Center for Communication and Disparities Research

Building Relationships and Eliminating Disparities

Ronald M. Epstein, M.D., Director
Professor of Family Medicine, Psychiatry and Oncology

Kevin Fiscella, M.D., MPH, Co-director
Associate Professor of Family Medicine

Mission
Rationale for the Center
Center for Communication and Disparities Research
Cross-Cutting Research Themes
Target Populations
Clinical Focus
Recent and Current Studies

Mission

The mission of the Center is to improve health and advance healthcare quality and equity through implementation and rigorous assessment of novel interventions, educating healthcare professionals, patients and their families and community, and conducting research on healthcare communication, with a special emphasis on underserved and vulnerable populations in order to identify and address pathways that produce disparities in health and healthcare.

The scope of the Center includes communication among health care professionals, between health professionals and patients and their families and caregivers, and between health care professionals and diverse communities to optimize health and health care and eliminate disparities.

By creating a vehicle for collaboration among various departments and Centers at the University, the Center contributes to research that shows that effective communication can (a) strengthen healing relationships characterized by trust, caring, compassion, humility, and a commitment to bridge differences in culture, class, and power (b) improve health outcomes of acute, chronic, and life-limiting conditions, (c) reduce the impact of racial, ethnic, disease-specific, and socioeconomic factors in care, and (c) improve the effectiveness of prevention and health promotion.

The Center is a national and international model for cutting-edge translational research in communication and health, and a vehicle for dissemination of strategies to improve healthcare communication.

Rationale for the Center

The Institute of Medicine report, “Crossing the Quality Chasm,” documented the large gap between expected and achieved quality in health care. Many of these gaps result from ineffective communication. The Institute of Medicine report: “Unequal Treatment: Confronting Racial and Ethnic Disparities in Care” documents disturbing gaps in quality between whites and minorities that are not explainable by differences in insurance or socioeconomic status. The report underscores the crucial role that inadequate communication and lack of cultural competence play. Many patients report that they are not satisfied with the quality of their interactions with healthcare professionals. Significant gaps in communication between patients and healthcare professionals are evident in the general population. These gaps are more pronounced among (a) marginalized groups such as those with disabilities, low literacy, limited English proficiency or low socioeconomic status, (b) stigmatized groups such as those with HIV infection, obesity, or mental illnesses, and (c) minority populations such as African-Americans, refugees, and Deaf persons.

Poor communication has a strongly negative impact on outcomes of (a) disease prevention and health promotion (b) chronic diseases including diabetes and hypertension, (c) acute illnesses, including pain control, morbidity following surgery, and length of hospital stay, (d) mental illnesses such as depression and schizophrenia, and (e) end of life care.

It is possible to improve communication in healthcare settings, and such improvements have led to better health outcomes. Better communication has led to improvements in prevention, motivation for behavior change, and adherence to treatment. Furthermore, these changes may contribute to greater equity in health and healthcare for racial, ethnic, socioeconomic, educational and minority populations when compared to the general population.

We integrate four parallel trends in research and interventions on communication and health.

The public health approach has traditionally focused on the use of printed and electronic media to transmit health-related messages to populations. Our standardized patient study of ad-driven requests for prescription medication has documented the strong impact of the media on physician prescribing habits.
The health professional behavioral approach has focused on improving specific physician behaviors believed to improve patient adherence, participation in decision-making and feeling of having been understood. Current programs include an intervention to assess clinicians' efforts to promote physical exercise promotion in inner-city populations and a mindful communication program for physicians on burnout and quality of care.
The patient empowerment approach has focused on training patients to assume a more active role in their care. Current programs provide question prompt lists and coaching to improve end-of-life care in cancer, interactive media to promote patient care-seeking for depression, and use of patient decision support to promote colon cancer screening.
Finally, the health systems approach develops new models and systems of care. Our patient navigator studies examine the effect of providing better access to—and communication with—health care professionals on outcomes of care for patients with newly-diagnosed cancer.

The Center addresses health-related communication on several levels, including (a) the individual psychological makeup of physician and patient and potential for bias, (b) the 1:1 patient-clinician relationship, (c) the patient’s family and relevant social networks, (d) clinical communication among members the health care team, (e) communication with specific, targeted groups of patients, including the use of electronic media, (f) communication between health care researchers and those in clinical settings, and (g) communication between the larger health care system and individual patients and populations.

Center for Communication and Disparities Research

The Department of Family Medicine is a national leader in research on healthcare communication and health disparities, with over $12 million in funding over the past 10 years. In 2009 the Department ranked #10 in the U.S. in funding from The National Institute of Health. The Department’s reputation of being one of the top Family Medicine Departments in the U.S. rests on our work on communication, health, and disparities.

During the past several years, there has been a significant expansion of funding for research on communication, disparities and health. Elias Zerhouni, former Director of the NIH, on the issue of health disparities, said that "to call it a priority is wrong. It should be a core mission… It is something that permeates the entire concerns of NIH."

Cross-Cutting Research Themes

Research areas include:

Basic and observational research to build knowledge about theory, basic science, and phenomenology of communication in health care settings, including pathways to disparities, and demonstrate links between communication, equity, and health outcomes.
Translational and theory-based intervention research to improve communication, behavior change, and relationships between health professionals and patients including those most marginalized, their families and caregivers, -- including patient, family, health professional, health systems, and community-based interventions.
Research on disparities in care for marginalized, underserved, and minority populations, particularly targeted interventions that make a difference.
Education of clinicians and patients.
Training the next generation of health communication researchers.

Target Populations

Vulnerable populations that have been the focus of research by members of the proposed Center include:

Members of racial and ethnic minority groups, including the Deaf
Those who are poor, uninsured and/or under-insured
Refugees
People with low health literacy and /or low education attainment
People with stigmatized conditions, such as HIV and depression
People facing a life-limiting illness, including palliative care settings
People with disabilities, including those who are deaf or hard-of-hearing
Health professionals with and at risk for burnout

In addition, studies have addressed physician competence, professionalism, burnout, and well-being.

Clinical Focus

Cancer: behavior change to prevent cancer; systems approaches to disparities in screening; interactive multimedia computer programs to facilitate informed decision making regarding colorectal cancer screening; navigation-activation interventions to reduce disparities in completion of initial treatment, improving communication about prognosis and treatment choices in advanced cancer; demographic disparities in pain management
Cardiovascular disease: patient understanding of risk; disparities in cardiovascular outcomes; palliative care for advanced heart failure
Mental health: patient-centered communication; effects of direct-to-consumer advertising on prescribing; targeted and tailored messages to improve care-seeking in depression; refugee mental health; treatment decision-making
HIV disease: technology enabled patient self management; risk behavior counseling
Palliative care: outcomes of prognosis discussions and goals-of-care consultations
Primary care: quality improvement through using novel approaches such as concurrent peer review patient visits

Recent and Current Studies

Targeted and tailored messages to improve detection and treatment of depression in primary care (Ron Epstein, Paul Duberstein, funded by National Institute of Mental Health, Richard Kravtiz, PI)
Social and behavioral influences in cancer communication and care (Ron Epstein, Bob Gramling, Kevin Fiscella, funded by National Cancer Institute, Ron Epstein and Cleveland Shields, co-PI's)
Direct to consumer advertising and depression treatment choices (Ron Epstein, funded by National Institute of Mental Health, Richard Kravtiz, PI)