Frances Wang’s research while affiliated with University of California, San Francisco and other places

As health systems strive to meet the needs of linguistically diverse patient populations, determining a physician's non-English language proficiency is becoming increasingly important. However, brief, validated measures are lacking. To determine if any of four self-reported measures of physician Spanish language proficiency are useful measures of fluency in Spanish. Physician self-report of Spanish proficiency was compared to Spanish-speaking patients' report of their physicians' language proficiency. 110 Spanish-speaking patients and their 46 physicians in two public hospital clinics with professional interpreters available. Physicians rated their Spanish fluency with four items: one general fluency question, two clinically specific questions, and one question on interpreter use. Patients were asked if their doctor speaks Spanish ("yes/no"). Concordance, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were calculated for each of the items, and receiver operating (ROC) curves were used to compare performance characteristics. Concordance between physician and patient reports of physician Spanish proficiency ranged from 84 to 91%. The PPV for each of the four items ranged from 91 to 99%, the NPV from 60 to 90%, and the area under their ROC curves from 90 to 95%. The general fluency question gave the best combination of PPV and NPV, and the item on holding sensitive discussions had the highest PPV, 99%. Physicians who reported fluency as "fair" were as likely to have patients report they did not speak Spanish as that they did. Physician self-report of Spanish language proficiency is highly correlated with patient report, except when physicians report "fair" general fluency. In settings where no financial or other incentives are linked to language skills, simple questions may be a useful way to assess physician language proficiency.

Despite the importance of self-management support (SMS), few studies have compared SMS interventions, involved diverse populations, or entailed implementation in safety net settings. We examined the effects of two SMS strategies across outcomes corresponding to the Chronic Care Model. A total of 339 outpatients with poorly controlled diabetes from county-run clinics were enrolled in a three-arm trial. Participants, more than half of whom spoke limited English, were uninsured, and/or had less than a high school education, were randomly assigned to usual care, interactive weekly automated telephone self-management support with nurse follow-up (ATSM), or monthly group medical visits with physician and health educator facilitation (GMV). We measured 1-year changes in structure (Patient Assessment of Chronic Illness Care [PACIC]), communication processes (Interpersonal Processes of Care [IPC]), and outcomes (behavioral, functional, and metabolic). Compared with the usual care group, the ATSM and GMV groups showed improvements in PACIC, with effect sizes of 0.48 and 0.50, respectively (P < 0.01). Only the ATSM group showed improvements in IPC (effect sizes 0.40 vs. usual care and 0.25 vs. GMV, P < 0.05). Both SMS arms showed improvements in self-management behavior versus the usual care arm (P < 0.05), with gains being greater for the ATSM group than for the GMV group (effect size 0.27, P = 0.02). The ATSM group had fewer bed days per month than the usual care group (-1.7 days, P = 0.05) and the GMV group (-2.3 days, P < 0.01) and less interference with daily activities than the usual care group (odds ratio 0.37, P = 0.02). We observed no differences in A1C change. Patient-centered SMS improves certain aspects of diabetes care and positively influences self-management behavior. ATSM seems to be a more effective communication vehicle than GMV in improving behavior and quality of life.

No studies have evaluated the quality of anticoagulation control among populations characterized by low socioeconomic status, diverse racial and ethnic backgrounds, or limited English proficiency. We conducted a retrospective cohort study to evaluate the effects of race/ethnicity and language on anticoagulation outcomes among patients (N=864) receiving continuous anticoagulation services at a university-affiliated public hospital. White/non-Hispanic patients made up 24%, Asian/Pacific Islanders 33%, Hispanics 22%, African Americans 18%. English (63%), Spanish, (14%), and Cantonese (13%) were the most common languages. Mean time in therapeutic range (TTR) was 43%. After adjustment, TTR was lower for African Americans than for Whites (absolute difference, -8.7%, p< .001) and for Spanish-speaking than for English-speaking Hispanics (absolute difference, -7.2%, p< .05). There were no differences between Asian/Pacific Islanders and Whites, nor between Cantonese-speaking and English-speaking Asian/Pacific Islanders. Future research should examine mechanisms by which race/ethnicity and language affect quality of anticoagulation and evaluate programs to improve treatment in diverse communities.

Informed consent is legally and ethically required before invasive non-emergent procedures. Language barriers make obtaining informed consent more complex. Determine the impact of language barriers on documentation of informed consent among patients in a teaching hospital with on-site interpreter services. Matched retrospective chart review study. Eligible Chinese- and Spanish-speaking patients with limited English proficiency (LEP) who received a thoracentesis, paracentesis, or lumbar puncture were matched with eligible English-speaking patients by procedure, hospital service, and date of procedure. Charts were reviewed for documentation of informed consent (IC), including a procedure note documenting an IC discussion and a signed consent form. For LEP patients, full documentation of informed consent also included evidence of interpretation, or a consent form in the patient's primary language. Seventy-four procedures in LEP patients were matched with 74 procedures in English speakers. Charts of English-speaking patients were more likely than those of LEP patients to contain full documentation of informed consent (53% vs 28%; odds ratio (OR): 2.81; 95% CI, 1.42-5.56; p = 0.003). Upon multivariate analysis adjusting for patient and service factors, English speakers remained more likely than LEP patients to have full documentation of informed consent (Adj OR: 3.10; 95% CI, 1.49-6.47; p = 0.003). When examining the components of informed consent, charts of English-speaking and LEP patients were similar in the proportion documenting a consent discussion; however, charts of English speakers were more likely to contain a signed consent form in any language (85% vs 70%, p = 0.03). Despite the availability of on-site professional interpreter services, hospitalized patients who do not speak English are less likely to have documentation of informed consent for common invasive procedures. Hospital quality initiatives should consider monitoring informed consent for LEP patients.

Misunderstanding between clinicians and patients may lead to medication-related errors and poor clinical outcomes, particularly in anticoagulant care. One hundred forty-seven chronic warfarin users were randomized to receive a visual medication schedule at each visit, along with brief counseling, versus standard care, and followed for 90 days. At baseline, patient and clinician reports of the prescribed warfarin regimen were recorded to identify patients as "discordant" versus "concordant" to determine whether the effect of the intervention varied with clinician-patient discordance. At baseline, clinician-patient warfarin regimen discordance was common in intervention and control groups (38% versus 42%). Intervention subjects achieved anticoagulation control more rapidly than control subjects (median 28 versus 42 days; hazard ratio [HR], 1.43; confidence interval [CI], 1.00, 2.06). The benefit of the intervention was significant among subjects with baseline regimen discordance (median, 28 versus 49 days; HR, 1.92; CI, 1.08, 3.39) but not among subjects with baseline concordance (median 28 versus 35 days; HR, 1.14; CI, 0.71,1.83). Among patients in poor anticoagulant control whose understanding of their warfarin regimen is discordant with their providers', a visual medication schedule, combined with brief counseling, reduced time to anticoagulation control. The study suggests a simple strategy to enhance medication safety and efficacy for at-risk patients.

Objective Miscommunication between patients and providers can have serious consequences—especially where medications are concerned. Because oral anticoagulants are associated with preventable adverse events at disproportionately high rates, we used the model of anticoagulant care to examine the extent to which regimen discordance between patient and provider contributes to unsafe medication management. Methods We performed a study among 220 long-term users of warfarin in an anticoagulation clinic to characterize the importance of two medication assessment components. We measured (1) adherence to warfarin by asking patients to report any missed doses during the prior 30 days, and (2) concordance between patients’ and providers’ reports of prescribed warfarin regimens. We categorized patients as having complete adherence if they missed no doses and regimen concordance if there was patient-provider agreement in the total weekly dosage. We examined the independent relationships between (a) adherence and anticoagulant outcomes, and (b) concordance and anticoagulant outcomes. We characterized anticoagulant outcomes as unsafe if international normalized ratio (INR) values either were < 2.0 (at risk for thrombosis) or > 4.0 (at risk for hemorrhage) over 90 days, using repeated measures analysis. Results One hundred fifty-five patients (70.5 percent) reported no missed warfarin doses during the prior 30 days. In multivariate models, poor adherence was associated with under-anticoagulation (adjusted odds ratio [AOR] = 2.33; 95% confidence interval [CI] = 1.56–3.45; P < 0.001), but not with over-anticoagulation (AOR = 1.36; 95% CI = 0.69–2.66; P = 0.38). One hundred ten patients (50 percent) reported warfarin regimens that were discordant with respect to the clinicians’ report. Among adherent patients, discordance was associated with both under-anticoagulation (AOR = 1.67; 95% CI = 1.00–2.78; P = 0.05) and over-anticoagulation (AOR = 3.44; 95% CI = 1.32–9.09; P = 0.01). There was no relationship between patients’ reports of adherence and concordance (odds ratio [OR] = 1.14 95% CI = 0.64–2.04; P = 0.66). Conclusion Discordance between clinicians and patients regarding warfarin regimens is unsettlingly common and places patients at risk for thromboembolic and hemorrhagic events. To promote safe and effective care, clinicians should sequentially determine adherence (missed doses) and regimen concordance during routine medication assessments. Systems need to be developed to ensure patient-provider concordance in medication regimens.

Clinical performance examinations (CPX) with standardized patients (SPs) have become a preferred method to assess communication skills in US medical schools. Little is known about how trainees' backgrounds impact CPX performance. The objective of this paper is to examine the impact of student ethnicity, primary childhood language, and experience of diversity on the communication scores of a high-stakes CPX using SPs. This research was designed as an observational study. The participants of this study were third-year medical students at one US medical school. The measurements used in this study were CPX scores from mandatory exam, student demographics and experience with diversity measured by self-report on a survey, and Medical College Admission Test (MCAT) and United States Medical Licensing Examination (USMLE) scores. A total of 135 students participated. Asian and black students scored lower than white students on the communication portion of the CPX by approximately half a standard deviation (Asian, 67.4%; black, 64.4%; white, 69.4%, p < .05). There were no differences by ethnicity on history/physical exam scores. Multivariate analysis controlling for MCAT verbal scores reduced ethnic differences in communication scores (Asian-white mean differences = 1.95, p = 0.02), but Asian-white differences were eliminated only after sequential models included primary childhood language (difference = 0.57, p = 0.6). Even after controlling for English language knowledge as measured in MCAT verbal scores, speaking a primary childhood language other than English is associated with lower CPX communication scores for Asian students. While poorer communication skills cannot be ruled out, SP exams may contain measurement bias associated with differences in childhood language or culture. Caution is indicated when interpreting CPX communication scores among diverse examinees.

To describe physicians use of jargon with diabetes patients with limited health literacy. We audiotaped 74 outpatient encounters and coded unclarified jargon, assigning each term a clinical function. We administered telephone questionnaires to determine if comprehension of diabetes-related jargon varied with context. Eighty-one percent of encounters contained at least one unclarified jargon term (mean of 4/visit). Thirty-seven percent of jargon use occurred when making recommendations, and 29% when providing health education. Patient comprehension rates were generally low and never reached adequate thresholds. Physicians caring for patients with limited health literacy employ unclarified jargon during key clinical functions.

The authors examined whether tailored self-management support (SMS) strategies reach patients in a safety net system and explored variation by language, literacy, and insurance. English-, Spanish-, and Cantonese-speaking diabetes patients were randomized to weekly automated telephone disease management (ATDM) or monthly group medical visits. The SMS programs employ distinct communication methods but share common objectives, including behavioral "action plans." Reach was measured using three complementary dimensions: (a) participation among clinics, clinicians, and patients; (b) patient representativeness; and (c) patient engagement with SMS. Participation rates were high across all levels and preferentially attracted Spanish-language speakers, uninsured, and Medicaid recipients. Although both programs engaged a significant proportion in action planning, ATDM yielded higher engagement, especially among those with limited English proficiency and limited literacy. These results provide important insights for health communication and translational research with respect to realizing the public health benefits of SMS and can inform system-level planning to reduce health disparities.