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Background: Little is known about patients who have caregiver proxies communicate with healthcare providers via portal secure messaging (SM). Since proxy portal use is often informal (e.g., sharing patient accounts), novel methods are needed to estimate the prevalence of proxy-authored SMs., Objective: (1) Develop an algorithm to identify proxy-authored SMs, (2) apply this algorithm to estimate predicted proxy SM (PPSM) prevalence among patients with diabetes, and (3) explore patient characteristics associated with having PPSMs., Design: Retrospective cohort study., Participants: We examined 9856 patients from Diabetes Study of Northern California (DISTANCE) who sent ≥ 1 English-language SM to their primary care physician between July 1, 2006, and Dec. 31, 2015., Main Measures: Using computational linguistics, we developed ProxyID, an algorithm that identifies phrases frequently found in registered proxy SMs. ProxyID was validated against blinded expert categorization of proxy status among an SM sample, then applied to identify PPSM prevalence across patients. We examined patients' sociodemographic and clinical characteristics according to PPSM penetrance, "none" (0%), "low" (≥ 0-50%), and "high" (≥ 50-100%)., Key Results: Only 2.3% of patients had ≥ 1 registered proxy-authored SM. ProxyID demonstrated moderate agreement with expert classification (Κ = 0.58); 45.7% of patients had PPSMs (40.2% low and 5.5% high). Patients with high percent PPSMs were older than those with low percent and no PPSMs (66.5 vs 57.4 vs 56.2 years, p < 0.001) had higher rates of limited English proficiency (16.1% vs 3.2% vs 3.5%, p < 0.05), lower self-reported health literacy (3.83 vs 4.43 vs 4.44, p < 0.001), and more comorbidities (Charlson index 3.78 vs 2.35 vs 2.18, p < 0.001)., Conclusions: Among patients with diabetes, informal proxy SM use is more common than registered use and prevalent among socially and medically vulnerable patients. Future research should explore whether proxy portal use improves patient and/or caregiver outcomes and consider policies that integrate caregivers in portal communication.

Background: Safety-net systems serve patients with limited health literacy and limited English proficiency (LEP) who face communication barriers. However, little is known about how diverse safety-net patients feel about increasing clinician electronic health record (EHR) use., Objective: The aim of this study was to better understand how safety-net patients, including those with LEP, view clinician EHR use., Methods: We conducted focus groups in English, Spanish, and Cantonese (N=37) to elicit patient perspectives on how clinicians use EHRs during clinic visits. Using a grounded theory approach, we coded transcripts to identify key themes., Results: Across multiple language groups, participants accepted multitasking and silent clinician EHR use if focused on their care. However, participants desired more screen share and eye contact, especially when demonstrating physical concerns. All participants, including LEP participants, wanted clinicians to include them in EHR use., Conclusions: Linguistically diverse patients accept the value of EHR use during outpatient visits but desire more eye contact, verbal warnings before EHR use, and screen-sharing. Safety-net health systems should support clinicians in completing EHR-related tasks during the visit using patient-centered strategies for all patients., (©Elaine C Khoong, Roy Cherian, George Y Matta, Courtney R Lyles, Dean Schillinger, Neda Ratanawongsa. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 22.05.2019.)

Importance: Medication adherence is essential to diabetes care. Patient-physician language barriers may affect medication adherence among Latino individuals., Objective: To determine the association of patient race/ethnicity, preferred language, and physician language concordance with patient adherence to newly prescribed diabetes medications., Design, Setting, and Participants: This observational study was conducted from January 1, 2006, to December 31, 2012, at a large integrated health care delivery system with professional interpreter services. Insured patients with type 2 diabetes, including English-speaking white, English-speaking Latino, or limited English proficiency (LEP) Latino patients with newly prescribed diabetes medication., Exposures: Patient race/ethnicity, preferred language, and physician self-reported Spanish-language fluency., Main Outcomes and Measures: Primary nonadherence (never dispensed), early-stage nonpersistence (dispensed only once), late-stage nonpersistence (received ≥2 dispensings, but discontinued within 24 months), and inadequate overall medication adherence (>20% time without sufficient medication supply during 24 months after initial prescription)., Results: Participants included 21 878 white patients, 5755 English-speaking Latino patients, and 3205 LEP Latino patients with a total of 46 131 prescriptions for new diabetes medications. Among LEP Latino patients, 50.2% (n = 1610) had a primary care physician reporting high Spanish fluency. For oral medications, early adherence varied substantially: 1032 LEP Latino patients (32.2%), 1565 English-speaking Latino patients (27.2%), and 4004 white patients (18.3%) were either primary nonadherent or early nonpersistent. Inadequate overall adherence was observed in 1929 LEP Latino patients (60.2%), 2975 English-speaking Latino patients (51.7%), and 8204 white patients (37.5%). For insulin, early-stage nonpersistence was 42.8% among LEP Latino patients (n = 1372), 34.4% among English-speaking Latino patients (n = 1980), and 28.5% among white patients (n = 6235). After adjustment for patient and physician characteristics, LEP Latino patients were more likely to be nonadherent to oral medications and insulin than English-speaking Latino patients (relative risks from 1.11 [95% CI, 1.06-1.15] to 1.17 [95% CI, 1.02-1.34]; P < .05) or white patients (relative risks from 1.36 [95% CI, 1.31-1.41] to 1.49 [95% CI, 1.32-1.69]; P < .05). English-speaking Latino patients were more likely to be nonadherent compared with white patients (relative risks from 1.23 [95% CI, 1.19-1.27] to 1.30 [95% CI, 1.23-1.39]; P < .05). Patient-physician language concordance was not associated with rates of nonadherence among LEP Latinos (relative risks from 0.92 [95% CI, 0.71-1.19] to 1.04 [95% CI, 0.97-1.1]; P > .28)., Conclusions and Relevance: Nonadherence to newly prescribed diabetes medications is substantially greater among Latino than white patients, even among English-speaking Latino patients. Limited English proficiency Latino patients are more likely to be nonadherent than English-speaking Latino patients independent of the Spanish-language fluency of their physicians. Interventions beyond access to interpreters or patient-physician language concordance will be required to improve medication adherence among Latino patients with diabetes.

Health systems are heavily promoting patient portals. However, limited health literacy (HL) can restrict online communication via secure messaging (SM) because patients' literacy skills must be sufficient to convey and comprehend content while clinicians must encourage and elicit communication from patients and match patients' literacy level. This paper describes the Employing Computational Linguistics to Improve Patient-Provider Secure Email (ECLIPPSE) study, an interdisciplinary effort bringing together scientists in communication, computational linguistics, and health services to employ computational linguistic methods to (1) create a novel Linguistic Complexity Profile (LCP) to characterize communications of patients and clinicians and demonstrate its validity and (2) examine whether providers accommodate communication needs of patients with limited HL by tailoring their SM responses. We will study >5 million SMs generated by >150,000 ethnically diverse type 2 diabetes patients and >9000 clinicians from two settings: an integrated delivery system and a public (safety net) system. Finally, we will then create an LCP-based automated aid that delivers real-time feedback to clinicians to reduce the linguistic complexity of their SMs. This research will support health systems' journeys to become health literate healthcare organizations and reduce HL-related disparities in diabetes care., Competing Interests: The authors declare that they have no competing interests.

Objectives: Language barriers negatively impact health care access and quality for US immigrants. Latinos are the second largest immigrant group and the largest, fastest growing minority. Health care systems need simple, low cost and accurate tools that they can use to identify physicians with Spanish language competence. We sought to address this need by validating a simple and low-cost tool already in use in a major health plan., Design Setting Participants: A web-based survey conducted in 2012 among physicians caring for patients in a large, integrated health care delivery system. Of the 2,198 survey respondents, 111 were used in additional analysis involving patient report of those physicians' fluency., Main Outcome Measures: We compared health care physicians' responses to a single item, Spanish language self-assessment tool (measuring "medical proficiency") with patient-reported physician language competence, and two validated physician self-assessment tools (measuring "fluency" and "confidence")., Results: Concordance between medical proficiency was moderate with patient reports (weighted Kappa .45), substantial with fluency (weighted Kappa .76), and moderate-to-substantial with confidence (weighted Kappas .53 to .66)., Conclusions: The single-question self-reported medical proficiency tool is a low-cost tool useful for quickly identifying Spanish competent physicians and is potentially suitable for use in clinical settings. A reasonable approach for health systems is to designate only those physicians who self-assess their Spanish medical proficiency as "high" as competent to provide care without an interpreter., Competing Interests: Conflicts of Interest: None declared.

The purpose of this study was to explore communication barriers as independent predictors and potential mediators of variation in clinical recognition of diabetic peripheral neuropathy (DPN). In this cross-sectional analysis, we estimated the likelihood of having a DPN diagnosis among 4,436 patients with DPN symptoms. We controlled for symptom frequency, demographic and clinical characteristics, and visit frequency using a modified Poisson regression model. We then evaluated 4 communication barriers as independent predictors of clinical documentation and as possible mediators of racial/ethnic differences: difficulty speaking English, not talking to one's doctor about pain, limited health literacy, and reports of suboptimal patient-provider communication. Difficulty speaking English and not talking with one's doctor about pain were independently associated with not having a diagnosis, though limited health literacy and suboptimal patient-provider communication were not. Limited English proficiency partially attenuated, but did not fully explain, racial/ethnic differences in clinical documentation among Chinese, Latino, and Filipino patients. Providers should be encouraged to talk with their patients about DPN symptoms, and health systems should consider enhancing strategies to improve timely clinical recognition of DPN among patients who have difficult speaking English. More work is needed to understand persistent racial/ethnic differences in diagnosis.

Objective: Patient-provider communication about complementary health approaches can support diabetes self-management by minimizing risk and optimizing care. We sought to identify sociodemographic and communication factors associated with disclosure of complementary health approaches to providers by low-income patients with diabetes., Methods: We used data from San Francisco Health Plan's SMARTSteps Program, a trial of diabetes self-management support for low-income patients (n=278) through multilingual automated telephone support. Interviews collected use and disclosure of complementary health approaches in the prior month, patient-physician language concordance, and quality of communication., Results: Among racially, linguistically diverse participants, half (47.8%) reported using complementary health practices (n=133), of whom 55.3% disclosed use to providers. Age, sex, race/ethnicity, nativity, education, income, and health literacy were not associated with disclosure. In adjusted analyses, disclosure was associated with language concordance (AOR=2.21, 95% CI: 1.05, 4.67), physicians' interpersonal communication scores (AOR=1.50, 95% CI: 1.03, 2.19), shared decision making (AOR=1.74, 95% CI: 1.33, 2.29), and explanatory-type communication (AOR=1.46, 95% CI: 1.03, 2.09)., Conclusion: Safety net patients with diabetes commonly use complementary health approaches and disclose to providers with higher patient-rated quality of communication., Practice Implications: Patient-provider language concordance and patient-centered communication can facilitate disclosure of complementary health approaches., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: Treat-to-target guidelines promote shared decision making (SDM) in rheumatoid arthritis (RA). Also, because of high cost and potential toxicity of therapies, SDM is central to patient safety. Our objective was to examine patterns of perceived communication around decision making in 2 cohorts of adults with RA., Methods: Data were derived from patients enrolled in 1 of 2 longitudinal, observational cohorts [University of California, San Francisco (UCSF) RA Cohort and RA Panel Cohort]. Subjects completed a telephone interview in their preferred language that included a measure of patient-provider communication, including items about decision making. Measures of trust in physician, education, and language proficiency were also asked. Logistic regression was performed to identify correlates of suboptimal SDM communication. Analyses were performed on each sample separately., Results: Of 509 patients across 2 cohorts, 30% and 32% reported suboptimal SDM communication. Low trust in physician was independently associated with suboptimal SDM communication in both cohorts. Older age and limited English proficiency were independently associated with suboptimal SDM in the UCSF RA Cohort, as was limited health literacy in the RA Panel Cohort., Conclusion: This study of over 500 adults with RA from 2 demographically distinct cohorts found that nearly one-third of subjects report suboptimal SDM communication with their clinicians, regardless of cohort. Lower trust in physician was independently associated with suboptimal SDM communication in both cohorts, as was limited English language proficiency and older age in the UCSF RA Cohort and limited health literacy in the RA Panel Cohort. These findings underscore the need to examine the influence of SDM on health outcomes in RA.

Electronic health record (EHR) implementation may affect patient-clinician communication for diverse safety-net populations. We conducted a cross-sectional survey of English-, Spanish-, and Cantonese-speaking patients in a public hospital clinic with a basic EHR. We examined multivariate associations of patient race/ethnicity, language, and education with perceptions of primary-care provider (PCP) computer use. Among 399 respondents, 25% had less than a high school education, 22% preferred Spanish, and 17% Cantonese. Asian (AOR 3.1), non-English-speakers (AOR 3.6) were more likely to report that PCPs used the computer half or more of the visit. Asians were more likely to report that computers helped PCPs remember patient concerns (AOR 5.6). Non-English-speakers had lower odds of reporting that PCPs listened less carefully to them because of computers (AOR 0.3). Patients at risk for communication barriers may perceive advantages of PCP computer use. Safety-net clinics should consider EHR impact on communication disparities.

Objective: A patient's sense of his/her standing in the social hierarchy may impact interpersonal processes of care (IPC) within the patient-provider encounter. We investigated the association of perceived social position with patient-reported IPC., Methods: We used survey data from the Diabetes Study of Northern California (DISTANCE), studying 11,105 insured patients with diabetes cared for in an integrated healthcare delivery system. Perceived social position was based on the MacArthur subjective social status ladder. Patient-reported IPC was based on a combined scale adapted from the Consumer Assessment of Health Plans Study provider communication subscale and the Trust in Physicians scale., Results: Lower perceived social position was associated with poorer reported IPC (p<0.001). The relationship remained statistically significant after controlling for age, sex, race/ethnicity, depressive symptoms, physical functioning, income and education., Conclusion: Beyond objective measures of SES, patients' sense of where they fall in the social hierarchy may represent a pathway between social position and patient satisfaction with the quality of patient-provider communication in chronic disease., Practice Implications: Interventions to address disparities in communication in primary care should incorporate notions of patients' social position., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: Agreement between patients and physicians is an indicator of successful communication. Concordance in domains of communication among patients with heart disease and communication barriers has not been studied., Methods: English, Spanish, or Cantonese-speaking patients seen at a public hospital cardiology clinic were assessed with pre-visit questionnaires. Surveys of patients and their physicians immediately after the visit asked each about: (1) cardiac functional status, (2) barriers to self-management, (3) cardiac diagnoses, and (4) treatment. We assessed patient-physician concordance in these domains., Results: 179 patients and 56 physicians completed the study. Patients had low educational attainment, limited literacy and limited English proficiency. Physicians underestimated patients' cardiac functioning status (NYHA Classes 2-4), by 1 class or more in 50% of visits. Physicians were frequently unaware of medication (38/57, 67%) and psychosocial (61/88, 69%) barriers. Patients were unable to describe even 1 matching diagnosis (72/170, 42% concordant) among 5 categories. Physicians' reported medication changes in 106/179 (59%) but patients failed to report these changes in 55% (58/106). Multivariate logistic regression analyses showed no significant association between patient characteristics and concordance., Conclusion: Patients and physicians often fail to communicate effectively and determinants of concordance in CVD care require further investigation., Practice Implications: Developing strategies to improve communication within the medical encounter are critical to improving ambulatory chronic disease management., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: A significant proportion of US Latinos with diabetes have limited English proficiency (LEP). Whether language barriers in health care contribute to poor glycemic control is unknown., Objective: To assess the association between limited English proficiency (LEP) and glycemic control and whether this association is modified by having a language-concordant physician., Design: Cross-sectional, observational study using data from the 2005-2006 Diabetes Study of Northern California (DISTANCE). Patients received care in a managed care setting with interpreter services and self-reported their English language ability and the Spanish language ability of their physician. Outcome was poor glycemic control (glycosylated hemoglobin A1c > 9%)., Key Results: The unadjusted percentage of patients with poor glycemic control was similar among Latino patients with LEP (n = 510) and Latino English-speakers (n = 2,683), and higher in both groups than in whites (n = 3,545) (21% vs 18% vs. 10%, p < 0.005). This relationship differed significantly by patient-provider language concordance (p < 0.01 for interaction). LEP patients with language-discordant physicians (n = 115) were more likely than LEP patients with language-concordant physicians (n = 137) to have poor glycemic control (27.8% vs 16.1% p = 0.02). After controlling for potential demographic and clinical confounders, LEP Latinos with language-concordant physicians had similar odds of poor glycemic control as Latino English speakers (OR 0.89; CI 0.53-1.49), whereas LEP Latinos with language-discordant physicians had greater odds of poor control than Latino English speakers (OR 1.76; CI 1.04-2.97). Among LEP Latinos, having a language discordant physician was associated with significantly poorer glycemic control (OR 1.98; CI 1.03-3.80)., Conclusions: Language barriers contribute to health disparities among Latinos with diabetes. Limited English proficiency is an independent predictor for poor glycemic control among insured US Latinos with diabetes, an association not observed when care is provided by language-concordant physicians. Future research should determine if strategies to increase language-concordant care improve glycemic control among US Latinos with LEP.

Objective: To assess the association of limited English proficiency (LEP) and physician language concordance with patient reports of clinical interactions., Methods: Cross-sectional survey of 8638 Kaiser Permanente Northern California patients with diabetes. Patient responses were used to define English proficiency and physician language concordance. Quality of clinical interactions was based on 5 questions drawn from validated scales on communication, 2 on trust, and 3 on discrimination., Results: Respondents included 8116 English-proficient and 522 LEP patients. Among LEP patients, 210 were language concordant and 153 were language discordant. In fully adjusted models, LEP patients were more likely than English-proficient patients to report suboptimal interactions on 3 out of 10 outcomes, including 1 communication and 2 discrimination items. In separate analyses, LEP-discordant patients were more likely than English-proficient patients to report suboptimal clinician-patient interactions on 7 out of 10 outcomes, including 2 communication, 2 trust, and 3 discrimination items. In contrast, LEP-concordant patients reported similar interactions to English-proficient patients., Conclusions: Reports of suboptimal interactions among patients with LEP were more common among those with language-discordant physicians., Practice Implications: Expanding access to language concordant physicians may improve clinical interactions among patients with LEP. Quality and performance assessments should consider physician-patient language concordance., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: To determine the degree of discordance between patient and physician assessment of disease severity in a multiethnic cohort of adults with rheumatoid arthritis (RA), to explore predictors of discordance, and to examine the impact of discordance on the Disease Activity Score in 28 joints (DAS28)., Methods: Adults with RA (n = 223) and their rheumatologists completed a visual analog scale (VAS) for global disease severity independently. Patient demographics, the 9-item Patient Health Questionnaire (PHQ-9) depression scale score, the Health Assessment Questionnaire score, and the DAS28 were also collected. Logistic regression analyses were used to identify predictors of positive discordance, defined as a patient rating minus physician rating of >25 mm on a 100-mm VAS (considered clinically relevant). DAS28 scores stratified by level of discordance were compared using a paired t-test., Results: Positive discordance was found in 30% of cases, with a mean +/- SD difference of 46 +/- 15. The strongest independent predictor of discordance was a 5-point increase in PHQ-9 score (adjusted odds ratio 1.61, 95% confidence interval 1.02-2.55). Higher swollen joint count and Cantonese/Mandarin language were associated with lower odds of discordance. DAS28 scores were most divergent among subjects with discordance., Conclusion: Nearly one-third of RA patients differed from their physicians to a meaningful degree in assessment of global disease severity. Higher depressive symptoms were associated with discordance. Further investigation of the relationships between mood, disease activity, and discordance may guide interventions to improve care for adults with RA.

Objective: To examine whether the effect of health literacy (HL) on patient-physician communication varies with patient-physician language concordance and communication type., Methods: 771 outpatients rated three types of patient-physician communication: receptive communication (physician to patient); proactive communication (patient to physician); and interactive, bidirectional communication. We assessed HL and language categories including: English-speakers, Spanish-speakers with Spanish-speaking physicians (Spanish-concordant), and Spanish-speakers without Spanish-speaking physicians (Spanish-discordant)., Results: Overall, the mean age of participants was 56 years, 58% were women, 53% were English-speakers, 23% Spanish-concordant, 24% Spanish-discordant, and 51% had limited HL. Thirty percent reported poor receptive, 28% poor proactive, and 56% poor interactive communication. In multivariable analyses, limited HL was associated with poor receptive and proactive communication. Spanish-concordance and discordance was associated with poor interactive communication. In stratified analyses, among English-speakers, limited HL was associated with poor receptive and proactive, but not interactive communication. Among Spanish-concordant participants, limited HL was associated with poor proactive and interactive, but not receptive communication. Spanish-discordant participants reported the worst communication for all types, independent of HL., Conclusion: Limited health literacy impedes patient-physician communication, but its effects vary with language concordance and communication type. For language discordant dyads, language barriers may supersede limited HL in impeding interactive communication., Practice Implications: Patient-physician communication interventions for diverse populations need to consider HL, language concordance, and communication type.

Objective: To describe physicians use of jargon with diabetes patients with limited health literacy., Methods: We audiotaped 74 outpatient encounters and coded unclarified jargon, assigning each term a clinical function. We administered telephone questionnaires to determine if comprehension of diabetes-related jargon varied with context., Results: Eighty-one percent of encounters contained at least one unclarified jargon term (mean of 4/visit). Thirty-seven percent of jargon use occurred when making recommendations, and 29% when providing health education. Patient comprehension rates were generally low and never reached adequate thresholds., Conclusion: Physicians caring for patients with limited health literacy employ unclarified jargon during key clinical functions.

Objective: We examined whether diabetes patients report discrimination when seeking health care, whether problems with interpersonal processes of care (IPC) were associated with discrimination reports, and the linkage between discrimination and patients' health., Methods: 810 diabetes patients were surveyed. Surveys were linked to hemoglobin A1c (A1C) and total cholesterol test results., Results: 14% of participants reported experiencing discrimination in health care during the prior year, including discrimination due to their race (8%), education or income (9%), age (7%), and gender (10% of women). Patients with poorer than average ratings of their IPC had 2-8 times greater risk of reporting health care discrimination. Patients reporting health care discrimination had A1C levels that were higher than other patients (P = 0.002), more symptoms (P < 0.01), and poorer physical functioning (P = 0.007)., Conclusions: Diabetes patients' reports of health care discrimination are strongly linked to the quality of their interactions with providers as well as multiple health outcomes., Practice Implications: Physicians exert control over the clinical encounter and should endeavor to reduce patients' perceptions of discrimination during outpatient visits. Such efforts may result in more satisfied patients as well as improved health outcomes.

Purpose: Communication has been researched either as a set of behaviors or as a facet of the patient-physician relationship, often leading to conflicting results. To determine the relationship between these perspectives, we examined shared decision making (SDM) and the subjective experience of partnership for patients and physicians in primary care., Methods: From a convenience sample of experienced primary care physicians in 3 clinics, we recruited a stratified sample of 18 English- or Spanish-speaking patients. Direct observation of visits was followed by videotape-triggered stimulated recall sessions with patients and physicians. We coded decision moments for objective evidence of SDM, using a structured instrument. We classified patients' and physicians' subjective experience of partnership as positive or negative by a consensus analysis of stimulated recall sessions. We combined results from these 2 analyses to generate 4 archetypes of engagements and used grounded theory to identify themes associated with each archetype., Results: The 18 visits yielded 125 decisions, 62 (50%) of which demonstrated SDM. Eighty-two decisions were discussed in stimulated recall and available for combined analysis, resulting in 4 archetypes of engagement in decision making: full engagement (SDM present, subjective experience positive)--22%; simulated engagement (SDM present, subjective experience negative)--38%; assumed engagement (SDM absent, subjective experience positive)--21%; and nonengagement (SDM absent, subjective experience negative)--19%. Thematic analysis revealed that both relationship factors (eg, trust, power) and communication behavior influenced subjective experience of partnership., Conclusions: Combining direct observation and assessment of the subjective experience of partnership suggests that communication behavior does not ensure an experience of collaboration, and a positive subjective experience of partnership does not reflect full communication. Attempts to enhance patient-physician partnership must attend to both effective communication style and affective relationship dynamics.

Background: Many patients with chronic disease have limited health literacy (HL). Because physicians have difficulty identifying these patients, some experts recommend instituting screening programs in clinical settings. It is unclear if notifying physicians of patients' limited HL improves care processes or outcomes., Objective: To determine whether notifying physicians of their patients' limited HL affects physician behavior, physician satisfaction, or patient self-efficacy., Design: We screened all patients for limited HL and randomized physicians to be notified if their patients had limited HL skills., Participants: Sixty-three primary care physicians affiliated with a public hospital and 182 diabetic patients with limited HL., Measurements: After their visit, physicians reported their management strategies, satisfaction, perceived effectiveness, and attitudes toward HL screening. We also assessed patients' self-efficacy, feelings regarding HL screening's usefulness, and glycemic control., Results: Intervention physicians were more likely than control physicians to use management strategies recommended for patients with limited HL (OR 3.2, P=.04). However, intervention physicians felt less satisfied with their visits (81% vs 93%, P=.01) and marginally less effective (38% vs 53%, P=.10). Intervention and control patients' post-visit self-efficacy scores were similar (12.6 vs 12.9, P=.6). Sixty-four percent of intervention physicians and 96% of patients felt HL screening was useful., Conclusions: Physicians are responsive to receiving notification of their patients' limited HL, and patients support the potential utility of HL screening. However, instituting screening programs without specific training and/or system-wide support for physicians and patients is unlikely to be a powerful tool in improving diabetes outcomes.

While patients with poor functional health literacy (FHL) have difficulties reading and comprehending written medical instructions, it is not known whether these patients also experience problems with other modes of communication, such as face-to-face encounters with primary care physicians. We enrolled 408 English- and Spanish-speaking diabetes patients to examine whether patients with inadequate FHL report worse communication than patients with adequate FHL. We assessed patients' experiences of communication using sub-scales from the Interpersonal Processes of Care in Diverse Populations instrument. In multivariate models, patients with inadequate FHL, compared to patients with adequate FHL, were more likely to report worse communication in the domains of general clarity (adjusted odds ratio [AOR] 6.29, P<0.01), explanation of condition (AOR 4.85, P=0.03), and explanation of processes of care (AOR 2.70, p=0.03). Poor FHL appears to be a marker for oral communication problems, particularly in the technical, explanatory domains of clinician-patient dialogue. Research is needed to identify strategies to improve communication for this group of patients.

Objective: To evaluate the effect of primary care coordination on utilization rates and satisfaction with care among public hospital patients., Design: Prospective randomized gatekeeper intervention, with 1-year follow-up., Setting: The Adult General Medical Clinic at San Francisco General Hospital, a university-affiliated public hospital., Patients: We studied 2,293 established patients of 28 primary care physicians., Intervention: Patients were randomized based on their primary care physician's main clinic day. The 1,121 patients in the intervention group (Ambulatory Patient-Physician Relationship Organized to Achieve Coordinated Healthcare [APPROACH] group) required primary care physician approval to receive specialty and emergency department (ED) services; 1,172 patients in the control group did not., Measurements and Main Results: Changes in outpatient, ED, and inpatient utilization were measured for APPROACH and control groups over the 1-year observation period, and the differences in the changes between groups were calculated to estimate the effect of the intervention. Acceptability of the gatekeeping model was determined via patient satisfaction surveys., Results: Over the 1-year observation period, APPROACH patients decreased their specialty use by 0.57 visits per year more than control patients did ( P =.04; 95% confidence interval [CI] -1.05 to -0.01). While APPROACH patients increased their primary care use by 0.27 visits per year more than control patients, this difference was not statistically significant (P =.14; 95% CI, -0.11 to 0.66). Changes in low-acuity ED care were similar between the two groups (0. 06 visits per year more in APPROACH group than control group, P =. 42; 95% CI, -0.09 to 0.22). APPROACH patients decreased yearly hospitalizations by 0.14 visits per year more than control patients (P =.02; 95% CI, -0.26 to -0.03). Changes in patient satisfaction with care, perceived access to specialists, and use of out-of-network services between the 2 groups were similar., Conclusions: A primary care model of health delivery in a public hospital that utilized a gatekeeping strategy decreased outpatient specialty and hospitalization rates and was acceptable to patients.