Disclosures ADDRESSING HEALTH CARE NIH-NIDDK DISPARITIES - - PowerPoint PPT Presentation

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ADDRESSING HEALTH CARE DISPARITIES AT THE BEDSIDE

Alicia Fernandez, MD University of California, San Francisco Zuckerberg San Francisco General

Disclosures

• NIH-NIDDK
• NIH-NIMHD
• NIH-NHLBI
• PCORI BOG

No conflicts of interest

Health care disparities: The evidence base

• Robust literature with strengths and limitations
• Studies can provide guidance when responding to clinical

situations

• Often, no single right answer even when guided by

literature

Goals for talk:

• Connect Health Care Disparities (HCD) to daily clinical

care

• Provide skills to address HCD at the bedside
• Focus on the subset of HCD driven by provider behavior
• Help expand our role as teachers about HCD

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Overview of talk

• Four cases
• Commonly encountered clinical scenarios drawn from

resident focus groups

• Illustrate role of provider-driven HCD in care
• Each case includes:
• Possible clinical outcomes
• Review (a little bit) of relevant evidence
• Practical skills and teaching papers
• Revisit with possible responses
• Engender thought and discussion about our role

MD-driven HCD are subset of all HCD

Structural disparities Access disparities MD Driven Health Care System Disparities

Case 1: “I speak Spanish”

The ER is very busy and you are very tired. A two year old girl is there with lower abdominal pain and vomiting. The mother is clearly very concerned. She speaks only Spanish and there is no interpreter in sight. Your medical student says he speaks “a little Spanish” and begins to take a history. It is clear that there is communication difficulty. What do you do?

I speak Spanish: Options

A.

Get whatever history you can from the conversation between the MS-3 and the parent

B.

Make a note to get an interpreter in the morning

C.

Try to use the AT&T operator while in the ED hallway

D.

Ask a nurse or family member to interpret

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I speak Spanish: Possible outcomes

1.

Unclear about the patient’s history but not wanting to miss anything, your team orders a full panel of studies. The patient spends the next eight hours in the ED awaiting the results, all of which are normal.

2.

Unclear about the history, your team makes a diagnosis of gastroenteritis and discharges the patient with reassurance and fluid precautions. She returns to the ED four days later, worse, and found to have a a ruptured appendix.

“False fluency”: The evidence

• False fluency: the inaccurate perception of

language competence

• False fluency is associated with increased medical

errors, including major errors

• Limited English Proficiency (LEP) patients have:
• Longer lengths of stay
• Higher costs
• More difficulty with medical comprehension
• More medication errors

Errors in Medical Interpretation and their Potential Clinical Consequences in Pediatric Encounters

• Study design: Interviews using an interpreter were taped.
• Findings: Errors in interpretation were common
• averaging 31 per encounter, with 19 per encounter labeled as

clinically significant

• Examples of clinically significant errors include:
• omitting questions about drug allergies
• adding that hydrocortisone cream must be applied to the entire

body instead of only to facial rash

• instructing a mother to put amoxicillin in both ears for treatment
• f otitis media
• Ad hoc interpreters (staff, family) had higher error rates.

Flores, 2003

Impact of Language Barriers on Documentation

• f Informed Consent at a Hospital with On-site

Interpreter Services

• Study at SFGH: 75 LEP (Chinese- & Spanish-speaking)

patients matched with English-speaking patients

• Thoracentesis
• Lumbar puncture
• Paracentesis
• Patients excluded if procedure emergent, patient

incapable of informed consent, confusion, intubated

Schenker/Fernandez, JGIM, 2007

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Documentation of informed consent

LEP N (%) English N (%) P-value Full Informed Consent 21 (28) 39 (53) 0.003 Signed Consent Form - any language 52 (70) 63 (85) 0.03

Remember informed consent is a legal and ethical imperative. LEP patients must have documentation of an interpretation in a discussion.

Schenker/Fernandez, JGIM, 2007

Language is the only significant predictor

• f documentation of informed consent

OR CI Adj OR CI Language (English vs. LEP) 2.8 1.4-5.6 3.1 1.5-6.5 Age 1.0 0.9-1.0 1.0 1.0-1.1 Gender – ref men 0.7 0.3-1.5 0.7 0.3-1.5 Infection Malignancy 1.0 1.4 0.5-2.0 0.5-4.0 0.9 1.5 0.4-2.1 0.5-4.7 LP Paracentesis 1.1 1.0 0.4-2.9 0.3-2.9 2.0 1.1 0.6-6.5 0.3-3.4 ED vs Wards 0.5 0.2-1.1 0.5 0.2-1.2

Schenker/Fernandez, JGIM, 2007

Why Don’t We Use Interpreters?

• Qualitative study IM

residents SFGH/Yale- NH

• Hassle factor vs

“Getting By”

• Explicit decision

making

• Underuse of

interpreters normalized despite recognition of impact on care

DOCTOR AND PATIENT

When the Patient Gets Lost in Translation

Diamond/Fernandez JGIM, 2009

“I Speak Spanish” What could you say?

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Summary

• Law, ethics and effective clinical care all mandate

interpreters

• This can be difficult
• Know the resources available to you
• Advocate for your patients

Case 2: “I blew it”

As cross-cover at the public hospital you are called to see a patient for pain control after I&D of an abscess on his arm. Arriving at the bedside, you see a thin man in his thirties in

• bvious discomfort. He is African-American.

Remembering that your last patient with an abscess needed high doses of opiates to adequately control his pain, your first question to him is “how much heroin do you use a day?” The patient explodes in anger, yelling that “all the doctors in this hospital think all black men are addicts.” It becomes clear he has lymphoma and the abscess is a complication

• f a recent node extraction.

I blew it: Options

A.

Leave and let the nightfloat resident return without you.

B.

Explain to the patient that most abscess are caused by addict needles and you made an honest mistake because you were trying to help him.

C.

Apologize.

I blew it: Possible outcomes

1.

The patient declines additional doses of morphine, although clearly uncomfortable, and leaves the following day

2.

The patient’s pain is better controlled over the next day and he is discharged, but fails to keep his follow-up appointment for chemotherapy

3.

You apologize to the patient, who describes feeling repeatedly mistreated. He accepts pain control.

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Facts about medical mistakes

• Stereotyping happens when we are stressed, tired or
• verwhelmed
• Communication is a procedure and is subject to mistakes,

as are all procedures

• Literature on how physicians handle mistakes shows

common responses are:

• denial
• concealment (from colleagues and patients)
• Patients want disclosure and clear discussion of errors

Do house officers learn from their mistakes?

• Landmark study of UCSF IM trainees, reports of errors
• Patients had serious outcomes in 90% of cases, including

death in 31%

• House officers who accepted responsibility for the mistake

and discussed it were more likely to report constructive changes in practice

• Cultural shift toward increased discussion of system

errors

• Recent vignette study of PCPs indicates majority not fully

disclose or apologize for delayed cancer diagnoses

Wu, JAMA, 1991

Errors: What can you say?

• Studies show that patients strongly desire error

disclosure:

• An explicit statement that an error occurred
• What the error was
• Why the error happened
• How recurrences will be prevented
• A simple apology (resist the urge to justify)
• Although disclosure is beneficial, it does create emotional

distress for the doctor

Gallagher, NEJM, 2007; Levinson, W; 2005

Apologizing

• Hard to do
• Embarrassing
• Fear of legal repercussions
• Keep it simple and focused on what you did
• “I am sorry”
• Name the error
• “I made an assumption that was wrong”
• Allow patient to continue to have an emotional response
• Better in the long run, less malpractice?

Gallagher, NEJM, 2007 Kachalia, Ann Intern Med, 2010

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Summary

• Subconscious stereotyping is common in medicine, as

pattern recognition informs much of our thinking

• Approximately 15% of patients feel disrespected due to

race, ethnicity, and/or language

• We all make mistakes
• Learning to take responsibility and apologize is important

Case 3: “Take two pills”

You are seeing a 5 year old patient in busy urgent care with possible pneumonia and asthma exacerbation before running to clinic. You give the mother discharge instructions: “Take two of the antibiotic pills three times a day for the next seven days; take two prednisone pills daily for five days; use two puffs of inhaler four times daily and return if worse. The mother looks up at you, confused.

Take two pills: Options

A.

Assume the nurse will go over the medication instructions also, and something will get through.

B.

Make sure the family has clear written instructions in addition to the verbal ones.

C.

Review again to make sure the parent understands how to give the meds.

D.

Ask your medical student to go over the patient’s meds while you move on.

Take two pills: Possible outcomes

1.

The patient is leaves and returns to the ED two days later, having failed to take the prednisone.

2.

The patient’s mother is unable to follow the written instructions provided and fails to keep the follow-up appointment in pediatrics clinic.

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Take two pills: Facts on FHL

• 90 million adults have trouble understanding and acting
• n health information
• The prevalence of inadequate health literacy increases

with age and lower SES

• Low literacy is linked to poorer health, lower quality care,

medication errors, and poor outcomes

IOM report, 2006 IOM, 2004; AHRQ Evidence Report; Gazmararian,1999 Davis, T. C. et. al. Ann Intern Med 2006;145:887-894

Percentage of Patients Understanding Primary Prescription Drug Label Instructions and Attending to Auxiliary Labels* by Literacy Level

Take two pills: What to say?

• Strategies for increasing patient comprehension:
• Limit information to 3-5 key points
• Be specific and concrete, not general
• Demonstrate, draw pictures, use models
• Repeat and summarize
• Assess understanding: “Teach Back” method
• Use Universal Medication Schedule (available in Epic)

Schillinger, Arch Intern Med, 2003

Case 4: Just in case?

You are evaluating a Latino 30 month old boy with a radial

• blique fracture after falling down the stairs. He is brought

in by his mother. The mechanism of injury is appropriate, and there is no history or signs of previous injuries. After the child is splinted by orthopedics in ED, your sub-I wants to admit the patient to get a skeletal survey in the morning to assess for child abuse “just to make sure.”

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Just in case: Options

A.

Let the sub-I know you are not concerned about abuse in this case and discharge the patient to home.

B.

Admit the patient for a skeletal survey in the morning: it is your responsibility to identify cases of child abuse.

C.

Ask the sub-I: “Why the concern for abuse in this case?”

Just in case: Possible outcomes

1.

You admit the patient overnight. In the morning, after the negative skeletal series, the mother is furious to find out the team has kept her son and herself in the hospital for a child abuse evaluation. She leaves with her child, stating she’s never coming back to this hospital again.

2.

The patient is discharged in the am after a negative

• scan. The mother does not know understand why the

child was hospitalized.

Paper: Racial differences in the evaluation

• f pediatric fractures for physical abuse
• Large urban children's hospital
• Chart review study with reviewers blinded to race
• Reviewers rated likelihood of child abuse
• Black and Latino children age 1-3 years old with long

bone fractures were:

• 5.3 times more likely to have a skeletal survey than their white

counterparts, for similar clinical presentation

• 3 times more likely to be reported to child protective services
• Drill down analysis showed that Black-white difference

was greatest in lowest suspicion situations

Lane, JAMA, 2002

The effect of race and socioeconomic status on physicians’ perceptions of patients

• 193 MDs surveyed about 618 patients who had just

undergone angiography

• MDs rated Black patients as:
• less intelligent
• less likely to adhere
• more likely to have risky behavior
• MDs rated low SES patients as:
• less likely to comply with cardiac rehab
• less likely to desire a physically active lifestyle
• less intelligent
• True even after adjusting for multiple potential

confounders: income, education, occupation, frailty, age, gender, social assertiveness

Van Ryn, Med Care, 2002

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The effect of race and sex on physicians’ recommendation for cardiac catheterization

• Videotaped vignettes with 8 actors as patients
• men/women, white/African American, 55/70yo
• All “patients” with identical description of chest pain
• Convenience sample of physicians
• Outcome was decision to refer for cardiac catheterization

Schulman, NEJM, 1999

“Patients” experiencing symptoms of heart disease

Schulman, NEJM, 1999 Schulman, NEJM, 1999

“Patients” experiencing symptoms of heart disease

Schulman Summary

• Videotaped vignettes with 8 actors representing

men/women, AA/whites, 55y/70y

• Convenience sample of physicians at ACP and ACC

meetings

• All “patients” had identical script describing chest pain –
• utcome was decision to refer for angiography

Black White Men Age 55 91% 91% Age 70 90% 90% Women Age 55 84% 92% Age 70 73% ** 89%

** p<0.01

Shulman, et al. NEJM 1999

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Summary: Health care disparities at the bedside

• Provider-driven disparities in health care are common and

arise in daily practice

• Addressing HCD is part of delivering effective, evidence-

based clinical care

• Explicit recognition of issues, use of the evidence base,

and modeling effective care may decrease provider driven disparities