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We piloted a triad leadership model consisting of a unit-based hospitalist medical director, nurse manager, and case manager on five medical inpatient units. The purpose of this explanatory case study was to determine what, if any, impact the triad team would have on commonly measured operational and quality metrics: observed to expected length of stay, likelihood to recommend the hospital, hand-washing compliance, all-cause 30-day readmission rates, percent of discharges by noon, and percent of discharge to skilled nursing facilities. Over the course of a year triad units demonstrated improvement in most metrics in comparison to the baseline period. While trends for the metrics were favorable, most striking was a statistically significant improvement in the observed to expected length of stay ratio (1.25 to 1.15, p < 0.001) which is the organization's most widely used marker for efficient hospital patient flow.As a result of these sustained operational, safety, quality, and financial performance metrics the model is being generalized to other medical as well as surgical units, including our observation unit. Intangible benefits include creating leadership development path for hospitalist, nursing, and case management colleagues.

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OBJECTIVES: We sought to determine whether low acculturation, based on language measures, leads to disparities in cardiovascular risk factor control in U.S. Hispanic adults. METHODS: We studied 4729 Hispanic adults aged 18 to 85 years from the National Health and Nutrition Examination Survey, 1999-2004. We examined the association between acculturation and control of low-density lipoprotein (LDL) cholesterol, blood pressure, and hemoglobin A1c based on national guidelines among participants with hypercholesterolemia, hypertension, and diabetes, respectively. We used weighted logistic regression adjusting for age, gender, and education. We then examined health insurance, having a usual source of care, body mass index, fat intake, and leisure-time physical activity as potential mediators. RESULTS: Among participants with hypercholesterolemia, Hispanic adults with low acculturation were significantly more likely to have poorly controlled LDL cholesterol than Hispanic adults with high acculturation after multivariable adjustment (odds ratio [OR] = 3.4, 95% confidence interval [CI] 1.2, 9.5). Insurance status mildly attenuated the difference in LDL cholesterol control. After adjusting for diet and physical activity, the magnitude of the association increased. Other covariates had little influence on the observed relationship. Among those with diabetes and hypertension, we did not observe statistically significant associations between low acculturation and control of hemoglobin A1c (OR = 0.5, 95% CI 0.2, 1.2), and blood pressure (OR = 1.1, 95% CI 0.6, 1.7), respectively. CONCLUSIONS: Low levels of acculturation may be associated with increased risk of inadequate LDL cholesterol control among Hispanic adults with hypercholesterolemia. Further studies should examine the mechanisms by which low acculturation might adversely impact lipid control among Hispanic adults in the U.S.

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OBJECTIVE: Patient-physician language discordance is associated with worse quality of healthcare for patients with limited English proficiency. Patients with language-discordant physicians have more problems understanding medical situations. The impact of patient-physician language concordance on lifestyle counseling among Spanish-speaking patients is not known. METHODS: We performed a retrospective medical record review and identified 306 Spanish-speaking patients who used interpreter services between June 2001 and June 2006 in two Boston-based primary care practices. Our primary outcome was counseling on exercise, diet, and smoking. Our main predictor of interest was patient-physician language concordance. RESULTS: Patients with language-concordant physicians were more likely to be counseled on diet and physical activity compared to patients with language-discordant physicians. After adjustment for age, sex, insurance status, number of primary care visits, and comorbidity score, these differences in counseling persisted for diet [odds ratio (OR) = 2.2, CI 1.3-3.7] and physical activity (OR = 2.3, CI 1.4-3.8). There was no significant difference with regard to discussion of smoking (OR = 1.3, CI 0.8-2.1). CONCLUSIONS: Spanish-speaking patients are more likely to discuss diet and exercise modification if they have a Spanish-speaking physician compared to those having a non-Spanish-speaking physician. Further research is needed to explore whether matching Spanish-speaking patients with Spanish-speaking providers may improve lifestyle counseling.

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BACKGROUND: The association of acculturation and cardiovascular risk factor control among populations with high proportions of immigrants has not been well studied. METHODS: We studied 1,492 Hispanic participants in the Multi-Ethnic Study of Atherosclerosis (MESA) with hypertension, hypercholesterolemia, and/or diabetes. We used linear regression to examine the cross-sectional relationships between acculturation measures and cardiovascular risk factor levels. Outcome measures included systolic blood pressure (mm Hg), fasting low-density lipoprotein (LDL) cholesterol (mg/dL), and fasting blood glucose (mg/dL). Covariates included education, income, health insurance, physical activity, dietary factors, risk factor-specific medication use, duration of medication use, smoking, and body mass index. RESULTS: There were 580 Hispanics with hypertension, 539 with hypercholesterolemia, and 248 with diabetes. After adjustment for age and gender, Spanish-speaking Hispanics with cardiovascular risk factors had higher systolic blood pressure, fasting LDL cholesterol, and fasting blood glucose compared to English-speaking Hispanics. Differences in systolic blood pressure were accounted for mainly by education, whereas differences in LDL cholesterol were almost entirely accounted for by cholesterol-lowering medication use. Differences in fasting glucose were partly accounted for by socioeconomic variables but were augmented after adjustment for dietary factors. Similar associations were observed between proportion of life in the United States and risk factor levels. CONCLUSIONS: Among those with cardiovascular risk factors, Hispanics who spoke Spanish at home and lived less time in the United States had worse control of cardiovascular risk factors. Treatment strategies that focus on Hispanics with low levels of acculturation may improve cardiovascular risk factor control.

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Immigrants comprise vulnerable populations that are frequently exposed to a multitude of environmental and occupational hazards. The historical context behind state and federal legislation has helped to foster an environment that is particularly hostile toward caring for immigrant health. Current hazards include toxic exposures, air and noise pollution, motor vehicle accidents, crowded living and work environments with inadequate ventilation, poor sanitation, mechanical injury, among many others. Immigrants lack the appropriate training, materials, health care access, and other resources to reduce their exposure to preventable environmental and occupational health risks. This dilemma is exacerbated by current anti-immigrant sentiments, miscommunication between native and immigrant populations, and legislation denying immigrants access to publicly funded medical care. Given that current health policy has failed to address immigrant health appropriately and political impetus is lacking, efforts should also focus on alternative solutions, including organized labor. Labor unions that serve to educate workers, survey work environments, and defend worker rights will greatly alleviate and prevent the burden of disease incurred by immigrants. The nation's health will benefit from improved regulation of living and workplace environments to improve the health of immigrants, regardless of legal status.

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OBJECTIVE: Language barriers have been shown to negatively impact health care for immigrants. We evaluated the association between language use and the diagnosis of hypertension among elderly Mexican Americans. STUDY POPULATION: We studied subjects from the Hispanic Established Populations for Epidemiologic Studies of the Elderly, a cohort of 3050 Mexican American subjects age > or =65. PREDICTORS: Measures of language included Spanish and/or English language read/spoken, language used in social situations, and language of mass media use. OUTCOME MEASURE: Undiagnosed hypertension on physical exam was defined as systolic blood pressure > or =140 mm Hg and/or diastolic blood pressure > or =90 mm Hg in persons who did not report previous hypertension diagnosis or were not current users of anti-hypertensive medications. RESULTS: The age- and sex-adjusted prevalence of diagnosed hypertension and undiagnosed hypertension were 50.5% and 19.3%, respectively. Among 1347 older adults without previous diagnosis of hypertension that were included in the primary analysis, the mean age was 72 years and 43% were immigrants. After adjusting for age, gender, and education, Spanish use more often than English use in mass media was significantly associated with undiagnosed hypertension (adjusted OR 2.2 [1.3-3.6]). Other measures of acculturation were not independently associated with undiagnosed hypertension. In analyses restricted to persons with hypertension, similar language factors distinguished those who had been diagnosed from those whose hypertension was undiagnosed. CONCLUSIONS: Mexican American elders who reported using Spanish more often than English use in mass media were more likely to have undiagnosed hypertension compared to those using English language in mass media. Further studies are needed to elucidate the role of mass media language in hypertension awareness and management among Hispanic elders.

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