The American Journal of Managed Care September 2004 - Special Issue
Changing Healthcare Professionals' Behaviors to Eliminate Disparities in Healthcare: What Do We Know? How Might We Proceed?
The patientâ€“healthcare provider communication processâ€”particularly the provider's cultural competencyâ€”is increasingly recognized as a key to reducing racial/ethnic disparities in health and healthcare utilization. A working group was formed by the Office of Minority Health, Department of Health and Human Services to identify strategies for improving healthcare providers' cultural competency. This expert panel, one of several working groups called together to explore methods of reducing healthcare disparities, was comprised of individuals from academic medical centers and health professional organizations who were nationally recognized as having expertise in healthcare communication as it relates to diverse populations. During the 2-day conference, the panel identified, from personal experience and knowledge of the literature, key points of intervention and interventions most likely to improve the cross-cultural competency of healthcare providers. Proposed interventions included introduction of cultural competence education before, during, and after clinical training; implementation of certification and accreditation requirements in cross-cultural competence for practicing healthcare providers; use of culturally diverse governing boards for clinical practices; and active promotion of workforce cross-cultural diversity by healthcare organization administrators. For each intervention, methods for implementation were specified. On-going monitoring and evaluation of processes of care using race/ethnicity data were recommended to ensure the programs were functioning.
(Am J Manag Care. 2004;10:SP12-SP19)
Long-standing disparities in healthcare utilization among US minority populations are well documented across a variety of health conditions. Public awareness of this situation was heightened by the recent Institute of Medicine report on unequal access to healthcare.1 The causes of these disparities, and their effects on patients' health status, are now major foci of inquiry.
Even a casual review of the literature reveals an extensive number of studies that examine the reasons for, and consequences of, observed racial, ethnic, gender, and socioeconomic disparities in the clinical management of many conditions, including cardiovascular and cerebrovascular diseases,2-11 congestive heart failure,12 cancer,13,14 renal transplantation,15-17 hip and knee replacement,18,19 and pain management.20-23 These studies show that, even within equal-access healthcare systems and the universal healthcare financing programs of Medicare and Medicaid, patients who belong to minority groups are substantially less likely than whites to receive either key diagnostic procedures or effective therapies after adjustment for important clinical indications. Moreover, it is becoming clear that these disparities in the use of diagnostic and therapeutic procedures negatively affect minority patients' health status (see, eg, references 9-11).
There are numerous recommendations for potentially effective interventions; those of the Institute of Medicine report are the most recent.1 In 1985, the Department of Health and Human Services' Report of the Secretary's Task Force on Black and Minority Health identified the healthcare provider, patient, and the healthcare system as key points for intervention to correct the disparities in health and healthcare utilization.24-31 Among its recommendations, the task force called for educational efforts regarding health and disease that are targeted to minority populations, training healthcare providers and educators to be sensitive to minority cultural and language needs, and modifying services to be more culturally acceptable. Also recommended were ongoing monitoring of health data according to patients' demographic and socioeconomic characteristics, and continued research regarding the relationship between patients' cultural diversity and health outcomes.
Although the patient exercises some control over the outcome of the clinical decision-making process,32,33 the healthcare provider (eg, the physician) has the primary role in determining the clinical management of a condition.21,23,34-36 A recent study documents that among patients with a similar presentation of cardiac disease, there is significant variation in the physician's decision to refer a patient for cardiac catheterization based on the patient's sex and race. Black women were referred less often for further diagnostic evaluation than white men, black men, or white women.34 Similarly, another report indicates that for procedures involving a higher as opposed to a lower degree of provider discretion (eg, hysterectomy vs acute appendectomy), there is lower utilization among black patients.36 Because interventions directed at healthcare professionals seem more likely to effect change in healthcare utilization and, ultimately, patient outcomes, provider-focused interventions have a higher priority for implementation than interventions targeted at either patients or healthcare systems.
There is a long-standing need for an action agenda that will systematically move the nation from recommendations to impact. This process involves identifying optimal points of intervention, the potentially most effective interventions at each point, a method for implementation, and a plan for ongoing monitoring and evaluation. This report presents the recommendations from the Working Group on Changing Health Care Professionals' Behavior regarding the most effective approaches to improving healthcare providers' cultural competency so as to reduce disparities in healthcare utilization.
STUDY DESIGN AND METHODS
The Working Group
As part of the larger Conference on Diversity and Communication in Health Care sponsored by the Office of Minority Health, US Department of Health and Human Services, a working group was formed with the charge of developing a set of recommendations for effecting changes in healthcare professionals' behaviors to reduce healthcare disparities in the near term. Other working groups focused on effecting changes in patient behavior and healthcare systems. The working group members were identified by the conference organizers within the Office of Minority Health based on national recognition of expertise in the area of diversity and communication within the healthcare setting. Working group members were drawn from academic institutions and from healthcare professional organizations.
The major underlying premise of the working group was that observed disparities in healthcare utilization are primarily a function of healthcare professionals' lack of cultural competence. That is, healthcare professionals generally do not understand the health-related and health-system—related beliefs and attitudes of other racial, ethnic, or social class groups, as well as lack awareness of (usually covert or unconscious) biases that they themselves may bring to the processes of patient care.
The working group began with a brainstorming session from which a broad array of options for modifying providers' cultural competency were generated. Then, the group identified a subset of approaches they believed were most likely to be effective. Subgroups were formed to develop specific recommendations regarding the content and implementation of each approach.
Mechanisms for Changing Provider Behavior
The group began by considering the currently available mechanisms through which to change healthcare providers' behaviors, whether that behavior relates to cost containment, preferred diagnostic or therapeutic practices, or cultural competence.37 These mechanisms include (1) educational programs, (2) peer review and feedback, (3) administrative changes, (4) active participation, and (5) systems of rewards and penalties. It was recognized, though, that some of these mechanisms may not be either the most appropriate or the most useful approaches to improving healthcare providers' cultural competence. Great creativity may be required to identify administrative changes to increase the cultural competence of healthcare providers, whereas development of educational programs is more straightforward in conceptualization.
It is now well documented that the more passive forms of education such as consensus statements regarding clinical practice guidelines and didactic lectures (even with follow-up sessions) are generally ineffective,38-40 although this may be a consequence, in part, of organizational barriers.41 Indeed, organizational characteristics may explain the relative ineffectiveness of low-intensity educational programs; it is reported, for example, that an educational memorandum regarding appropriate use of less expensive histamine H2 blockers with feedback on personal prescribing patterns resulted in a significant change in prescribing patterns among group-based but not network-based HMO physicians.42
One intensive educational approach proven to be effective in changing healthcare providers' behaviors is educational outreach.43 Educational outreach or "detailing" is not the typical continuing-education program. It is based on marketing techniques routinely used by pharmaceutical companies.44 Key elements of detailing include the following:
The interaction between the healthcare provider and the educational agent or facilitator is brief (generally no more than 10 minutes) but highly focused.
Communication is targeted to the area of practice of highest concern.
Information is presented in terms relevant to the motivations of the provider.
Highest priority often is given to providers identified as "opinion leaders" or to providers whose changed behavior would have the greatest impact on practice patterns. (In the case of cultural competence, the high-priority providers would include the most influential providers in a given healthcare facility and those providers shown by actual practice patterns to have the lowest cultural competence. It is worth noting here that a healthcare organization must have an effective mechanism of monitoring practice patterns in order to identify the latter type of providers.)
The educational agent or facilitator provides a balanced presentation of the issue and involves the provider in the discussion.
The message is kept simple; that is, only a few points are emphasized.
There is a feedback mechanism established with reinforcement of the sought-after behavior.
An effective means of educating healthcare providers in training may be to incorporate the principles of detailing into the classroom setting.
Promising Approaches to Improving Cultural Competency
The working group identified various ways to improve communication between diverse patient groups and healthcare providers, with emphasis given to improving cultural competence among healthcare providers. Although a recent review indicates a lack of empirical evidence on the effectiveness of many of the mechanisms to achieve cultural competency with healthcare systems,45 5 interrelated initiatives were considered to have the greatest potential to improve healthcare providers' cultural competence. These initiatives are described in detail below and in Table 1.
Training in Cultural Competence. Cultural competence training for healthcare professionals should be a fundamental part of the curriculum and be required for professional certification. It is worth emphasizing that training in cultural competence is not similar to training in other "competencies" (eg, mastery of procedures). It is a complex mix of specific types of knowledge, self-awareness, and their application to the processes of diagnosis, treatment, and clinical decision making.46 The instruction in cultural competence should be continuous throughout the formal training period and during practice. The target audience for cultural competence training includes all healthcare professionals either in training or currently involved in direct patient care (eg, dentists, nurses, physicians, physician assistants, psychologists, social workers). Clinic staff and administrators also may benefit from cross-cultural training programs. The programs could be integrated into clinical care; that is, the training could occur in a clinical setting (eg, during a physical diagnosis). It also must be recognized that cultural competence is an incremental process that is unlikely to be achieved by a 1-time course of study.