# Presentation: 881026

## Hispanic patients receive high quality care in resident continuity practices: A CORNET study

- Scott D Krugman, MD, MS, Wendy L Hobson, MD, MSPH, Lynn C Garfunkel, MD, Janet R Serwint, MD, Lilia Parra-Roide, MD
- For the CORNET Research Network, Ambulatory Pediatric Association

## Disclosures

- None of the authors have any financial relationships with any company. No products will be discussed.
- Funding:
- Ambulatory Pediatric Association (APA) Young Investigator Award
- MedStar Research Institute Intramural grant

**Notes:**
None of the authors have any financial relationships to disclose in relation to this presentation or research.
I would like to acknowledge the funders of this study, the Ambulatory Pediatric Association and the Med Star research institute.

## Background

- Prior research has demonstrated that limited English proficiency (LEP) in Hispanic patients is associated with adverse health outcomes
- Many pediatric resident continuity practices serve underserved and Hispanic populations
- No large scale studies have evaluated the quality of care provided by residents to Hispanic patients with LEP
- The Parents Perception of Primary Care (P3C) is a validated quality of care survey tool suitable for measurement of resident care

## Objective

- To compare parental perception of resident quality of care between parents who completed the survey in Spanish and those who completed the survey in English in a national sample of parents from continuity practices

## CORNET

- The _Co_ntinuity _R_esearch _Net_work, (CORNET) was developed from the Continuity special interest group of the APA
- CORNET is a national, practice based research network of resident continuity clinics
- Research goals include studying health care issues of underserved children, health care disparities, and resident education
- 25 of 60 sites expressed an interest in participating in this study
- The network now includes over 95 resident training sites

## Methods

**Design**: Cross sectional survey
**Survey tool**: A 23 question version of the P3C with demographic information
- Survey assessed 6 domains of primary  care:
- Longitudinal continuity, access, contextual knowledge, comprehensiveness, coordination, and communication.

**Notes:**
We utilized a 23 question version of the P3C with a cross sectional design.

## Methods

**Data collection:**
- 19 CORNET sites were able to obtain IRB approval and completed the study
- The survey was distributed to all resident continuity patients at participating sites over a two-week time period in May or June 2004
- 14/19 sites had surveys completed in Spanish
- 2572 parents completed surveys with an average response rate of 85%/site

## Participating CORNET Sites

**Notes:**
The participating sites across the country are highlighted by the red dots.  As you can see, there was some clustering of the sites on the east and west coasts and the midwest.

## Methods

**Exclusion criteria**:
- Any survey that had less than 13/23 items of the P3C completed
- Any survey that identified a non-resident provider
- Unable to complete the survey in English or Spanish

**Notes:**
NOTE: 96% of English completed surveys included, 94% of Spanish. 

## Methods

**Data analysis:**
- Likert-scale (0 “never” through 4 “always”) for each item on 23 question scale converted to 0-100
- Students t-test to compare mean total score of each primary care domain between parents who completed the survey in Spanish and those in English
- Multiple linear regression models using demographic variables to obtain adjusted mean differences
- All models controlled for race, parental education, age of child, number of visits to site, ability to identify provider, and random effects from clustering

## Demographics

| Variable* | Survey in English
  n=1632 |  Survey in Spanish     
 n=490 |
| --- | --- | --- |
| Age (years)       
 <1
1-2
3-5
>5 | 
35%
24%
15%
26% | 
39%
23%
19%
19% |
| Race          Hispanic
                            AA
                       White
                       Other | 21%
43%
21%
15% | 100% |
| Insurance  Medicaid
           HMO/ Private
                       Other 
                        None           | 80%
14.5%
4.5%
1% | 86%
4%
1%
9% |
| Parent education
                         <HS
                   HS/GED
         some  college
           college grad | 
16%
37%
30%
17% | 
27%
48%
17%
8% |

- *All variables significantly different between two groups

**Notes:**
The demographic variables of the samples that completed the survey in English and in Spanish is shown in the table. The Spanish sample was significantly younger, more likely to have Medicaid insurance, and have a lower amount of education. All variables were significantly different and, as noted in the methods, controlled for in the multiple regression analysis.

## Mean score comparison between English and Spanish samples: full scale and domain

**Notes:**
The first graph demonstrates the comparison of the mean P3C score between the two populations. The Spanish sample results are in red, English in Blue. In the unadjusted results, for each domain, there were no significant differences between the mean scores of each sample. 

## Full scale mean score comparison between English and Spanish samples by sites with Spanish patients

**Notes:**
The mean scores of the fullscale P3C for the 14 sites with Spanish subjects are shown here. While there is some variablility by site, the majority of the sites had equivalent scores, while 4 sites had higher scores in the Spanish speaking population and 2 had higher in the English sample.

## Communication mean score comparison between English and Spanish samples by sites with Spanish patients

**Notes:**
When looking at the mean scores of the communication domain by site, the Spanish population reported higher or equivalent scores in this domain at each site.

## Adjusted mean scores comparing the two samples

|  | Total Score
(95% CI) | Access
(95% CI)
 | Longitudinal continuity
(95% CI) | Contextual knowledge
(95% CI)
 | Comprehensive care
(95% CI)
 | Communication*
(95% CI)
 | Coordination
(95% CI)
 |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Spanish | 74.9
(71.3, 78.4) | 73.8
(67.9, 79.6) | 44.9
(39.8, 50.0) | 76.9
(70.9, 81.1) | 82.7
(76.6, 88.8) | 92.7
(89.0, 96.3) | 80.0
(73.2, 86.8) |
| English | 73.5
(72.0, 74.9) | 72.4
(69.4, 75.4) | 46.4
(44.6, 48.3) | 76.5
(74.6, 78.4) | 79.4
(77.9, 81.0) | 88.4
(87.1, 89.7) | 79.3
(76.9, 81.9) |

-  *p<.0001
- A mean score of 75 signifies care is almost always consistent with definition of primary care.

**Notes:**
After adjusting for race, parental education, age of child, number of visits to site, ability to identify provider, and random effects, the mean scores and confidence intervals of the two samples are shown in this table. The communication domain was significantly higher after adjustment in the Spanish sample as compared to the english speaking sample.

## Slide 16

**Notes:**
Each site with Spanish speaking respondents to the survey reported their interpretive services for Spanish speaking patients at their continuity practices.
Every site had at least one system in place, many had more than one, and 80% had bilingual providers.

## Limitations

- Cross-sectional study
- Perception of care may not reflect actual quality
- Significant differences in all demographic variables between two populations
- Low literacy respondents may not have responded

**Notes:**
There were some important limitations with the study. First, the survey measured parental perception of quality and did not use “hard” quality measures.
the two samples had completely different demographic profiles, however we attempted to control for the differences in the adjusted analyses.
Low literacy parents may not have responded, potentially biasing the sample. Many sites, however, used techniques such as reading the survey to parents to administer the survey to low literacy patients. It is not clear, however, if there would have been a differential bias.

## Conclusions

- Resident continuity practices provide high quality care to Spanish speaking patients
- Every site with Spanish speaking patients demonstrated equivalent or higher scores than English speaking patients in both the full scale and communication domains
- The communication mean scores were significantly higher after controlling for other demographic variables
- Low continuity scores related to length of time patients in practice and time limitation of residents (turnover every three years, maximum score = 75)
- All continuity practices with Spanish respondents have systems in place to provide language services to Spanish speaking families

## Conclusions

- Possible reasons for high quality in the Spanish population:
- Parent perception may not reflect actual quality
- Low literacy patients have been shown to rate quality higher (Rosenthal et. al, Amb Peds, 2007)
- Resident practices have systems in place to provide quality care
- Cultural expectations may be different

## Implications

- Resident continuity practices serve as examples for providing high quality care to Spanish speaking families
- More research is needed to elucidate which features of care can be exported to other primary care settings to improve health disparities among LEP patients

## Acknowledgements

- CORNET Network Participants: East Carolina University, John Olsson, MD, Indiana University, Phillip Siefken, MD, Johns Hopkins Children’s Center, Janet Serwint, MD, Loma Linda University, Sharon Reisen, MD, MedPro/Maricopa Phoenix, Shawn McMahon, MD, Montifiore, Andrew Racine, MD, PhD, Nebraska University, Sheryl Pitner, MD, Northwestern University, Sandy, Sanguino, MD, Oregon Health Sciences University, Cynthia Ferrell, MD, University of Rochester/Rochester General Hospital, Lynn C. Garfunkel, MD, Rush University, Bill Stratbucker, MD, St. Joseph's, Phoenix, Lilia Parra-Roide, MD/Laurie Jones, MD, Uniformed Services, Joe Lopreiato, MD, MPH, University of Arizona, Tom Ball, MD, MPH/Karen Davenport, MD, U. California Davis, Richard Pan, MD, MPH, U. California Irvine, Lynn Hunt, MD, University of Florida, Allan Friedman, MD , U. South Florida, Sharon Dabrow, MD, University of Utah, Sarah Croskell, MD, MPH
- Walter Meyer, MA (statistics), Aynslee Wells and Raequi Wilson (Data entry).

**Notes:**
I would like to acknowledge my site collaborators in the network and the data entry and analysts from the University of Maryland.