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Significant racial and ethnic differences along several dimensions of patients’experiences with hospital care have been previously documented. However, the relationship between these differences and possible differences in processes of care has not been well described.
We conducted focus groups with 37 black and Hispanic men and women who had recently been discharged from either medical or obstetrical services at an urban academic medical center to assess which dimensions of these patients’ experiences with care were most important in determining overall levels of satisfaction.
Differences were found between Hispanics and blacks in the factors that influence their overall positive and negative experiences. Participants identified two themes that influence experiences with hospital care that are not commonly examined in many patient satisfaction instruments: availability and quality of translators, and attitudes of social workers and nursing staff.
Our findings suggest that hospitals should pursue hiring a culturally diverse work force and should collect racial and ethnically specific data about satisfaction with care including satisfaction with availability of social workers and interpreters.
As increasing focus is placed on disparities in health and health care in the United States, the influence of race and ethnicity on the relationship between patients and physicians has continued to attract interest.1–6 A number of studies have examined racial and ethnic differences in patients’ satisfaction with outpatient care in health maintenance organizations (HMO’s), physician group practices, and in a nationally representative survey.4,7–13 Several of these studies have noted higher levels of dissatisfaction among Latino patients than among whites, and many have noted conflicting results when comparing satisfaction of blacks and whites.8–14 For example, using a nationally representative sample of participants in the Medical Expenditure Panel Survey (MEPS), Dayton et al., reported that blacks were both more likely to report the most positive experiences of care than whites and more likely to report the most negative experiences compared with whites.14 As a result of the literature on patients’ experiences with care and the racial and ethnic differences documented, improving patients’ overall experiences with care and identifying mechanisms of disparities have become priorities in quality improvement health systems nationwide.15–17
The relationship of race to experiences with inpatient care, however, has not been as well characterized.18–20 Two studies, one conducted among military hospitals18 and another among Veterans Health Administration (VHA) hospitals,19 noted racial differences in patient satisfaction, but the relationship between these differences and possible differences in processes of care were not well described.
Recently, we examined survey results of over 2,600 patients recently hospitalized at an academic medical center, adjusting for socioeconomic status and facets of hospital care (such as hospital service) that might have accounted for these differences.20 Our study found significant racial and ethnic differences along several dimensions of patients’experiences with hospital care. Furthermore, we found that these racial and ethnic differences were greater among those who are hospitalized for surgical or obstetrical care.
Our prior findings suggest that further work is needed to better characterize the association between processes of hospital care and racial and ethnic differences in patients’ perceived experiences with care. To better understand the types of experiences during hospitalization that may influence racial and ethnic differences in satisfaction with hospital care, we conducted focus groups with recently hospitalized Hispanic and black patients.
To explore the types of positive and negative experiences that influence patients’ satisfaction with inpatient care, we conducted focus groups with 37 black and Hispanic men and women who had recently been discharged from either medical or obstetrical services at an urban academic medical center. Focus groups were conducted from March 2003 through August 2004.
Focus groups were conducted utilizing a structured focus group technique that invited patients to describe the details of their personal experiences of care within the seven dimensions measured by the standardized hospital care survey developed by the Picker Institute, Boston, MA 20,21: respect for patient preferences, coordination of care, information and education, physical comfort, emotional support, involvement of family and friends, and continuity and transition of care. The Human Studies Committee at the Brigham and Women’s Hospital approved this project.
The facilitators were paid consultants from the Greater Boston Center for Healthy Communities, The Medical Foundation (Boston, MA, USA), an organization with experience in organizing and conducting focus groups. Two trained, professional focus group facilitators conducted the six focus groups.
Each facilitator used a moderator’s guide that was based on our prior examination of racial differences in dimensions of patient experiences with inpatient care and how these differences vary by hospital service.20 Using the guide, facilitators used open-ended questions to elicit the kinds of experiences that black and Hispanic patients had that lead to negative and positive experiences with hospitalization in the seven Picker dimensions. One focus group facilitator was black; the other Latina, reflecting the race and ethnicity of the groups they facilitated.
Using hospital administrative data, we randomly selected a list of 2,802 black or Hispanic patients who returned a completed Picker Survey of Hospital Care20 after discharge from either the obstetrical or medical service from January 1, 2002 to December 30, 2003. Patients discharged from the medical service were considered eligible for the study if they were aged 18 years or older, had a discharge diagnosis of cardiovascular disease (ICD-9 code 410–414, 420–429), and had a valid mailing address. Obstetrics patients were considered eligible if they were aged 18 years or older and had a valid mailing address.
Potential participants were sent an explanatory letter and scheduling card by study staff in Spanish for Hispanic patients and English for others. Follow-up phone calls were made to those who responded, and focus groups were scheduled according to participants’ availability. Some of the focus groups had to be rescheduled when no one showed up at the scheduled time. Each participant received an honorarium of fifty dollars to take part in the study.
Black and Hispanic participants met in separate groups. We conducted six focus groups, each with between five and eight participants. Four groups (two black and two Hispanic) included cardiovascular patients, and two groups (one each, black and Hispanic) included postpartum obstetrical patients. Initially, the plan was to hold two focus groups for each of the following groups: black, Hispanic (Spanish-speaking only) and Hispanic (multilingual). However, it was challenging to recruit enough representatives of either Hispanic group at one time, so they were combined, and those focus groups were conducted in Spanish.
At the beginning of each focus group, facilitators introduced themselves and went over the Human Studies Committee at the Brigham and Women’s Hospital approved study consent forms to clear up any questions and/or address translation issues. After a brief explanation of the purpose of the focus group, participants were led through a brainstorming exercise to list all of their positive and negative experiences with their most recent hospitalization. Each experience was written on a post-it note by the facilitator or participant. Each person was given multiple opportunities to add additional post-its, until all experiences were shared. The post-its were divided among the members of the group, and they were asked to sort them according to the matrix shown in Table 1. A large format (30 in.×42 in.) matrix was used for the sorting task.
After the group finished the initial brainstorming exercise, each individual participant sorted and put his/her post-its on the matrix and was asked to move the post-its around if he/she thought any should be under a different heading. Participants were asked to be silent during the time an individual was moving his/her post-its to a different heading to avoid social pressures from other group members to either move or leave post-its in a particular space. Once all post-its had been moved, the groups were asked if they generally agreed on the final positions, once all post-its were moved to positions generally agreed upon by the group, the topics were ranked in terms of those most likely to lead to a positive overall view of hospital experience, and those most likely to lead to a negative overall view. Each focus group member was given 15 green chips and asked to distribute them among the positive experiences and 15 red chips and asked to distribute them among the negative experiences. This was also done silently.
After the voting, the participants discussed the votes made and were given an opportunity to change their votes, if desired. At this point, the facilitators also asked for more details on the top vote-getting topics, wrote the information on additional post-its and added them to the chart by topic.
After each participant was consented, the focus groups were audio taped for accuracy of analysis. Each moderator reviewed and edited a transcript of their focus groups to improve accuracy. Transcripts were translated from Spanish to English by conducting simultaneous translation–transcription. In some instances, direct back translation was not done due to the loss of significance of the patient’s responses.
Investigators analyzed the transcripts and facilitator notes using qualitative analytical software (NVIVO 7).22–24 Nodes were created from the seven dimensions of patients’ experiences of care, and transcript data were coded accordingly. A theme was identified when the transcript data and quotations dealt with the same concept.
We present the rankings of topics given by the focus groups according to their influence on overall positive and negative hospital experiences in each dimension of experiences with care, stratified by patient race and ethnicity, and hospital service. We also present the common positive and negative themes identified with representative quotes for each of the themes.
We recruited 27 of the 1,575 eligible cardiovascular patients (2%) and 14 of the 1,227 eligible obstetrics patients (1%) to attend the focus groups. Participants enrolled in the study a median of 16.5 months after their most recent hospitalization (16 months for cardiovascular patients and 17 months for obstetrics patients). The composition of the focus groups by race and ethnicity, sex, and discharge service are shown in Table 2. The median age was 25 years for obstetrical patients and 57 years for cardiovascular patients. Of the 36 participants with available insurance information, 8 were uninsured (38% of Hispanics and 10% of blacks).
There were noticeable differences by discharge services, as well as between black and Hispanic focus groups, in ranking experiences during hospitalization. These differences are presented in Table 3. Among Hispanics, information and education was ranked highest among patients’ overall negative experiences for both obstetrical and cardiovascular/medicine patients. Involvement of family and friends was rated as the most important positive experience among obstetrical patients, and emotional support was most important among cardiovascular/medicine patients.
Among blacks, emotional support was the most important negative experience for cardiovascular/medicine patients, and continuity and transition of care and emotional support were rated equally important negative experiences among obstetrical patients. Continuity and transition of care was also rated as most important positive experiences among obstetrical patients, and information and education was the most important positive experience among cardiovascular/medicine patients.
In addition to ranking the order of importance of each dimension in determining the overall experiences with hospitalization, focus group participants mentioned several themes that influenced their overall experiences with hospital care; these themes are presented in Table 4 for obstetrical patients and in Table 5 for cardiovascular/medicine patients. The focus group discussions of the Hispanic and black patients included frequent mention of two themes that influenced experiences with hospital care that are not currently examined in the current Picker instrument:17 (1) availability and quality of translators and (2) attitudes of social workers and nursing staff. Below, for each domain of experiences with care, we present the positive and negative experiences noted by patients in their own words.
Hispanic obstetrics patients reported more positive experiences in this dimension when interpreters were available. However, they also reported that they often had negative experiences relating to their preferences around surgical procedures and that they often felt pressured to have a procedure when they were undecided. Two Hispanic women spoke of these matters in this way:
“I was pressured to have a caesarean. They wanted me to make a quick decision.”
“I was pressured to have my tubes closed.”
Black obstetrics patients reported that their experiences were largely determined by whether they agreed with staff on the time of discharge.
“I wanted to leave the hospital early but the hospital discouraged me and the nurses basically chastised me for wanting to leave. My impression was that the nurses were trying to control my behavior. This was not my first child.”
Both black and Hispanic cardiovascular patients stated that when physicians and nurses appeared to have time to assess patients’ feelings and opinions, they had more positive experiences. In addition, black patients often reported that respect for their preferences was demonstrated by the hospital’s attentiveness to their menu request.
“Nurses and other staff assistant were positive, my immediate request was attended to (change, menu) if I wanted something different.” [Black cardiovascular patient #1]
“[They] need [a] new menu, I fill out the menu and they would bring something different.” [Black cardiovascular patient #2]
Both Hispanic and black participants in each of the focus groups related their experiences with pain management as an important predictor of positive or negative experiences in the hospital. One black cardiovascular patient said
“I had a lot of discomfort and the hospital would not give me anything for the pain when I needed it; they would wait for a certain time, when my pain came anytime it wanted.”
Among obstetrics patients, both black and Hispanic women described the importance of nurses allowing patients’ families to participate during labor in determining the nature of their experiences in the hospital. Many black and Hispanic obstetrics participants reported that limited visiting hours and limited numbers of family and friends allowed during labor were negative experiences with their care (Table 4). One black woman related her positive experiences in this domain:
“During my labor my family was included in the labor process, and assisted me when asked by the doctor, plus the nursery took very good care of my daughter.”
Among obstetrics patients, women of both racial and ethnic groups reported that the degree of information provided at discharge and during post-discharge follow-up were major predictors of positive hospitalization experiences. One Hispanic woman stated:
“They gave me formula, diapers, a crib, transportation and cash money.”
One black woman summarized her negative experiences with discharge care:
“The discharge wait was too long and getting my car was a very long wait.”
Among cardiovascular patients, racial and ethnic groups reported that the transport available at discharge and for post-discharge follow-up were major predictors of experiences with their hospitalization. One black participant noted:
“My discharge went smoothly, even the valet who put me in the car.”
A Hispanic focus group participant summarized her negative experience as follows:
“I left the hospital feeling bad and had to come back soon to the emergency room and pay $32.”
Among all focus groups, coordination of care appeared to be an important predictor of negative experiences with hospitalization. While there were no common themes for positive experiences within this dimension, Hispanic participants from both obstetrics and cardiovascular groups reported several negative experiences with continuity of nursing staff or midwives and with receiving contradictory instructions from doctors and staff (Tables 4 and and5).5). One Hispanic cardiovascular focus group participant provided the following example:
“They gave me contradictory instructions. The nurse was telling me to lift my hand for radiography and the doctor was telling me not to lift my hand.”
Hispanic patients from both discharge services rated information and education received as the most important predictor of negative experiences of care (Table 3). Among obstetrical patients, these experiences were most often driven by the amount of information received about breastfeeding (Table 4). One Hispanic woman provided the following example:
“This [problems with breastfeeding] could have been avoided. They could have explained [it] to me. The doctor never said anything else about it; they never told me what to do.”
Black patients from both discharge services rated emotional support received as the most important predictor of negative experiences of care (Table 3). Black focus group participants identified the perceived racial attitudes of nurses and social workers as frequently leading to negative experiences in care (Tables 4 and and5).5). Hispanic focus groups, however, rated emotional support as an important predictor of positive experiences with care and often cited the availability of social workers and nursing staff as important. One Hispanic cardiovascular/medicine participant provided the following example:
“The nurses are very good. They treat you nice...they are friendly, including those who don’t speak Spanish...They look for somebody to help with translation. The nurses are attentive to your needs, they treat you well, [and] they care how you feel.”
Results from the focus groups show differences between Hispanics and blacks in several dimensions of satisfaction with hospital care. We also found newly observed racial and ethnic differences in the importance of each dimension and its effect on overall experiences with hospitalization. Participants identified two additional themes that are not commonly examined in many patient satisfaction instruments: attitudes of social workers and nursing staff, and availability and quality of translators.
Numerous studies have demonstrated racial and ethnic differences in experiences with care but the processes that account for these differences are not well understood. In a prior study, we found that some differences may be due to the medical or surgical services providing care during hospitalization.20 We found that medical patients were less satisfied with their care overall than surgical or obstetrical patients; however, black and Hispanic patients who received their care on obstetrical and surgical services were more likely than white patients to perceive that their preferences were not well respected. We hypothesized that those racial and ethnic differences in perceived respect for patients’ preferences among obstetrical and surgical patients might reflect differences in unmeasured patient expectations to receive differential therapies when hospitalized for surgical procedures. This hypothesis is consistent with our finding that Hispanic women in our obstetrics focus groups reported feeling pressure to have surgical procedures (such as tubal ligation) performed and that black women often noted that their preferences for postpartum length of stay were not respected. These findings are particularly important, as prior research has demonstrated that Hispanic and black women are more likely to terminate breast feeding their infants earlier than non-Hispanic white women and that these differences may be attributable to differences in postpartum length of stay.25
Prior studies have documented racial and ethnic differences in satisfaction with provider communication and management, the adequacy of pain management, and in patients’ perceptions of their ability to participate in their care.4,13,14,26–28 To our knowledge, ours is the first study to describe the relative importance of each dimension of care in forming patients’ overall experiences with their hospitalization and that these dimensions differ by race/ethnicity. If confirmed in larger studies, our findings may help hospital administrators and staff to prioritize areas better for quality improvement when seeking to improve overall patient satisfaction. Examining reports of patients’ satisfaction by dimensions of their experiences may provide a guide to developing interventions to reduce racial disparities in satisfaction with hospital care.
Both black and Hispanic participants in our focus groups emphasized the importance of the availability and attitudes of social workers in determining their overall experiences of care. There have been several studies that have examined the role of perceived provider attitudes, including perceptions of provider prejudice, in determining patients’ experiences of the patient–physician relationship.10,29–30 For example, in a study of African-American and white Veteran’s Affairs patients with coronary artery disease29, participants rated provider communication and attitudes as a major theme potentially related to racial/ethnic differences in cardiovascular outcomes. Our study, however, demonstrates that attitudes of nonphysician staff may also play a critical role in inpatients’ experiences with care. If confirmed, our findings suggest that hospital administrators should focus programs, such as training on patient-centered counseling techniques, on allied health professionals and social workers in addition to nurses and physicians.
Hispanic participants from both discharge services also emphasized the importance of having well qualified interpreters readily available as a major predictor of satisfaction with care. These findings are supported by prior studies that have examined the link between limited English proficiency among patients and their difficulty with navigating a complex health care delivery system.31–32 These findings further underscore the need for health care systems to recruit a diverse work force that is culturally competent and emphasizes the need for hospitals to increase staffing to provide adequate interpreter services.
There are several potential limitations to our study. Although focus group research is a valuable and effective method for exploring patients’ health-related needs and perception of health care quality, they may include a self-selected group of individuals who may be more articulate about their opinions than nonparticipants or may have had more extremely negative or positive experiences than the norm, potentially leading to biased results. The majority of our cardiovascular disease participants (73%) were women; as a result, if gender differences in cardiovascular disease patient experiences exist, information regarding these patients’ experiences may be biased toward the women in our groups. As well, we recruited a small number of patients from a larger sample who received their care at a single large urban teaching hospital. As a result, our findings may not be representative of the larger sample or generalizable to smaller, rural, or public hospitals where there may be differences in the racial and ethnic mix of patients or in processes of inpatient care. The results do demonstrate the feasibility of conducting a study of racial and ethnic differences in processes and outcomes of care within a single institution to examine potentially modifiable variables to target for intervention.33
We found significant racial and ethnic differences in the types of experiences that influenced patients’ overall positive and negative experiences with hospitalization. Racial and ethnic differences in patient experiences with hospitalization, and differences in the understanding that health care providers, social workers, and hospital staff have about these experiences may be associated with the previously noted disparities in satisfaction with hospital care. Assuming that our findings could be replicated in a larger study, our data suggest: (1) physicians and hospital staff should strive to better understand and address the expectations of black and Latino patients, (2) health care systems should pursue hiring a culturally diverse work force, and (3) hospitals should collect racially and ethnically specific data34 about satisfaction with care, including satisfaction with availability of social workers and interpreters.
The authors would like to thank Shari Sprong of the Greater Boston Center for Healthy Communities, The Medical Foundation for her assistance in coordinating the focus groups and in preparation of the focus group report.
This study was supported by a grant from the Commonwealth Fund. The Robert Wood Johnson Foundation’s Harold Amos Medical Faculty Development Program (no. 043486) and the NCMHD, Project Export Center Grant (P20MD00537) supported Dr. Hicks.
Conflicts of interest None disclosed.