Opening the Black Box of Cultural Competence

 描述(由申请人提供)： 在美国，少数族裔美国人得到的医疗保健质量低于非少数族裔。这些差距在包括糖尿病护理在内的各种医疗保健服务中都很明显。文化能力(CC)培训已成为卫生专业人员解决医疗保健差距的主要手段。CC已经在美国得到了广泛的认可和部署，但CC计划提供的内容几乎没有一致性，也没有证据表明目前提供的CC培训如预期的那样改善了医疗质量或公平。鉴于CC培训投入了大量的资源和时间，CC计划必须以证据为依据，了解什么将提高提供者和医疗团队在不同患者群体中公平提供高质量医疗服务的能力，这一点至关重要。该项目建立在以前工作的基础上：1)通过对概念框架的系统审查生成CC维度的概念图，在卫生专业人员中定义CC；2)使用该概念图开发了一种测量初级保健提供者(PCP)CC的工具；以及3)证明了通过该工具测量的CC与非裔美国患者的更高质量的护理相关，并减少了种族差异。该项目将把对CC的研究扩展到PCP之外，包括其他以患者为中心的护理团队(PACT)成员，并试图找出为什么CC较高与更公平的护理相关，具体地说，高CC提供者在他们的临床接触中采取了哪些不同的做法，从而为非裔美国患者带来了更高质量的护理。本研究的目的是：1.了解高CC和低CC初级保健提供者在患者-提供者沟通方面的差异。2.了解患者对他们与高、低CC提供者/契约的互动和关系的看法。3.了解提供者/契约中的CC对糖尿病护理的质量和公平的贡献。这些目标将使用混合方法来实现，其中将包括对录音临床接触中观察到的沟通行为进行定量和定性分析，以及对患者进行定量调查和定性访谈，了解他们对接触的看法以及他们与PCP和PACT成员的关系。这项研究将在4个退伍军人医学中心进行。将招募50名PCP的目标样本，在自我评估的CC中，25名高，25名低。将招募与这些PCP一起工作的PACT团队成员。来自每个初级保健小组的糖尿病患者将被招募，每个初级保健小组的目标是5名非裔美国人和5名白人患者。患者对其初级保健医生的访问将被录音，然后使用评估不同类型沟通行为的有效沟通编码系统对对话进行编码以获得沟通内容。将分析提供商CC在通信方面的差异。我们还将评估PCP/PACT CC与其他结果的关系，包括人际护理质量、患者对PCP/PACT CC的认知、糖尿病的了解和自我管理以及血糖控制。将采访来自CC五分位数最高和最低的PCP患者的一个子样本，目标是每个这些PCP患者中有一名非裔美国人和一名白人患者。患者将听取他们录制的临床接触录音，并就互动和他们与PCP的关系提供观点。对于这些患者，访谈和录音临床会面的成绩单都将被并排进行定性分析。混合方法的目的是提供广度和深度，以了解提供者CC如何在与患者的临床互动中表现出来，并导致医疗质量和结果的差异。了解提供者CC清单将为更有可能在减少差异方面更有效的干预措施提供信息，因为它们将基于提供更公平护理的提供者如何与患者互动的经验证据。

 DESCRIPTION (provided by applicant): Racial and ethnic minority Americans receive lower quality health care than non-minorities in the U.S. These disparities are evident across a wide range of health care services, including the care of diabetes mellitus. Cultural competence (CC) training has become the principal vehicle adopted by the health professions to address healthcare disparities. CC has been widely endorsed and deployed in the U.S., but there is little consistency to what is offered in CC programs and little evidence that CC training as currently delivered is improving health care quality or equity as intended. Given the substantial resources and time being devoted to CC training, it is critical that CC programs are informed by evidence about what will improve the ability of providers and healthcare teams to deliver high-quality care equitably, across diverse patient populations. This project builds on prior work that: 1) defined CC among health professionals by producing a conceptual map of CC dimensions from a systematic review of conceptual frameworks; 2) used that conceptual map to develop an instrument measuring CC among primary care providers (PCPs); and 3) demonstrated that CC, as measured by the instrument, was associated with higher quality care for African American patients, and reduced racial disparity. This project will extend the study of CC beyond PCPs to include other Patient Aligned Care Team (PACT) members, and attempt to discern why higher CC is associated with more equitable care, specifically, what high CC providers are doing differently in their clinical encounters that results in higher quality care for African American patients. The aims of the study are to: 1. Understand differences in patient-provider communication among high and low CC primary care providers. 2. Understand patients' perceptions of their interactions and relationships with high and low CC providers/PACTs. 3. Understand the contribution of CC among providers/PACTs to quality and equity of diabetes care. These aims will be addressed using a mixed-methods approach that will include quantitative and qualitative analysis of communication behaviors observed in audiotaped clinical encounters, coupled with quantitative surveys and qualitative interviews of patients about their perceptions of the encounters and their relationships with their PCPs and PACT members. The study will be conducted in 4 VA Medical Centers. A target sample of 50 PCPs will be recruited, 25 high and 25 low on self-assessed CC. PACT teamlet members working with these PCPs will be recruited. Patients with diabetes from each PCP's primary care panel will be recruited, with a target of 5 African American and 5 white patients per PCP. Patients' visits to their PCPs will be audio- recorded and the dialogue then coded for communication content using validated communication coding systems that evaluate different types of communication behaviors. Differences in communication by provider CC will be analyzed. We will also evaluate associations between PCP/PACT CC and other outcomes, including the quality of interpersonal care, patients' perceptions of PCP/PACT CC, diabetes understanding and self-management, and glycemic control. A subsample of patients from PCPs in the top and bottom CC quintiles will be interviewed, with a goal of 1 African American and 1 white patient for each of these PCPs. Patients will listen to their audiotaped clinical encounters and offer perspectives on the interaction and their relationships with the PCP. For these patients, transcripts from both the interview and from the audio-recorded clinical encounter will be qualitatively analyzed, side-by-side. The mixed-methods approach is intended to provide both breadth and depth in understanding how provider CC manifests in clinical interactions with patients and contributes to disparities in healthcare quality and outcomes. Understanding how provider CC manifests will inform interventions that are more likely to be effective in reducing disparities, because they will be based on empirical evidence of how providers who deliver more equitable care interact with patients.