The goal of this supplement is to present new information about the quality of health care among US Latino groups and focuses on the Latino patient’s perspective. Consistent with recommendations of the Institute of Medicine’s Crossing the Quality Chasm report1 and that of others2–4, this issue emphasizes patient-centeredness as a core component of a health care system designed to improve quality of care. Patient-centeredness is defined as providing care that is respectful of and responsive to individual preferences, needs, and values, while ensuring that patient preferences inform clinical decisions. This presumes that clinicians do a good job of assessing patient needs, expectations and environment, using information from patients about their family, cultural background, health and health care behaviors, primary language, health care literacy and other factors to improve and create new services.
This supplement includes a series of articles with information collected in recent population surveys to assess Latinos experiences with the United States health care systems. The authors put forth a careful understanding of how Latino population heterogeneity is related to help-seeking behavior, appraisal of the medical care experience and quality of services received. Patient-reported experiences are commonly used by researchers to determine how patient perspectives and behaviors influence their health care and potentially affect disparities in access and quality of care. The aim of this issue is to provide new knowledge and advance the conceptual and operational grounding for future policy research.
The value of health services research is significantly advanced through the use of models that have policy relevance for primary care. Extensive reliance on safety net providers by low-income Latinos, especially immigrants and their families, amplifies the importance of primary care as the point of service5. This impression is reinforced by the limited access that safety net consumers have to specialty providers6. Therefore, it is essential to promote optimal clinician and organizational practices to assure quality in processes of care, especially in primary care settings. Patient-centeredness provides an important framework for organizing and assessing the impact of explanatory factors.
The Latino population, already the nation’s largest minority group at an estimated 47 million in 2009, will double in size and comprise 29% of the US population in 2050, compared to 14% in 20057. Paralleling this population growth is a new wave of chronic diseases8 among Latinos and other similarly underserved predominantly low income populations. Prevention and clinical management of these diseases will require long-range strategies to deliver improved access to quality health care. One of the most evident gaps in knowledge stems from Latino population heterogeneity and its potential effects on quality of care and treatment-related transactions between consumers and the health care system. This cross-cutting theme for the articles in this special issue uses patient-centeredness as an organizing principle.
The Institute of Medicine’s Crossing the Quality Chasm report emphasized the components of quality of health care to be safe, effective, patient-centered, timely, efficient, and equitable1. Unfortunately, persistent widespread disparities in health care exist related to race, ethnicity and socioeconomic status. In key studies9, the Institute of Medicine (IOM) acknowledged the many possible reasons for these disparities in health care quality, including cultural and language barriers, time limitations imposed by the pressures of clinical practice, distrust for the health care establishment by many minority patients, lack of minority and bilingual physicians who may have better understanding and communication with co-ethnic patients, conscious or subconscious biases, clinical uncertainty, and negative racial stereotypes or perceptions that produce a different course of treatment for patients of diverse ethnic backgrounds. Abundant evidence demonstrates that ethnic minorities receive inferior, inappropriate or inadequate treatment.
Despite improvement in medical therapeutics, significant differences in measures on quality of care among Latinos continue. The 2008 National Healthcare Disparities Report again documented the lack of progress in overcoming a broad range of health care quality problems10. For most core quality measures (approximately 70%), no improvement or worsening was found for Latinos10 from 2000–2001 to 2005–2006. Increasing disparities were especially prevalent in chronic disease management. For most core access measures, 80% remained unchanged or worsened for Latinos10.
Overcoming deficits in quality of care among Latino and other underserved groups requires improving the quantity and quality of information about the problems they encounter. This includes early disease detection, addressing health literacy issues with appropriate sources of information about health and health care, promoting personal and family healthy behaviors, improving effectiveness of disease management and ability to navigate the health care systems, increasing continuity and coordination of care, and responding effectively to patient perceptions regarding poor quality of interpersonal communication, satisfaction, and effectiveness of care.
The Challenges of Obtaining Adequate Population Information
The Robert Wood Johnson Foundation supported the creation of the Network for Multicultural Research on Health and Health Care at UCLA to foster high-quality research on health care access and quality of care issues affecting Latino and Native American consumers. This special issue is one outcome of this support. The Network has linked leading scholars to use the best and most appropriate datasets to produce original research. Coinciding with the advent of the Network was the completion of the Robert Wood Johnson Foundation-PEW Latino national health surveys, a two-wave series of field interviews with a baseline of nearly 4,000 respondents. The first survey was designed to adequately sample subgroups usually underrepresented in other national health surveys and, together with the second wave, included an adequate sample of undocumented, Spanish speakers and people with chronic diseases11.
In addition to the availability of the RWJF-Pew survey data, the research presented in this special issue incorporated other datasets containing information about Latino health care perceptions, utilization behaviors, and patient-centeredness and how these may influence access and quality. We wholeheartedly thank the Network scholars and invited investigators who contributed to this special issue. Their hard work and professional insights have produced this substantial body of new research.
Scope of Coverage in the Special Issue
The peer-reviewed articles of this special issue inform us on quality of care for Latinos in the areas of receipt of preventive care, hypertension and diabetes awareness and treatment, as well as self-reported quality of care. The article authored by Michael Rodriguez, Arturo Vargas Bustamante, and Alfonso Ang entitled, “Perceived Quality of Care, Receipt of Preventive Care, and Usual Source of Care Among Undocumented Latinos” underscores the importance of having a usual source of care on outcomes and highlights outcomes for the understudied group of undocumented as well as other Latino subgroups. Receipt of preventive care is also examined by Anne Beal, Susan E. Hernandez, and Michelle Doty in their article entitled “Latino Access to the Patient Centered Medical Home.” They used the 2005 Medical Expenditure Panel Survey Household Component data to examine the concept of the medical home for Latinos and, in particular, how regular access to providers affects rates of preventive care among Latino subgroups. The article authored by Andrea Bersamin, Randall S. Stafford, and Marilyn A. Winkleby entitled “Predictors of Hypertension Awareness, Treatment, and Control Among Mexican American Women and Men” examines the quality and intensity of hypertension treatment for Latinos and the adverse consequences of inadequate access to care. The article by Hector M. Gonzalez, William Vega, Michael Rodriguez, Wassim Tarraf, and William Sribney entitled “Diabetes Awareness and Knowledge Among Latinos: Does a Usual Source of Healthcare Matter?” uses the Andersen health services model to examine the impact of having a usual source of health care on diabetes awareness, in the context of various explanatory factors including socioeconomic factors and sex.
Several articles focus on factors that affect patient-reported quality of care. Margarita Alegria, William Sribney, Mara Laderman, and Kristen Keefe’s article entitled, “The Role of Patient Activation on Patient-Provider Communication and Quality of Care for US and Foreign Born Latino Patients” examines the distribution of patient activation in Latinos and, in turn, the effects of activation on quality of medical care, including the quality of doctor-patient communication. The article describing self-reported quality of care and health behaviors authored by Carlos Reyes-Ortiz, Michael A. Rodriguez, and Kyriakos Markides and entitled “The Role of Spirituality Healing with Perceptions of the Medical Encounter Among Latinos” examines the association among spirituality, healing and patient attitudes based on medical encounter experiences. Determinants include patient-reported confusion, frustration and perceptions of quality of care based on their medical care experiences. An article by Debra Perez, William Sribney and Michael Rodriguez entitled, “Perceived Discrimination and Self-Reported Quality of Care Among Latinos in the United States” examined the relationship between Latino patient reports of discrimination in non-clinical and clinical interpersonal encounters and perceived quality of medical care. Another article authored by Debra Perez, Alfonso Ang, and William A. Vega entitled, “Effects of Health Insurance on Quality of Care Among Latinos in the United States” addresses the distribution and covariates of health insurance in the Latino population, and the association of health insurance with quality of care, including effects on intensity of service use for various chronic diseases. Lastly, an article from Arturo Vargas-Bustamante, Hai Fang, John A. Rizzo, and Alex Ortega entitled, “Heterogeneity in Health Insurance Coverage Among US Latino Adults” describes the distribution of health insurance among Latinos residing in the United States with a focus on nativity and nationality subgroup differences, and identifies determinants of health insurance coverage.
Individually and collectively, these studies provide valuable insights for clinicians and policymakers while highlighting directions for future health disparities research. Our primary goal is to provide new information that can illuminate how Latino population heterogeneity and other factors affect access to services and quality of care within the framework of evolving models of patient-centered care. In the context of health care reform, it is critical to provide health care coverage for all Americans including immigrants to promote societal well-being and to prevent deterioration of Latino population health. It is very important to assure a safety net for Latinos and therefore support the patient-centered medical home model as a tool to reduce disparities caused by access and quality of care. These articles also call for enhancing services for limited English proficient populations such as Spanish-speaking Latinos through supplying culturally and linguistically appropriate providers. The authors strongly support the recently published Institute of Medicine recommendations for health systems to consistently collect and report race/ethnicity and language data on all patients12. These issues deserve national attention and are a useful way forward in the provision of equitable health care services for the rapidly expanding Latino population of the United States.