed)

Not at all (1) A little (2) Somewhat (3) Quite a bit (4) Very (5)

Black (n=88), Asian (n=51), White (n=483)

0 1 2 3 4 5

Physician Knowledge (self-assessed)

0 1 2 3 4 5

Demographics of diverse groups

Sociocultural aspects of diversegroups

Health risks of diverse groups

Health disparities of diverse groups

Ethnopharmacology

Different healing traditions

Impact of racism and bias in healthcareCivil rights policy against nationalorigin discrimination

CLAS standards

Sociocultural issues in health promotion and disease prevention

2.54

2.52

3.00

2.66

3.15

3.51

3.58

3.27

3.30 BAW

BAW

BAW

BAW

BAWBAW

BAW

BAW

BAW

BAW

3.51

B

A

W

B

A

W

B

A

W

Numbers represent percentages of responses per category.

0 1 2 3 4 5

Office Staff -- CLAS Standards Compliance

Eliciting information about practitioners of alternative healing

24 26 30 15

15 24 30 28

12 25 37 20

11 21 2934

BAW

* p<.05

*********

*****

*********

*

*

*

*

97.6% 66.9%

33.1% 26.8%

73.2%

Standard 1: Culturally-Appropriate

Care Delivery

Standard 2:Leadership andStaff Diversity

Standard 3:Staff Training

and Assessment

Compliant

Not compliant

3.10

3.60

3.65

3.12

2.89

3.26

3.18

3.12

3.09

3.04

3.22

3.09

2.99

3.03

2.97

For more information, please contact: Jill Foster, MD MPH or Greg Salinas, PhD

CE Outcomes, LLC jill.foster@ceoutcomes.com

greg.salinas@ceoutcomes.com

This study was supported by an educational grant to the American Heart Association from Pfizer.

Culturally Appropriate Cardiovascular Risk Management -- Are Physicians Prepared for the Task?

SpecialtyPrimary care (family physician/general internist) 73.4%Specialist (cardiologist/neurologist) 26.6%

Caucasian/white 74.2% Asian 5.6%African American/black 8.9%Other/multiple ethnicity 11.3%

Ethnicity

Ethnicity of physician

Caucasian/white 67.2%Asian 11.5%African American/black 9.0%Hispanic/Latino 4.9%Other/multiple ethnicity 7.4%

*

23 18 23 22 14

19 15 37 21 8

8 20 69

9 17 30 44

18 29 31 17

16 35 39

25 31 29 12

8

6

7 24 35 26

5 15 28 38 14

26 72

9

Among practicing physicians in the southern US: 1 in 4 report no prior training in cultural diversity Nearly 4 of 5 consider sociocultural issues at least somewhat important in patient interactions and similarly value multicultural training for healthcare professionals, however, a significant portion show minimal interest in these constructs Self-assessed cross-cultural knowledge and skill are moderate for most items assessed, but are limited in some important areas such as knowledge of CLAS standards There is marked variation in cultural sensitivity as well as cross-cultural knowledge and skill by physician race, with black physicians reporting higher levels than whites for all items except knowledge of traditional healing traditions Almost all physician offices are compliant with aspects of CLAS standards that are broadly considered indicative of standard health care delivery. Far fewer have implemented the more formal processes needed to ensure culturally- appropriate healthcare delivery

14 45 27

13 25 34 23

Although a significant segment of physicians in the southern US have little or no formal education in multicultural healthcare, overall, they appear to be moderately knowledgeable and skilled in key aspects of cross-cultural care. Findings vary significantly by physician race. This may reflect personal life experiences that attune physicians to cultural variations and help them broker cultural differences. The study also identifies several opportunities to improve cultural competence at both the physician and practice levels.

Improving physician cultural competence is an American Heart Association strategy for reducing disparities in cardiovascular disease. The American Heart Association Board of Directors has defined several goals in its strategic plan. These include a call to impact the healthcare system so that effective care is provided for diverse populations. These goals support the Association’s overall 2020 goal which is “to improve the cardiovascular health of all Americans by 20 % while reducing deaths from cardiovascular diseases and stroke by 20%”.

In order to improve the cardiovascular care delivery system for all Americans, this study indicates a need to sensitize physicians to relevant cultural nuances, provide education on multicultural issues in cardiovascular health, and cultivate cross-cultural skills. Since a portion of physicians appear reluctant to embrace culturally competent care, the evidence demonstrating its value should be further disseminated and developed.

[1] Mensah GA. Circulation 2005;111: 1332-1336.[2] Betancourt JR, et al. Public Health Rep 2003;118: 293-302[3] National Heart, Lung, and Blood Institute. The stroke belt: stroke mortality by race and sex. 1989.[4] www.umdnj.edu/fmedweb/chfcd/aetna_foundation.htm[5] National Standards for Culturally and Linguistically Appropriate Services in Health Care - Final Report. 2001.

N=697

Background

Methods

Key Findings

Cultural Competency to Reduce Stroke Disparities - A Patient PerspectiveJill A. Foster1, Gregory D. Salinas1, Andrew Sanchez1, Linda Casebeer1, Clyde W. Yancy2

1CE Outcomes LLC, Birmingham, AL, 2Baylor University Medical Center, Dallas, TX

Reported History-Taking Behaviors of PCPs

Reported Explanatory Behaviors of PCPs

Patient Trust and SatisfactionMy doctor discusses:If I seek advice from family and friends in healthcare decisions

If I include family members when discussing diagnosis and treatment

Traditional healing remedies I may use

Why I think I got sick

Medications I may use other than the ones he/she prescribes

My doctor:Informs me of local resources

Helps me answer questions

Encourages me to stop him/herwhen I am confused

Helps me to ask questions aboutmy condition and treatment

Takes time to help me understandpossible side effects of prescriptions

Helps me make treatment decisions

Asks if I understand instructions &repeats them when necessary

Asks if I have other questions orconcerns before I leave the office

I trust the information my doctorgives me about my health/future problems

I trust the recommendations myphysician makes to treat me

I am satsfied with the way mydoctor treats me as a person

I am satisfied with the quality of care my doctor provides

Sampling Frame

0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5

3.02.9

3.53.5

2.12.5

2.32.1

1.81.7

4.4

4.5

4.4

4.5

4.5

4.5

4.4

4.4

*3.1

2.9

3.63.5

2.42.4

2.01.7

2.42.1

4.5

4.5

4.5

4.5

4.5

4.5

4.4

4.4

**

*

*

*

*

3.03.0

3.63.5

2.42.0

2.42.2

2.01.7

4.5

4.5

4.5

4.4

4.5

4.5

4.4

4.4

*

0 1 2 3 4 5

*

2.6

3.73.7

2.5

3.43.3

3.73.7

3.83.8

3.83.9

4.24.1

3.73.6

*

0 1 2 3 4 5

2.5

3.3

3.5

3.33.7

3.73.9

3.83.9

3.84.2

4.14.4

2.9

3.93.6

0 1 2 3 4 5

2.42.9

3.33.5

3.43.7

*

*

3.7

3.9

3.94.1

4.24.4

3.73.9

*

3.73.8

Perceptions of black/white patients n=501/647

Perceptions regarding black/white physicians n=215/821

Perceptions of black patients regarding their own physicians (black/white) n=193/238

An IRB-approved survey instrument based on the validated Patient-Reported Provider Cultural Competence(PRPCC) survey [5] was sent by mail to residents of 25 randomly selected counties from the ten states comprising the “stroke belt.” To be eligible, responders had to be between age 40 and 75 and have a PCP whom they had seen at least once in the past 12 months. A small incentive was offered for participation. The instrument assessed the perceived frequency of specific communication behaviors associated with physician cultural competence. Respondents were asked to rate the frequency of their PCP performing a list of behaviors on a 5-point scale, from “Never” (1) to “Always ” (5). Four items were added to assess patient trust and satisfaction in their provider.

*

Numbers indicate means of items rated “Never” (1) to “Always” (5). Bolded items indicate that >40% of overall respondents selected “Never” (1). p<.05

For more information, please contact: Jill Foster, MD MPH or Greg Salinas, PhD / CE Outcomes, LLC jill.foster@ceoutcomes.com / greg.salinas@ceoutcomes.com

[1] Lloyd-Jones D, et al. Circulation 2009. 119: e21-181.[2] Howard G, et al. Ann Epidemiol 2007. 17: 689-96.[3] Smedley B, et al. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2003[4] Mensah GA. Circulation 2005. 111: 1332-6.[5] Thom DH, Tirado MD. Med Care Res Rev. 2006 63: 636-55.

This study was supported by an educational grant to the AmericanHeart Association from Pfizer.

Stroke affects roughly 795,000 Americans each year and is a leading cause of mortality in the US [1]. The burden of stroke varies across the US with southeastern states having some of the highest prevalence rates in the nation [2]. Blacks have a stroke risk that is nearly twice that of whites and tend to have strokes that are more severe and lead to greater mortality [1]. According to an IOM report, clinicians’ stereotypes, biases and clinical uncertainty play a role in racial and ethnic disparities and alter how stroke risk factors and other health conditions are diagnosed and managed [3]. The CDC has also called for improved physician cultural competence within their framework for eliminating cardiovascular health disparities [4].

When physicians and patients have inherently different cultural backgrounds, extra steps may be needed in order to create and nurture an effective partnership. Physicians who are culturally competent are positively attuned to cultural variations and possess relevant knowledge and skills that enable them to empathetically navigate across sociocultural and literacy divides.

There are few current studies that characterize practicing physicians’ preparedness for culturally appropriate care delivery. The present study seeks to help fill this gap by assessing Southern patients’ perceptions of the cultural competency of their primary care provider (PCP).

Stroke rate per 100,000

70-113

114-123

124-133

134-146

147-241

Selected states

Counties sampled

County Stroke Death RatesAges 35+, 1991-1998

Race Black, non-Hispanic 42.7%White, non-Hispanic 54.8%Other 2.5%

40-50 31.2%51-60 39.2%61-70 19.9%71+ 9.7%

Age

Family physician 68.8%General internist 24.6%Nurse practitioner or physician assistant 5.8%Other 5.0%

High blood pressure 61.7%Diabetes 21.9%Heart attack 7.5%Stroke 4.9%

Black, non-Hispanic 18.2%White, non-Hispanic 69.5%Other 12.3%

PCP type

PCP race

Diagnosis

Demographics N=1189

In this survey study, patients in the southeastern US with an established PCP were found to have high levels of trust and satisfaction toward their physician. This relationship provides a sound foundation for cardiovascular risk assessment and intervention. At the same time, findings suggest that many physicians don’t ask about key health influences such as family involvement in decision-making that vary by race and culture. Patients’ PCPs commonly, but inconsistently, used communication strategies that facilitate accurate information exchange. Whether physicians used thesetactics with sufficient frequency could not be determined.

Overall, black patients reported levels of trust and satisfaction as well as physician behavior frequencies similiarly to white patients, with one exception – black patients reported less frequent assessment of traditional healing remedies by their physician than white patients. When patient responses were examined by physician race, several behaviors were reported more frequently for black compared to white physicians. Nearly 90% of white patients had a physician of the same race, but only a third of black patients had a race concordant PCP, making these differences by physician race particularly relevant for black patients.

Many patients in the South have an established relationship with their PCP characterized by trust and satisfaction. Such relationships are conducive to effective cardiovascular risk management, which often entail long-term lifestyle change and medication adherence. Yet, key aspects of culturally-appropriate, patient-centered care are sometimes under-utilized. Although patients and physicians may not recognize these omissions, they represent missed opportunities to improve healthcare quality and reduce disparities. Further research is needed among patients without an established primary care relationship to determine whether a lack of physician cultural competence is a contributing factor.

Conclusions