Study Design
As part of a region-wide quality improvement initiative to reduce healthcare disparities among African American patients with uncontrolled hypertension, a two-part culturally tailored communication training program was developed and delivered to care management teams.
Participants
Three care management teams, comprised of 14 registered nurses, 15 registered pharmacists, and 7 non-clinical support staff, were invited to participate in the training program and self-assessment. Participation in the program and assessment was voluntary.
Training Program
The training was adapted from a series of resources and similar quality improvement initiative developed by, and with, Kaiser Permanente’s Equitable Care Health Outcomes team that incorporated an evidence-based communication model (AIDET – Acknowledge, Introduce, Duration, Explanation, and Thank You) and general awareness of African American culture and barriers within the healthcare system.9 The newly developed training program consisted of a 25-minute on-demand web-based module and 1.5 hour live interactive session. The web-based module, “Touching the Dream: Focus on African American Culture and Health”, is part of the Diversity & Health Series created in the Kaiser Permanente Colorado Region to raise cultural awareness of healthcare providers to eliminate healthcare disparities within African American communities. The live interactive session included the delivery of a presentation, “Building Connections Using Culturally Tailored Communication: AIDET Training for African American/Black Patients”, and participant discussion of scenarios and experiences.
Effectiveness Outcomes
The primary effectiveness outcome was estimated using a paired samples t-test based on the change in self-assessed cultural competency from baseline on one index and two scales within the Cultural Competence Assessment (CCA) instrument before and after the training program. The CCA was developed to assess cultural competency in a multi-disciplinary setting, with adequate test-retest validity overall (r = 0.85, p = 0.002) and for each of the subscales, culturally competent behaviors (CCB, r = 0.87, p = 0.002;) and cultural awareness and sensitivity (CAS, r = 0.82, p = 0.002) and acceptable reliability (Cronbach’s alpha = 0.89).10, 11 The instrument was used with permission from its creators. The index item assesses overall self-reported cultural competence using a single 5-point Likert-like question, “Overall, how competent do you feel working with people who are from other cultures different from your own?”. The CAS subscale uses a 7-point Likert-like response set ranging from “strongly agree” to “strongly disagree”, while the CCB subscale uses a similar 7-point scale with responses from ‘always’ to ‘never”. Responses are translated to numerical values and summed to yield a score for the CCA index and both the CAS and CCB subscales, where higher scores reflect greater self-reported overall competence, greater knowledge, more positive attitudes, and more frequently demonstrated behaviors.
Program Costs
Program costs were calculated using a micro-costing approach, where resource units are multiplied by unit costs. All participants were employees of Kaiser Foundation Health Plan at the time of training. Administrative time to develop and deliver the intervention was tracked throughout the program. Participant salaries and fringes were estimated using the most recent Bureau of Labor median occupation wages for the Atlanta-Sandy Springs-Roswell, GA metropolitan service area for the state of Georgia and employer costs for employee compensation, respectively.12, 13 For those participants that were not located at the regional office where the training took place, travel time and distance for participants was estimated based on average time and distance from medical offices to the regional office and mileage reimbursement was calculated based on the January 1, 2019 standard mileage rate as dictated by the Internal Revenue Service.14
Cost-effectiveness Analysis
The cost-effectiveness analysis was from the employer perspective. Net costs (the costs associated with the training program) and net effectiveness (the difference between pre- and post-training CCA scores, where statistically significantly different) were used to calculate the average cost-effectiveness ratio (ACER)(EQ.1). The average cost-effectiveness ratio is used for this analysis because there is no comparison between interventions.
EQ.1
Sensitivity analysis was applied to establish how the costs and cost-effectiveness of the program might vary from the base-case for three participants mix scenarios: all nurses, all pharmacists, or all support staff.
Institutional Review Board review and approval were not required for this work, as it was deemed a quality improvement activity by the organization.