Latinos/Hispanics have become the largest ethnic minority group in the United States. In 2005, the U.S. Hispanic population of 43 million individuals ranked third worldwide, surpassed only by Mexico and Colombia. Hispanics in the United States are a heterogeneous group made up of individuals of Mexican (65.5%), Puerto Rican (8.6%), Cuban (3.7%), Central American (8.2%), and South American (6%) descent, with the remainder from other Hispanic/Latino backgrounds. The rapidly growing U.S. Hispanic population is expected to number more than 102 million by the year 2050 (U.S. Census Bureau, 2006).
Hispanics in the United States experience a disproportionate rate of HIV infection, three times higher than that of non-Hispanic Whites. Hispanics have the second highest rate of HIV infection among racial/ethnic minority groups in the United States and face disparities in HIV-related health outcomes (Dean, Steele, Satcher, & Nakashima, 2005; Espinoza et al., 2007). This population tends to enter care later in the course of HIV disease and have a lower survival rate than non-Hispanic Whites (Hall, McDavid, Ling, & Sloggett, 2006; McGinnis et al., 2003). Potential explanations for the disparities in HIV health outcomes among Hispanics include lack of access to quality care, nonadherence to HIV treatment, scarcity of ethnic minority clinicians, and an inability to navigate the health care system (Fitzpatrick, Sutton, & Greenberg, 2006; Hall et al., 2006; Sohler, Fitzpatrick, Lindsay, Anastos, & Cunningham, 2007).
The Bilingual/Bicultural Care Team
Truman Medical Center (TMC), located in the urban core of Kansas City, Missouri, is the primary clinical partner for the University of Missouri-Kansas City's medical, nursing, pharmacy, and dental schools. The TMC hospital and its clinics serve a diverse patient population, 90% of whom are under- or uninsured. The HIV specialty clinic at TMC, established in 1987, provides primary care to adults living with HIV infection. As the Hispanic population in the midwest region of the United States has grown, the number of individuals of Hispanic background who have sought care at the HIV specialty clinic has increased. Of the 600 adults served by the clinic in 2007, 14% were Hispanic. Many of the clinic's Hispanic patients are first generation immigrants whose second language is English, and many have limited English language ability. Before March 2006, Hispanic patients were assigned at random to a primary care provider and case manager. Because most clinic personnel did not speak Spanish, many patients required an interpreter to mediate health services, and the delivery of services lacked a team approach. In an effort to better serve the Hispanic HIV patient population, the clinic HIV program manager brought together three Hispanic bilingual/bicultural care providers (i.e., a nurse practitioner, a Ryan White case manager, and a peer educator) who began working together as a team in the clinic 1 day per week in March, 2006. At the same time, the director of the hospital's interpreter services department, also a bilingual and bicultural Hispanic, worked with clinic personnel to adapt all patient education and case management materials for cultural and Spanish language appropriateness, with the result that all written materials were revised.
When the team was implemented, many established Hispanic patients, particularly those who had Spanish as their language preference, transferred their care to the team without reluctance. Some patients who preferred English or could not come to the clinic on the day the team was present continued to receive care in the clinic from their established providers. Bilingual care team clinical activities and responsibilities are shown in Table 1.
This retrospective study was conducted to examine the impact of the bilingual/bicultural care team on selected HIV-related health outcomes. The study protocol was approved by the institutional review board of the University of Missouri-Kansas City, and the TMC privacy board.
The electronic medical records of adult patients (N = 86) who were HIV-infected, self-identified as Hispanic, and treated at the TMC HIV specialty clinic from March 2005 to March 2007 were reviewed. Patients included in the study were those who visited the HIV specialty clinic during the 1-year period before the implementation of the bilingual care team (March 2005 to March 2006) and during the 1-year period after the formation of the team (March 2006 to March 2007). Patients who did not visit the clinic during these time periods were excluded, resulting in 43 eligible medical records.
Data Collection Methods
A registered nurse research assistant reviewed the electronic medical records (N = 43) and used a standardized data collection form to extract the data of interest for this study. Demographic, health care services utilization, and clinical data were collected. Variables included age range, gender, insurance information, number of outpatient clinic visits, number of emergency department (ED) visits and reason for visits, number of hospital admissions and reason for admissions, opportunistic infections, comorbid conditions, whether or not antiretroviral (ARV) medications were prescribed, reasons ARV medications were not prescribed, CD4+ T cell counts, and viral loads (HIV 1 RNA by polymerase chain reaction) for each patient over the 2-year period. Chronic illnesses other than HIV infection including mental illness were considered comorbid conditions. All data were extracted from the medical record, deidentified, and entered into a database using Statistical Package for the Social Sciences version 15.0 software (SPSS, Inc., Chicago).
Descriptive analyses were conducted for all demographic and clinical characteristics, including age range (i.e., 18-25, 26-39, 40-55, and > 55), gender, insurance, CD4+ T cell count, HIV-1 RNA by polymerase chain reaction (i.e., < 50, 51-100,000, > 100,000 copies/ml), prescription of ARV medication, comorbid conditions, and opportunistic infections. A comparative approach was used to explore changes in CD4+ T cell counts, HIV viral loads, outpatient clinic visits, ED visits, and hospital admissions between the time periods of interest (i.e., 1 year before and 1 year after the implementation of the bilingual care team). Paired t-tests and Wilcoxon signed rank tests were used to examine differences in the number of HIV clinic visits, CD4+ T cell counts, and number of patients who suppressed HIV viral load to < 50 copies/ml before and after implementation of the team. Data on types of comorbid conditions, ED visits, hospital admissions, and reasons that ARV medications were not prescribed were analyzed separately and grouped into categories/patterns.
Demographic and Clinical Characteristics of Study Sample
Demographic and clinical characteristics of the patients in this retrospective medical record review study are shown in Table 2. All patients in this study (N = 43) were low-income Hispanic adults, because all met criteria for either Ryan White or Medicaid assistance. The sample consisted of more men (n = 34, 79.1%) than women (n = 9, 20.9%), and most individuals (n = 26, 60.5%) were between the ages of 26 and 39. A majority (n = 35, 81.4%) were living with a chronic comorbid condition in addition to HIV, and about half (n = 22, 51.2%) were living with two or more comorbid conditions. The most common comorbid conditions were depression, cardiac disease, infectious hepatitis, and diabetes mellitus. A small number of patients (n = 7, 16.3%) had a history of or experienced opportunistic infections during the study period. The majority of patients (n = 38, 88.4%) met treatment criteria for ARV therapy (i.e., a CD4+ T cell count below 300 cells/mm3 or an HIV viral load > 100,000 copies/ml), and most (n = 34, 79.1%) had been prescribed ARV medications. Of the patients who met ARV treatment criteria yet had not been prescribed such therapy, psychological and social factors were the reasons most often cited in the medical records for not prescribing ARV medications.
Health Care Services Utilization
The number of clinic visits increased significantly (t, = 6.29, p < .05) after the formation of the bilingual care team, from a mean of 2.81 (SD = 2.34, range = 1-10) preimplementation visits to a mean of 5.30 (SD = 2.69, range = 1-11) postimplementation visits per patient per year because of an increase in both scheduled and kept appointments in the HIV specialty clinic. In addition, after the formation of the bilingual care team, there was an increase in visits to other specialty clinics such as dermatology; ear, nose, and throat; urology; endocrinology; cardiology; and mental health. There was also a rise in use of the ED: 18 patients visited the ED at TMC 33 times over the 2-year period. More than half of the ED visits occurred during the year after the implementation of the bilingual care team. There was a wide variety of reasons for ED visits, ranging from self-limiting illnesses to problems that necessitated hospital admission. Reasons for ED visits included ear infection, upper respiratory infection, asthma, and chest pain. A total of 17 patients accounted for 35 hospital admissions, 15 before implementation of the care team and 20 after implementation. A total of 10 of the hospitalizations that occurred after the implementation of the care team were for non-HIV-related reasons: 2 for delivery of a baby, 1 for ectopic pregnancy, 1 for chest pain, and 1 for pyelonephritis in a pregnant patient; 5 admissions were incurred by 1 patient who had complications of cancer chemotherapy. Admissions related to HIV included rashes and gastrointestinal complaints after starting ARV treatment. Of patients who were hospitalized for an illness during the 2-year study period, most (i.e., 11 of 17) had CD4+ T cell counts below 200 cells/mm3 at the time of admission.
CD4+ T Cell Counts and HIV Viral Loads
Only 8 (21.1%) of the 38 patients who met treatment guideline criteria for ARV therapy had suppressed viral loads (< 50 copies/ml) at the close of the year before the implementation of the bilingual care team, compared with 20 patients (52.6%) at the end of the year after the team was in place (z = 4.47, p < .05). CD4+ T cell counts improved during the year after the team was implemented with a mean group increase of 158.33 cells/mm3 (preimplementation: CD4+ T cell M = 185, SD = 142.53, range = 11-453; postimplementation: CD4+ T cell M = 343.33, SD = 223.76, range = 115-1,025), (t = 4.01, p < .05) for the suppressed patients. Only 15 of the 20 suppressed patients were included in the analysis of CD4+ T cell counts because CD4+ T cell laboratory data were missing for 5 patients.
This retrospective medical records review study aimed to examine the impact of a bilingual/bicultural care team and the use of educational materials adapted for Hispanics on selected HIV health outcomes. Patients in this study were low-income Hispanic/Latino adults (N = 43) with HIV who received care in an HIV specialty clinic during the 1-year period before and the 1-year period after the implementation of the care team. Most patients in this study preferred to communicate in Spanish, and many were first generation immigrants. The majority were men under the age of 40, corresponding to national trends in HIV diagnoses rates among Hispanics (Espinoza et al., 2007).
During the 1-year period after the implementation of the bilingual/bicultural care team, the number of outpatient HIV clinic and other subspecialty clinic visits per individual increased, and a higher percentage of individuals had suppressed HIV viral loads to < 50 copies/ml compared with the 1-year period before implementation of the team. Patients who suppressed their viral loads also significantly increased their CD4+ T cell counts. In addition, more ED visits and hospital admissions occurred during the 1-year period after the team was formed. Although the increase in the number of ED visits and inpatient hospital admissions was not substantial, the authors would have expected ED and inpatient health services utilization rates to decrease as outpatient visits and CD4+ T cell counts increased. Most of these admissions were unrelated to the patients' HIV status or treatment. A potential reason for the increase in ED and inpatient utilization after the implementation of the bilingual care team may have been a rising rate of HIV complications, such as those related to ARV medication toxicities, which tend to become more prevalent over time (Fleishman et al., 2005). Another plausible explanation for the increase in use of ED services may have been increased patient familiarity and comfort with the TMC health care system, promoting the likelihood to seek care at TMC rather than other hospitals. Overall, hospital admissions were higher among patients with low CD4+ T cell counts, a result that has been reported in other studies (Fleishman et al., 2005).
In addition to the reported changes in health care utilization and clinical health outcomes, there were other anecdotal results that had merit. The need for interpreter services in the HIV specialty clinic decreased, leading to shorter clinic visits and the ability to expedite services. In an era of limited resources, the ability to use fewer interpreter resources and yet provide the same service in a shorter time frame was welcomed. Members of the bilingual care team believed that the ability to interact with patients within the patients' cultural context improved communication, enhanced patients' understanding of HIV treatment adherence, increased patients' trust in the health care system, and helped facilitate referrals for other community services. In addition, for some patients, interactions with peer educators became a major source of social support. Although patient satisfaction data were not collected, informal feedback from patients and family members has been uniformly positive.
Although the results of this study are encouraging, there are limitations that must be acknowledged. This was a retrospective review with a small sample size conducted in only one clinic located in the midwestern United States. Results may have been different if there had been a prospective study design or a larger sample size or if the study had been conducted in a different geographic location. Because this was a retrospective study, there were no controls for external factors such as community events or programs, which may have influenced the study results. Another limitation was the fact that data regarding ED visits and admissions to hospitals outside the TMC system were available only if the patient reported this information and the provider then documented the information in the medical record. Hence, some ED visits and hospital admission data may not have been captured.
In this retrospective study, the number of clinic visits, CD4+ T cell counts, and the number of patients with HIV viral load suppressed to < 50 copies/ml increased significantly among Hispanic adults living with HIV (N = 43) after the implementation of a bilingual/bicultural care team. Specifically, more than half of patients had a suppressed viral load at the end of the 1-year period after implementation of the care team compared with 21.1% at the end of the 1-year period before the team was implemented. The suppression of HIV viral load has been associated with reduced morbidity and mortality, decreased risk of disease progression, and lowered likelihood of infecting other individuals with drug-resistant strains of HIV (Simoni, Pearson, Pantalone, Marks, & Crepaz, 2006). Whereas other factors may have contributed to the positive changes observed in this patient population, the investigators were not aware of major changes in community programs or substantial treatment advances during the period of interest in this study. Hence, it can be concluded that in this specialty clinic setting, health outcomes of Hispanic adults living with HIV infection were enhanced after the bilingual/bicultural care team was implemented and after educational materials were adapted for cultural and linguistic appropriateness. Similar models for delivery of outpatient care to comparable patient groups should be considered.
The number of new Hispanic/Latino patients referred to the Truman Medical Center HIV specialty clinic continues to increase. Hence, a fourth bilingual/bicultural full-time clinic staff member was added at the end of 2007 to serve as a liaison between the bilingual care team, clinic staff, and patients. In addition, this new member facilitates follow-up care activities.
The authors are willing to share Spanish educational materials referred to in this article with interested readers.
- Although the recruitment of bilingual and bicultural clinical personnel can be challenging in some settings, the beneficial results for Hispanic patients may justify the effort required.
- Given the current critical shortage of minority clinicians, one viable solution may be to seek bilingual and bicultural Hispanic HIV community members with leadership potential who can be trained as peer educators.
- Increasing the number of bilingual/bicultural peer educators may be one practical way to enhance health outcomes for Hispanics living with HIV.
The authors gratefully acknowledge their colleagues at the Truman Medical Center specialty clinic and the Guadalupe Center for their support in implementing the bilingual/bicultural care team; Mark Hecker, PharmD, for his assistance with institutional review board approval and data deidentification procedures; Ms. Kathleen Neff and Dr. Patricia J. Kelly for thoughtful manuscript review; and Dr. David S. McKinsey for encouragement to conduct this study.
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