Medical Care Research and Review

Twenty-one million Americans are limited in English proficiency (LEP), but little is known about the effect of medical interpreter services on health care quality. Asystematic literature review was conducted on the impact of interpreter services on quality of care. Five database searches yielded 2,640 citations and a final database of 36 articles, after applying exclusion criteria. Multiple studies document that quality of care is compromised when LEP patients need but do not get interpreters. LEP patients' quality of care is inferior, and more interpreter errors occur with untrained ad hoc interpreters. Inadequate interpreter services can have serious consequences for patients with mental disorders. Trained professional interpreters and bilingual health care providers positively affect LEP patients' satisfaction, quality of care, and outcomes. Evidence suggests that optimal communication, patient satisfaction, and outcomes and the fewest interpreter errors occur when LEP patients have access to trained professional interpreters or bilingual providers.

This article develops a conceptual model of cultural competency’s potential to reduce racial and ethnic health disparities, using the cultural competency and disparities literature to lay the foundation for the model and inform assessments of its validity. The authors identify nine major cultural competency techniques: interpreter services, recruitment and retention policies, training, coordinating with traditional healers, use of community health workers, culturally competent health promotion, including family/community members, immersion into another culture, and administrative and organizational accommodations. The conceptual model shows how these techniques could theoretically improve the ability of health systems and their clinicians to deliver appropriate services to diverse populations, thereby improving outcomes and reducing disparities. The authors conclude that while there is substantial research evidence to suggest that cultural competency should in fact work, health systems have little evidence about which cultural competency techniques are effective and less evidence on when and how to implement them properly.

The authors examine determinants of satisfaction with medical care among 1,784 (781 African American and 1,003 white) cardiac patients. Patient satisfaction was modeled as a function of predisposing factors (gender, age, medical mistrust, and perception of racism) and enabling factors (medical insurance). African Americans reported less satisfaction with care. Although both black and white patients tended not to endorse the existence of racism in the medical care system, African American patients were more likely to perceive racism. African American patients were significantly more likely to report mistrust. Multivariate analysis found that the perception of racism and mistrust of the medical care system led to less satisfaction with care. When perceived racism and medical mistrust were controlled, race was no longer a significant predictor of satisfaction.

Patient-centered care (PCC) has been studied for several decades. Yet a clear definition of PCC is lacking, as is an understanding of how specific PCC processes relate to patient outcomes. We conducted a systematic review of the PCC literature to examine the evidence for PCC and outcomes. Three databases were searched for all years through September 2012. We retained 40 articles for the analysis. Results found mixed relationships between PCC and clinical outcomes, that is, some studies found significant relationships between specific elements of PCC and outcomes but others found no relationship. There was stronger evidence for positive influences of PCC on satisfaction and self-management. Future research should examine specific dimensions of PCC and how they relate to technical care quality, particularly some dimensions that have not been studied extensively. Future research also should identify moderating and mediating variables in the PPC–outcomes relationship.

Existing scales to measure trust in physicians have differing content and limited testing. To improve on these measures, a large item pool (n = 78) was generated following a detailed conceptual model and expert review. After pilot testing, the best-performing items were validated with a random national sample (n = 9) and a regional sample of HMO members (n = 99). Various psychometric tests produced a 10-item unidimensional scale consistent with most aspects of the conceptual model.Compared with previous scales, the Wake Forest physician trust scale has a somewhat improved combination of internal consistency, variability, and discriminability. The scale is more strongly correlated with satisfaction, desire to remain with a physician, willingness to recommend to friends, and not seeking second opinions; it is less correlated with insurer trust, membership in managed care, and choice of physician; and correlations are equivalent with lack of disputes, length of relationship, and number of visits.

Many Latinos have limited English proficiency and this may negatively affect their use of health care services. To examine this, the authors interviewed 465 Spanish-speaking Latinos and 259 English speakers of various ethnicities who presented to a public hospital emergency department with nonurgent medical problems to assess previous physician visits, sociodemographic characteristics, and level of English proficiency. The proportion of patients who reported no physician visit during the 3 months before study enrollment was not related to English proficiency. However, among the 414 patients who saw a physician at least once, Latinos with fair and poor English proficiency reported approximately 22 percent fewer physician visits (p = 0.020 and p = 0.015, respectively) than non-Latinos whose native language was English, even after adjusting for other determinants of physician visits. The magnitude of the association between limited English proficiency and number of physician visits was similar to that for having poor health, no health insurance, or no regular source of care.

Previous reviews of research on electronic health record (EHR) data quality have not focused on the needs of quality measurement. The authors reviewed empirical studies of EHR data quality, published from January 2004, with an emphasis on data attributes relevant to quality measurement. Many of the 35 studies reviewed examined multiple aspects of data quality. Sixty-six percent evaluated data accuracy, 57% data completeness, and 23% data comparability. The diversity in data element, study setting, population, health condition, and EHR system studied within this body of literature made drawing specific conclusions regarding EHR data quality challenging. Future research should focus on the quality of data from specific EHR components and important data attributes for quality measurement such as granularity, timeliness, and comparability. Finally, factors associated with poor or variability in data quality need to be better understood and effective interventions developed.

To assess the public’s perceptions and attitudes about racial and ethnic differences in health care, the Kaiser Family Foundation surveyed a nationally representative sample of 3,884 whites, African Americans, and Latinos in 1999. The survey found that the majority of Americans are uninformed about health care disparities—many were unaware that blacks fare worse than whites on measures susch as infant mortality and life expectancy, and that Latinos are less likely than whites to have health insurance. Views on whether the health system treats people equally were strikingly different by race. For example, most minority Americans perceive that they get lower quality care than whites, but most whites think otherwise. Nonetheless, more minority Americans were concerned about the cost of care than racial barriers. Efforts to eliminate disparities will need to improve public awareness of the problems as well as address racial and financial barriers to care.

The authors examined health care coverage for Veterans' Health Administration (VHA) enrollees and how their reliance on VHA care varies by coverage, using the largest and most detailed survey of veterans using VHA services ever conducted. The results showed that a majority of veterans who use VHA services have alternative health care coverage and that most of them use both VHA and non-VHA health care. The findings have important implications for quality of care and coordination of care.

The authors developed and empirically tested a model reflecting a system of interrelations among patient loyalty, trust, and satisfaction as they are related to patients' intentions to stay with a primary care physician (PCP) and recommend the doctor to other people. They used a structural equation modeling approach. The fit statistics indicate a well-fitting model: root mean square error of approximation = .022, goodness-of-fit index = .99, adjusted goodness-of-fit index = .96, and comparative fit index = 1.00. The authors found that patient trust and good interpersonal relationships with the PCP are major predictors of patient satisfaction and loyalty to the physician. Patients need to trust the PCP to be satisfied and loyal to the physician. The authors also found that patient trust, satisfaction, and loyalty are strong and significant predictors of patients' intentions to stay with the doctor and to recommend the PCP to others.