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Primary Care Provider Cultural Competence and Racial Disparities in HIV Care and Outcomes

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ABSTRACT

BACKGROUND

Health professional organizations have advocated for increasing the “cultural competence” (CC) of healthcare providers, to reduce racial and ethnic disparities in patient care. It is unclear whether provider CC is associated with more equitable care.

OBJECTIVE

To evaluate whether provider CC is associated with quality of care and outcomes for patients with HIV/AIDS.

DESIGN AND PARTICIPANTS

Survey of 45 providers and 437 patients at four urban HIV clinics in the U.S.

MAIN MEASURES

Providers’ self-rated CC was measured using a novel, 20-item instrument. Outcome measures included patients’ receipt of antiretroviral (ARV) therapy, self-efficacy in managing medication regimens, complete 3-day ARV adherence, and viral suppression.

KEY RESULTS

Providers’ mean age was 44 years; 56 % were women, and 64 % were white. Patients’ mean age was 45; 67 % were men, and 77 % were nonwhite. Minority patients whose providers scored in the middle or highest third on self-rated CC were more likely than those with providers in the lowest third to be on ARVs, have high self-efficacy, and report complete ARV adherence. Racial disparities were observed in receipt of ARVs (adjusted OR, 95 % CI for white vs. nonwhite: 6.21, 1.50–25.7), self-efficacy (3.77, 1.24–11.4), and viral suppression (13.0, 3.43–49.0) among patients of low CC providers, but not among patients of moderate and high CC providers (receipt of ARVs: 0.71, 0.32–1.61; self-efficacy: 1.14, 0.59–2.22; viral suppression: 1.20, 0.60–2.42).

CONCLUSIONS

Provider CC was associated with the quality and equity of HIV care. These findings suggest that enhancing provider CC may reduce racial disparities in healthcare quality and outcomes.

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REFERENCES

  1. Wong MD, Shapiro MF, Boscardin WJ, Ettner SL. Contribution of major diseases to disparities in mortality. N Engl J Med. 2002;347:1585–1592.

    Article  PubMed  Google Scholar 

  2. Wong MD, Tagawa T, Hsieh HJ, et al. Differences in cause-specific mortality between Latino and white adults. Med Care. 2005;43:1058–1062.

    Article  PubMed  Google Scholar 

  3. Harper S, Lynch J, Burris S, Davey Smith G. Trends in the black–white life expectancy gap in the United States, 1983–2003. JAMA. 2007;297:1224–1232.

    Article  PubMed  CAS  Google Scholar 

  4. Shapiro MF, Morton SC, McCaffrey DF, et al. Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study. JAMA. 1999;281:2305–2315.

    Article  PubMed  CAS  Google Scholar 

  5. Institute of Medicine. Unequal Treatment: confronting Racial and Ethnic Disparities in Health Care. Washington: National Academies Press; 2002.

    Google Scholar 

  6. Gebo KA, Fleishman JA, Conviser R, et al. Racial and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients in 2001. J Acquir Immune Defic Syndr. 2005;38:96–103.

    Article  PubMed  Google Scholar 

  7. King WD, Minor P, Ramirez Kitchen C, et al. Racial, gender and geographic disparities of antiretroviral treatment among US Medicaid enrollees in 1998. J Epidemiol Community Health. 2008;62:798–803.

    Article  PubMed  CAS  Google Scholar 

  8. Halkitis P, Palamar J, Mukherjee P. Analysis of HIV medication adherence in relation to person and treatment characteristics using hierarchical linear modeling. AIDS Patient Care STDS. 2008;22:323–335.

    Article  PubMed  Google Scholar 

  9. Golin CE, Liu H, Hays RD, et al. A prospective study of predictors of adherence to combination antiretroviral medication. J Gen Intern Med. 2002;17:812–813.

    Article  Google Scholar 

  10. Gifford AL, Bormann JE, Shively MJ, et al. Predictors of self-reported adherence and plasma HIV concentrations in patients on multidrug antiretroviral regimens. J Acquir Immune Defic Syndr. 2000;23:386–395.

    PubMed  CAS  Google Scholar 

  11. Schackman BR, Ribaudo HJ, Krambrink A, et al. Racial differences in virologic failure associated with adherence and quality of life on efavirenz-containing regimens for initial HIV therapy: results of ACTG A5095. J Acquir Immune Defic Syndr. 2007;46:547–554.

    Article  PubMed  CAS  Google Scholar 

  12. Centers for Disease Control and Prevention (CDC). Epidemiology of HIV/AIDS—United States, 1981–2005. MMWR Morb Mortal Wkly Rep. 2006;55:589–592.

    Google Scholar 

  13. Levine RS, Briggs NC, Kilbourne BS, et al. Black–white mortality from HIV in the United States before and after highly active antiretroviral therapy in 1996. Am J Public Health. 2007;97:1884–1892.

    Article  PubMed  Google Scholar 

  14. Woldemichael G, Christiansen D, Thomas S, Benbow N. Demographic characteristics and survival with AIDS: health disparities in Chicago, 1993–2001. Am J Public Health. 2009;99(Suppl1):S118–S123.

    Article  PubMed  Google Scholar 

  15. Lemly DC, Shepherd BE, Hulgan T, et al. Race and sex differences in antiretroviral therapy use and mortality among HIV-infected persons in care. J Infect Dis. 2009;199:991–998.

    Article  PubMed  Google Scholar 

  16. Beach MC, Keruly J, Moore RD. Is the quality of the patient–provider relationship associated with better adherence and health outcomes for patients with HIV? J Gen Intern Med. 2006;21:661–665.

    Article  PubMed  Google Scholar 

  17. Ingersoll KS, Heckman CJ. Patient–clinician relationships and treatment system effects on HIV medication adherence. AIDS Behav. 2005;9:89–101.

    Article  PubMed  Google Scholar 

  18. Bakken S, Holzemer WL, Brown MA, et al. Relationships between perception of engagement with health care provider and demographic characteristics, health status, and adherence to therapeutic regimen in persons with HIV/AIDS. AIDS Patient Care STDS. 2000;14(4):189–197.

    Article  PubMed  CAS  Google Scholar 

  19. Roberts KJ. Physician–patient relationships, patient satisfaction, and antiretroviral medication adherence among HIV-infected adults attending a public health clinic. AIDS Patient Care STDS. 2002;16:43–50.

    Article  PubMed  Google Scholar 

  20. Johnson MO, Chesney MA, Goldstein RB, et al. Positive provider interactions, adherence self-efficacy, and adherence to antiretroviral medications among HIV infected adults: a mediation model. AIDS Patient Care STDS. 2006;20:258–268.

    Article  PubMed  Google Scholar 

  21. Saha S, Arbelaez JJ, Cooper LA. Patient–physician relationships and racial disparities in the quality of health care. Am J Public Health. 2003;93:1713–1719.

    Article  PubMed  Google Scholar 

  22. Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient–physician racial concordance and the perceived quality and use of health care. Arch Intern Med. 1999;159:997–1004.

    Article  PubMed  CAS  Google Scholar 

  23. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583–589.

    Article  PubMed  CAS  Google Scholar 

  24. Cooper LA, Roter DL, Johnson RL, et al. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139:907–915.

    Article  PubMed  Google Scholar 

  25. King WD, Wong MD, Shapiro MF, Landon BE, Cunningham WE. Does racial concordance between HIV-positive patients and their physicians affect the time to receipt of protease inhibitors? J Gen Intern Med. 2004;19:1146–1153.

    Article  PubMed  Google Scholar 

  26. American Medical Association. H-295.897. Enhancing the cultural competence of physicians. Health and ethics policies of the AMA House of Delegates. Available at http://www.ama-assn.org/ad-com/polfind/Hlth-Ethics.pdf; accessed November 14, 2012.

  27. American Academy of Nurse Practitioners. Position statement on nurse practitioner curriculum. Available at http://www.aanp.org/images/documents/publications/NPCurriculum.pdf; accessed November 14, 2012.

  28. American Academy of Family Physicians. Culturally competent health care. Available at http://www.aafp.org/online/en/home/policy/policies/c/crosscult.html; accessed November 14, 2012.

  29. American College of Physicians. Racial and ethnic disparities in health care: a position paper of the American College of Physicians. Ann Intern Med. 2004;141:226–232.

    Article  Google Scholar 

  30. Saha S, Beach MC, Cooper LA. Patient centeredness, cultural competence and healthcare quality. J Natl Med Assoc. 2008;100:1275–1285.

    PubMed  Google Scholar 

  31. Beach MC, Saha S, Korthuis PT, Sharp V, Cohn J, Wilson IB, Eggly S, Cooper LA, Roter D, Sankar A, Moore R. Patient–provider communication differs for black compared to white HIV-infected patients. AIDS Behav. 2011;15(4):805–811.

    Article  PubMed  Google Scholar 

  32. Beach MC, Saha S, Korthuis PT, Sharp V, Cohn J, Wilson I, Eggly S, Cooper LA, Roter D, Sankar A, Moore R. Differences in patient–provider communication for Hispanic compared to non-Hispanic white patients in HIV care. J Gen Intern Med. 2010;25:682–687.

    Article  PubMed  Google Scholar 

  33. Saha S, Sanders DS, Korthuis PT, Cohn JA, Sharp VL, Haidet P, Moore RD, Beach MC. The role of cultural distance between patient and provider in explaining racial/ethnic disparities in HIV care. Patient Educ Couns. 2011;85:e278–e284.

    Article  PubMed  Google Scholar 

  34. Gebo KA, Moore RD, Fleishman JA. The HIV Research Network: a unique opportunity for real time clinical utilization analysis in HIV. Hopkins HIV Rep. 2003;15:5–6.

    PubMed  Google Scholar 

  35. Gozu A, Beach MC, Price EG, et al. Self-administered instruments to measure cultural competence of health professionals: a systematic review. Teach Learn Med. 2007;19:180–190.

    Article  PubMed  Google Scholar 

  36. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Washington: U.S. Department of Health and Human Services; 2006.

    Google Scholar 

  37. Shively M, Smith TL, Bormann J, Gifford AL. Evaluating self-efficacy for HIV disease management skills. AIDS Behav. 2002;6:371–379.

    Article  Google Scholar 

  38. Chesney MA, Ickovics JR, Chambers DB, et al. Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: the AACTG adherence instruments. Patient Care Committee & Adherence Working Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group (AACTG). AIDS Care. 2000;12:255–266.

    Article  PubMed  CAS  Google Scholar 

  39. Mannheimer S, Thackeray L, Huppler Hullsiek K, et al. A randomized comparison of two instruments for measuring self-reported antiretroviral adherence. AIDS Care. 2008;20:161–169.

    Article  PubMed  CAS  Google Scholar 

  40. Davis TC, Crouch MA, Long SW, et al. Rapid assessment of literacy levels of adult primary care patients. Fam Med. 1991;23:433–435.

    PubMed  CAS  Google Scholar 

  41. Cacciola JS, Alterman AI, McLellan AT, Lin YT, Lynch KG. Initial evidence for the reliability and validity of a “Lite” version of the Addiction Severity Index. Drug Alcohol Depend. 2007;87:297–302.

    Article  PubMed  Google Scholar 

  42. Turner BJ, Fleishman JA, Wenger N, et al. Effects of drug abuse and mental disorders on use and type of antiretroviral therapy in HIV-infected persons. J Gen Intern Med. 2001;16:625–633.

    Article  PubMed  CAS  Google Scholar 

  43. Glaspy J, Bukowski R, Steinberg D, Taylor C, Tchekmedyian S, Vadhan-Raj S. Impact of therapy with epoetin alfa on clinical outcomes in patients with nonmyeloid malignancies during cancer chemotherapy in community oncology practice. Procrit Study Group. J Clin Oncol. 1997;15:1218–34.

    PubMed  CAS  Google Scholar 

  44. Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale). Am J Prev Med. 1994;10:77–84.

    PubMed  CAS  Google Scholar 

  45. HCSUS Baseline Questionnaire. Module 9: Social support and coping. Available at http://www.rand.org/health/projects/hcsus/Base/index.html; accessed November 14, 2012.

  46. Beach MC, Inui T, Relationship-Centered Care Research Network. Relationship-centered care. A constructive reframing. J Gen Intern Med. 2006;21(Suppl 1):S3–S8.

    Article  PubMed  Google Scholar 

  47. Cooper LA, Beach MC, Johnson RL, Inui TS. Delving below the surface. Understanding how race and ethnicity influence relationships in health care. J Gen Intern Med. 2006;21(Suppl 1):S21–S27.

    Article  PubMed  Google Scholar 

  48. Hall ET. Beyond culture. New York: Anchor Books; 1976.

    Google Scholar 

  49. Sanchez-Jones TR. Cross-cultural communication. In: Williams CL, Davis CM, eds. Therapeutic Interaction in Nursing. Sudbury: Jones & Bartlett Publishers; 2004.

    Google Scholar 

  50. Paez KA, Allen JK, Beach MC, Carson KA, Cooper LA. Physician cultural competence and patient ratings of the patient-physician relationship. J Gen Intern Med. 2009;24:495–498.

    Article  PubMed  Google Scholar 

  51. Paez KA, Allen JK, Carson KA, Cooper LA. Provider and clinic cultural competence in a primary care setting. Soc Sci Med. 2008;66:1204–1216.

    Article  PubMed  Google Scholar 

  52. Fernandez A, Schillinger D, Grumbach K, Rosenthal A, Stewart AL, Wang F, Pérez-Stable EJ. Physician language ability and cultural competence. An exploratory study of communication with Spanish-speaking patients. J Gen Intern Med. 2004;19:167–174.

    Article  PubMed  Google Scholar 

  53. Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med. 2004;19:101–110.

    Article  PubMed  Google Scholar 

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Acknowledgements

This research was supported by a contract from the Health Resources and Services Administration and the Agency for Healthcare Research and Quality (AHRQ 290-01-0012). Representatives of both funding agencies were involved in the design of the study, but not in its conduct; in collection, management, analysis, or interpretation of the data; or in preparation, review, or approval of the manuscript. Drs. Saha, Moore, and Beach had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Dr. Saha was supported by the Department of Veterans Affairs. Dr. Beach was supported by the Agency for Healthcare Research and Quality (K08 HS013903-05), and both Drs. Saha and Beach were supported by Generalist Physician Faculty Scholar awards from the Robert Wood Johnson Foundation. Dr. Korthuis was supported by the National Institute on Drug Abuse (K23 DA019809). The views expressed in this article are those of the authors, and no official endorsement by the Agency for Healthcare Research and Quality, the Department of Veterans Affairs, or the U.S. Department of Health and Human Services is intended or should be inferred.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Author information

Authors and Affiliations

  1. Section of General Internal Medicine, Portland VA Medical Center, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA

    Somnath Saha MD, MPH

  2. Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, OR, USA

    Somnath Saha MD, MPH & P. Todd Korthuis MD, MPH

  3. Division of Infectious Diseases, Department of Medicine, Wayne State University School of Medicine, Detroit, MI, USA

    Jonathan A. Cohn MD

  4. Center for Comprehensive Care, St. Luke’s-Roosevelt Hospital Center, New York, NY, USA

    Victoria L. Sharp MD

  5. Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Richard D. Moore MD, MHS & Mary Catherine Beach MD, MPH

Authors
  1. Somnath Saha MD, MPH
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  2. P. Todd Korthuis MD, MPH
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  3. Jonathan A. Cohn MD
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  4. Victoria L. Sharp MD
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  5. Richard D. Moore MD, MHS
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  6. Mary Catherine Beach MD, MPH
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Corresponding author

Correspondence to Somnath Saha MD, MPH.

Appendix

Appendix

Table 5 Self-Rated Cultural Competence Instrument for Primary Care Providers
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Saha, S., Korthuis, P.T., Cohn, J.A. et al. Primary Care Provider Cultural Competence and Racial Disparities in HIV Care and Outcomes. J GEN INTERN MED 28, 622–629 (2013). https://doi.org/10.1007/s11606-012-2298-8

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  • DOI: https://doi.org/10.1007/s11606-012-2298-8

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