1. Assessing Culturally Competent Diabetes Care with Unannounced Standardized Patients Kutob RM, Bormanis J, Crago M, Senf J, Gordon P. Shisslak C. Randa M. Kutob, MD, MPH John Bormanis, PhD Department of Family and Community Medicine University of Arizona, College of Medicine rkutob@email.arizona.edu johnbormanisphd@comcast.net

2. The Problem More effective diabetes care is desperately needed and The provider-patient relationship is a key point of intervention.

3. Scope of the Problem Diabetes and Pre-diabetes 18.8 million with diabetes 7.0 million undiagnosed +79.0 million w/pre-diabetes ______________________ = 104.8 million!!!! Centers for Disease Control and Prevention. National Diabetes Fact Sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.

4. Diabetes Disparities African Americans, American Indians, and Hispanic/Latinos have higher rates of diabetes (CDC, 2011) African Americans have a 2–4 times higher rate of renal disease, blindness, and amputations.(Peek, 2007) U.S. Latinos have a higher rate renal disease and retinopathy. (Peek, 2007) African Americans, American Indians, and Hispanic/Latinos have higher diabetes-related death rates (AHRQ, 2003)

5. Reinke, 2012

6. The Medical Office Visit

7. Kleinman, 1980 Kutob, Senf, Harris, 2009

8. Medical Culture

9. What would a culturally competent physician do during the office visit, and which of these behaviors could be measured by an outside observer? Unannounced Standardized Patient (SPs) Study

10. Standardized Patients (SPs) Trained “fake” patients Used extensively in medical education o Objective Structured Clinical Examination Typically students know that they are being evaluated by a SP In our study physicians did not know.

11. Study Design Overview Unannounced SPs were sent to the offices of family and internal medicine physicians o 4 University-based clinics o 1 Community-based clinic All physicians were consented. Study was approved by the University of Arizona Institutional Review Board.

12. The Standardized Patient Checklist Developed by experts in anthropology, endocrinology, cultural competence, family medicine, internal medicine, Objective Structured Clinical Examination (OSCE) development, pediatrics, ethnic minority health care, and research methodology For an adult SP with a chief complaint of diabetes The checklist included items modeled on Kleinman’s cross-cultural office visit

13. SP Checklist: 7 Subscales, 41 dichotomous Items Explanatory Model Elicitation Cultural Knowledge Non-judgmental behavior Sharing the Biomedical Model Patient Empowerment Diabetes Specific Behaviors Arizona Clinical Interview Rating Scale

14. Explanatory Model Elicitation Asked the patient’s view of illness Asked the patient’s view of illness treatment Asked about patient’s use of other medical/traditional providers Asked about family support Asked about community support Asked abut gender role in family and how this influences care

15. Cultural Knowledge Indicated knowledge when asked, “Is it true that Mexican Americans have higher rates of diabetes?” Addressed health beliefs regarding fatalism Indicated knowledge when asked, “I have been eating nopalitos. Have you heard of those.” MD addressed health beliefs, before patient brought up MD brought up higher rates of diabetes in Mexican Americans before SP asked. MD brought up nopalitos before MD asked

16. Non-judgmental Behavior Did not threaten insulin if did not take medications Did not condemn use of alternative treatments Did not condemn use of alternative healers Was non-judgmental in response to elevated hemoglobin A1c Did not threaten complications if did not take medications

17. Sharing the Biomedical Model Shared knowledge about… The treatment of diabetes The benefits of exercise The benefits of weight control/diet The benefits of glycemic control The pathophysiology of diabetes Prevention of diabetes complications

18. Patient Empowerment Asked about patient’s fears about diabetes Asked patient to set her own goals Asked about barriers to care

19. Diabetes Specific Behaviors Ordered hemoglobin A1c Ordered urinary microalbumin Made appropriate referral to ophthalmology Performed monofilament test Put patient on aspirin

20. The Arizona Clinical Interviewing Scale Repeated questions only to verify/clarify Used no medical terms unless defined immediately without being asked Made sure patient understood future plans Avoided use of leading/multiple/why questions Avoided giving premature assessment and plan Avoided verbal/nonverbal judgment cues/reactions Used appropriate body contact Was aware of patient’s “space” Patient was comfortable with eye contact Gave nonverbal positive reinforcement

21. The Clinical Scenario Mexican American woman who did not have health insurance Recently diagnosed with diabetes Just moved from a different state Needed to establish care with a new physician Little understanding of diabetes Had a glucometer, but not using it Symptomatic She thought hemoglobin A1c value was 11

22. The SPs Explanatory Model Derived from qualitative studies in Mexican American populations Diabetes ran in her family, and she felt that there was no cure and that it could not be controlled. Her spouse and other family members were supportive. She had consulted her grandmother, a curandera. She was eating nopalitos.

30. Total Score 70.7±11.0%, with a range of 43.9 to 90.2% No significant differences by any demographic or other characteristics.

31. Correlations Non-Judgmental Behavior and Sharing the Biomedical Model, Spearman’s rho= -.403, p=.037. Sharing the Biomedical Model and Patient Empowerment, rho=.717, p<.001. Explanatory Model Elicitation and Diabetes-Specific Behaviors subscale, rho=.466, p=.014. The item, “Asked patient’s view of illness treatment” was associated with higher levels of cross-cultural training, p=.032.

32. Limitations Small study One time visit only Many university-based physicians with high levels of cultural competence training

33. Conclusions Providers asked about explanatory models Providers asked about social support less frequently How providers deliver the message (the biomedical model) is important! Medical student and resident training in motivational interviewing

34. Conclusions Our results suggest that culturally competent care and good diabetes care are intertwined.

35. Acknowledgements The authors would like to thank Dr. John Harris, Jr. for his contributions to the design of this research project. This research was supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (R41 DK62569). Dr. Kutob’s time also supported by the Arizona Area Health Education Centers’ Clinical Outcomes and Comparative Effectiveness Research Fellowship.