Interpersonal and Communication Skills in Patient-clinician Encounters, Patient-reported Satisfaction With Resident Physicians Involved in Their Care, Patients' Clinical Health Outcomes After Surgery, Resident Knowledge and Attitudes Regarding Cross-cultural Care
Conditions
Keywords
Medical education, Patient-reported satisfaction, Patient-reported outcomes, Cultural dexterity, Cross cultural care, Resident physician education
Brief summary
This study is designed to test the impact of a new curriculum, called Provider Awareness Cultural Dexterity Toolkit for Surgeons (PACTS), on surgical residents' cross-cultural knowledge, attitudes, and skills surrounding the care of patients from diverse cultural backgrounds, as well as clinical and patient-reported health outcomes for patients treated by surgical residents undergoing this training.
Detailed description
In order to improve overall health outcomes of minority patients undergoing surgical care, the National Institute on Minority Health and Health Disparities (NIMHD) collaborated with the American College of Surgeons (ACS) and prioritized the evaluation and the the effect of improvement in culturally dexterous care on surgical outcomes for patients from disparity populations. Poor outcomes in patients are attributed to poor patient-provider communication which may lead to treatment errors, inadequate pain management, less patient-centered care, decreased adherence to treatment plans, and worse overall clinical outcomes. Additionally, studies have shown that some surgeons have pro-White implicit biases, which are unconscious, automated preferences that individuals may not even be aware of. Historically, formal training in cultural competency is generally integrated into medical education at the undergraduate level but it rarely continues up to the post-graduate level. Few surgical programs have attempted to incorporate cross-cultural communication skills into their educational paradigms, and the approaches to doing so have been inconsistent. In order to add the surgical context in post-graduate level medical education, the investigators adopted a novel approach to cross-cultural communication for surgical trainees, known as cultural dexterity. Cultural dexterity refers to a set of skills and cognitive practices used to maximize communication across multiple dimensions of cultural diversity and deviates from the concept of cultural competency in that it does not demand that learners associate certain practices and behaviors with individuals based on generalizations. Study design: Cross-over, cluster-randomized trial Study Procedures: Curriculum Administration The PACTS curriculum incorporates contemporary learning practices such as the flipped classroom model and team-based learning. It consists of e-learning modules and interactive sessions in which residents will apply concepts from the e-learning modules to role-play scenarios constructed in a team-based learning format. Residents will be given detailed, scripted prompts for the role-play sessions followed by structured feedback from peers and facilitators. Outcome Measurement: Residents To evaluate the impact of PACTS on surgical residents' knowledge and attitudes about caring for diverse patients, the investigators will use a pre- and post-test in the form of validated instruments that assess knowledge, attitudes, and self-reported skills on a Likert-type scale. Resident skills will also be objectively assessed through an Objective Structured Clinical Examination (OSCE) that will be created by the study staff and administered immediately before the intervention and 3 months after the intervention has been completed. The OSCE uses 5-point Likert scale questions to evaluate resident performance across multiple domains. These may be administered virtually or in-person. A Standardized Patient evaluator and a third-party trained impartial observer will evaluate the residents on these domains, and the resulting numerical scores will be averaged. It will serve both a summative and educational purpose in this context. Residents will be required to take a knowledge survey before and after receiving the PACTS curriculum or standard training. Attitudes regarding the importance of facing cross-cultural health care situations will be assessed across multiple domains using a novel survey instrument that is based on a survey that was used in a similar curriculum aimed at medical students, as well as the Values and Belief Systems domain. Patients To evaluate patients' satisfaction and clinical quality related to PACTS training, the investigators will administer surveys to patients treated by residents to determine satisfaction with pain management, communication, trust-building, and comprehension of the informed consent discussion two months before and after the intervention is implemented. Patient satisfaction will be assessed using elements of the validated Patient Satisfactions Survey. We plan to collect clinical surgical outcomes obtained from the National Surgical Quality Improvement Program (NSQIP) database for each patient participant before and after the PACTS curriculum is implemented to measure individual outcomes such as length of stay, postoperative complications, unplanned reoperations, and 30-day morbidity/mortality. A post hoc analysis of clinical outcomes will be performed.
Interventions
OTHERPACTS curriculum
The cultural dexterity curriculum, known as PACTS (Provider Awareness Cultural Dexterity Toolkit for Surgeons) focuses on developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care. The curriculum is comprised of four educational modules on establishing trust in the physician-patient relationship, communicating effectively with patients with limited English proficiency, discussing informed consent, and issues surrounding pain management. Each module consists of an independent learning activity, an interactive role-play, and a post-lesson assessment.
OTHERStandard Residency Curriculum
The standard residency curriculum consists of previously scheduled resident didactic sessions at all academic medical centers that may or may not include topics on cultural competency or cross-cultural care.
Sponsors
National Institute on Minority Health and Health Disparities (NIMHD)
Massachusetts General Hospital
Beth Israel Deaconess Medical Center
Howard University
Johns Hopkins University
Brown University
Eastern Virginia Medical School
Washington University School of Medicine
Brigham and Women's Hospital
Study design
Allocation
RANDOMIZED
Intervention model
CROSSOVER
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Masking description
Resident program directors and research staff will not be blinded to the implementation of curriculum
Intervention model description
Sites will be assigned to an early intervention/retention assessment group or a delayed intervention group (control) for examination of the effectiveness of the intervention as well as learner retention.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
\*Eligibility Criteria for Residents: Inclusion Criteria: \- All residents in the general surgery program at Johns Hopkins University, Brigham and Women's Hospital, Brown University, Eastern Virginia Medical School, Massachusetts General Hospital, Beth Israel Deaconess Medical Center, Howard University, and Washington University in St. Louis.
Exclusion criteria
\- Non-surgical residents at Johns Hopkins University, Brigham and Women's Hospital, Brown University, Eastern Virginia Medical School, Massachusetts General Hospital, Beth Israel Deaconess Medical Center, Howard University, and Washington University in St. Louis. \*Eligibility Criteria for Patients: Inclusion Criteria: * Admitted to surgical service under the care of a participating resident; * Able to recognize resident as the main care provider from a photo; * Able to consent as determined by a cognitive screen for capacity to give informed consent * Fluent in English or Spanish.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Residents' Cross Cultural Care Survey Scores From Pre- to Post-PACTS Curriculum | Period 2 (18 months) | The effect of PACTS curriculum on surgical residents' cross cultural care survey about caring for culturally diverse patients at time Period 2 (18 months). At this time period, the Early Intervention group received the PACTS curriculum, while the Delayed Intervention Group had not received the PACTS curriculum, serving as the control group. The cross cultural care survey was evaluated using a modified Likert type scale (with scale ranging from lowest to highest: very unprepared, somewhat unprepared, somewhat prepared, very well prepared). Resident scores were dichotomized into two groups, those reporting very unprepared and somewhat unprepared, and those reporting somewhat prepared and very well prepared. Here reported values are representative of the percentage of participants who reported somewhat prepared and very well prepared at time Period 2. |
| Change in Residents' Questionnaire Scores Regarding Their Beliefs From Pre- to Post-PACTS Curriculum | Period 2 (18 months) | The effect of PACTS curriculum on surgical residents' beliefs regarding caring for culturally diverse patients at time Period 2 (18 months). At this time, the Early Intervention Group had already received the PACTS curriculum. The Delayed Intervention Group had not received the PACTS curriculum, serving as the control group at this time period. The questionnaire was scored using a modified Likert type scale with a range from lowest to highest: strongly disagree, moderately disagree, mildly disagree, strongly agree, moderately agree, mildly agree. Answers were dichotomized into two groups: strongly disagree, moderately disagree, and mildly disagree; and strongly agree, moderately agree, and mildly agree. Here reported values are representative of the proportion of participants who answered strongly agree, moderately agree, and mildly agree. |
| Objective Structured Clinical Examination Scores | Period 2 (18 months) | Standardized Patient observers evaluated surgical residents on multiple dimensions of cultural dexterity and communication skills using Likert-type scales. The scale range, from lowest to highest was: Not at all; a little bit; somewhat; mostly; a great deal. Scores were put into two groups: 1) not at all, a little bit, and somewhat; 2) mostly and a great deal. The percentage of residents who received scores of mostly and a great deal in categories of trust, limited english proficiency, consent, and pain were reported. |
| Change in Residents' Questionnaire Scores Measuring Knowledge From Pre- to Post-PACTS Curriculum | Period 2 (18 months) | The effect of PACTS curriculum on surgical residents' questionnaire scores measuring knowledge about caring for culturally diverse patients at time Period 2 (18 months). At this time, the Early Intervention Group had already received the PACTS curriculum. The Delayed Intervention Group had not received the PACTS curriculum, serving as the control group at this time period. Resident knowledge: Percent score out of 100, with range 0-100%. Higher values represent a better outcome, with 100% as the highest score possible. This is the average score for the Early Intervention and Delayed Intervention groups at Period 2. |
| Change in Residents' Questionnaire Scores Regarding Self-Assessed Skills From Pre- to Post-PACTS Curriculum | Period 2 (18 months) | The effect of PACTS curriculum on surgical residents' self-assessed skills for caring for culturally diverse patients at time Period 2 (18 months). Self-assessed skills ranged from levels 1 to levels 4, with level 1 indicated less skilled, and level 4 indicating skillful. For purposes of comparison, resident scores were dichotomized into two groups: less skilled (referring to skill levels 1 and 2), and skillful (levels 3 and 4). Here reported values are representative of the percentage of participants who reported skill levels 3 or 4, indicating skillful. Results here demonstrate the proportion of residents in the Early Intervention (Intervention) group and Delayed Intervention (control group) who self-evaluated their skills as skillful at Period 2. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Median Hospital Length of Stay for Patient Participants | Period 2 (18 months) | National Surgical Quality Improvement Program (NSQIP) metrics for each patient participant capturing hospital length of stay in days. Patients designated to Early Intervention Group were cared for by a resident enrolled in the Early Intervention group, where the PACTS curriculum was administered between period 1 (0 months) and period 2 (18 months). Patients designated to the Delayed Intervention group were cared for by a resident enrolled in the Delayed Intervention group, where the standard curriculum was administered between period 1 (0 months) and period 2 (18 months). We are comparing median length of stay at period 2. |
| Patients' Self-reported Satisfaction Scores | Period 2 (18 months) | We used an adapted version of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) to assess patients' (1) satisfaction with pain management, (2) satisfaction with communication including specific measures for limited English proficiency (LEP), (3) trust, and (4) comprehension of informed consent. Patient satisfaction was captured using a modified Likert scale from lowest to highest: strongly disagree, disagree, neither agree nor disagree, agree, and strongly agree. The values reported below are the percentage of participants who reported agree or strongly agree. |
Countries
United States
Participant flow
Recruitment details
Recruitment of general surgery residents and surgical patients at Johns Hopkins University, Brigham and Women's Hospital, Brown University, and Eastern Virginia Medical School, Massachusetts General Hospital, Beth Israel Deaconess Medical Center, Howard University, and Washington University in St. Louis. We randomized at the site level to two groups: Early Intervention and Delayed Intervention. We reported our aggregate results for the residents and surgical patients in each group.
Pre-assignment details
Inclusion criteria (Residents): All general surgery residents at all participating sites Exclusion criteria (Residents): All non-surgical residents at all participating sites Inclusion criteria (Patients): Admitted to a surgical service under the care of a participating resident with the capacity to give informed consent Exclusion criteria (Patients): Mentally impaired, admitted to intensive care
Participants by arm
| Arm | Count |
|---|---|
| Early Intervention Group Residency sites and its residents designated to the Early Intervention group will undergo assessment to evaluate residents' knowledge, attitudes, and skills prior to and after the PACTS curriculum administration. Follow-up testing will be conducted after one year to evaluate learner retention.
Patients in the Early Intervention Group are patients who are cared for by a resident physician enrolled into the early intervention group, and monitors their patient satisfaction as well as clinical outcomes before and after the PACTS curriculum.
PACTS curriculum: The cultural dexterity curriculum, known as PACTS (Provider Awareness Cultural Dexterity Toolkit for Surgeons) focuses on developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care.
The curriculum is comprised of four educational modules on establishing trust in the physician-patient relationship, communicating effectively with patients with limited English proficiency, discussing informed consent, and issues surrounding pain management. Each module consists of an independent learning activity, an interactive role-play, and a post-lesson assessment. | 1,438 |
| Early Intervention Group Residency sites and its residents designated to the Early Intervention group will undergo assessment to evaluate residents' knowledge, attitudes, and skills prior to and after the PACTS curriculum administration. Follow-up testing will be conducted after one year to evaluate learner retention.
Patients in the Early Intervention Group are patients who are cared for by a resident physician enrolled into the early intervention group, and monitors their patient satisfaction as well as clinical outcomes before and after the PACTS curriculum.
PACTS curriculum: The cultural dexterity curriculum, known as PACTS (Provider Awareness Cultural Dexterity Toolkit for Surgeons) focuses on developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care.
The curriculum is comprised of four educational modules on establishing trust in the physician-patient relationship, communicating effectively with patients with limited English proficiency, discussing informed consent, and issues surrounding pain management. Each module consists of an independent learning activity, an interactive role-play, and a post-lesson assessment. | 4 |
| Delayed Intervention Group Residency sites and its participating residents designated to the delayed intervention group underwent baseline testing prior to the standard residency curriculum, and then received the PACTS curriculum the following year.
Both between- and within-group differences will be examined based on curriculum exposure in intervention year 1 as well as within-group differences for the Delayed Intervention Group at the end of year 2.
Patients designated to the Delayed Intervention Group are cared for by a resident physician enrolled into the delayed intervention group, and monitors their patient satisfaction as well as clinical outcomes before and after the PACTS curriculum.
PACTS curriculum: The cultural dexterity curriculum, known as PACTS (Provider Awareness Cultural Dexterity Toolkit for Surgeons) focuses on developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care.
The curriculum is comprised of four educational modules on establishing trust in the physician-patient relationship, communicating effectively with patients with limited English proficiency, discussing informed consent, and issues surrounding pain management. Each module consists of an independent learning activity, an interactive role-play, and a post-lesson assessment. | 1,372 |
| Delayed Intervention Group Residency sites and its participating residents designated to the delayed intervention group underwent baseline testing prior to the standard residency curriculum, and then received the PACTS curriculum the following year.
Both between- and within-group differences will be examined based on curriculum exposure in intervention year 1 as well as within-group differences for the Delayed Intervention Group at the end of year 2.
Patients designated to the Delayed Intervention Group are cared for by a resident physician enrolled into the delayed intervention group, and monitors their patient satisfaction as well as clinical outcomes before and after the PACTS curriculum.
PACTS curriculum: The cultural dexterity curriculum, known as PACTS (Provider Awareness Cultural Dexterity Toolkit for Surgeons) focuses on developing cognitive skills to adapt to individual patients' needs to ensure personal, patient-centered surgical care.
The curriculum is comprised of four educational modules on establishing trust in the physician-patient relationship, communicating effectively with patients with limited English proficiency, discussing informed consent, and issues surrounding pain management. Each module consists of an independent learning activity, an interactive role-play, and a post-lesson assessment. | 4 |
| Total | 2,818 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Period 1 (0 Months) | Lost to Follow-up | 51 | 40 |
Baseline characteristics
| Characteristic | Early Intervention Group | Delayed Intervention Group | Total |
|---|---|---|---|
| Age, Continuous Patients | 55.24 years STANDARD_DEVIATION 17 | 56.07 years STANDARD_DEVIATION 17.3 | 55.64 years STANDARD_DEVIATION 17.17 |
| Age, Continuous Residents | 30.1 years STANDARD_DEVIATION 3.8 | 30.1 years STANDARD_DEVIATION 3.8 | 30.1 years STANDARD_DEVIATION 3.79 |
| Education Patients Associates & Bachelors | 350 Participants | 304 Participants | 654 Participants |
| Education Patients Master, Professional, and Doctorate | 206 Participants | 148 Participants | 354 Participants |
| Education Patients No schooling, or completed to 1 or more years | 700 Participants | 634 Participants | 1334 Participants |
| Education Patients Not disclosed | 41 Participants | 112 Participants | 153 Participants |
| Education Residents Associates & Bachelors | 0 Participants | 0 Participants | 0 Participants |
| Education Residents Master, Professional, and Doctorate | 141 Participants | 174 Participants | 315 Participants |
| Education Residents No schooling, or completed to 1 or more years | 0 Participants | 0 Participants | 0 Participants |
| Education Residents Not disclosed | 0 Participants | 0 Participants | 0 Participants |
| Ethnicity (NIH/OMB) Patients Hispanic or Latino | 146 Participants | 53 Participants | 199 Participants |
| Ethnicity (NIH/OMB) Patients Not Hispanic or Latino | 944 Participants | 1020 Participants | 1964 Participants |
| Ethnicity (NIH/OMB) Patients Unknown or Not Reported | 207 Participants | 125 Participants | 332 Participants |
| Ethnicity (NIH/OMB) Residents Hispanic or Latino | 15 Participants | 10 Participants | 25 Participants |
| Ethnicity (NIH/OMB) Residents Not Hispanic or Latino | 123 Participants | 119 Participants | 242 Participants |
| Ethnicity (NIH/OMB) Residents Unknown or Not Reported | 3 Participants | 45 Participants | 48 Participants |
| Race/Ethnicity, Customized Patients Asian | 32 Participants | 30 Participants | 62 Participants |
| Race/Ethnicity, Customized Patients Black | 269 Participants | 320 Participants | 589 Participants |
| Race/Ethnicity, Customized Patients Multiracial/other | 172 Participants | 61 Participants | 233 Participants |
| Race/Ethnicity, Customized Patients Not disclosed | 27 Participants | 8 Participants | 35 Participants |
| Race/Ethnicity, Customized Patients White | 797 Participants | 779 Participants | 1576 Participants |
| Race/Ethnicity, Customized Residents Asian | 28 Participants | 20 Participants | 48 Participants |
| Race/Ethnicity, Customized Residents Black | 23 Participants | 11 Participants | 34 Participants |
| Race/Ethnicity, Customized Residents Multiracial/other | 17 Participants | 14 Participants | 31 Participants |
| Race/Ethnicity, Customized Residents Not disclosed | 0 Participants | 39 Participants | 39 Participants |
| Race/Ethnicity, Customized Residents White | 73 Participants | 90 Participants | 163 Participants |
| Sex/Gender, Customized Patient Sex/Gender Female | 601 Participants | 588 Participants | 1189 Participants |
| Sex/Gender, Customized Patient Sex/Gender Male | 670 Participants | 605 Participants | 1275 Participants |
| Sex/Gender, Customized Patient Sex/Gender Non-Binary, Self-Describe, Not disclosed | 26 Participants | 5 Participants | 31 Participants |
| Sex/Gender, Customized Resident Sex/Gender Female | 69 Participants | 66 Participants | 135 Participants |
| Sex/Gender, Customized Resident Sex/Gender Male | 72 Participants | 86 Participants | 158 Participants |
| Sex/Gender, Customized Resident Sex/Gender Non-Binary, Self-Describe, Not disclosed | 0 Participants | 22 Participants | 22 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk |
|---|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 192 | 0 / 214 | 0 / 1,297 | 0 / 1,198 |
| other Total, other adverse events | 0 / 192 | 0 / 214 | 0 / 1,297 | 0 / 1,198 |
| serious Total, serious adverse events | 0 / 192 | 0 / 214 | 0 / 1,297 | 0 / 1,198 |
Outcome results
Primary
Change in Residents' Cross Cultural Care Survey Scores From Pre- to Post-PACTS Curriculum
The effect of PACTS curriculum on surgical residents' cross cultural care survey about caring for culturally diverse patients at time Period 2 (18 months). At this time period, the Early Intervention group received the PACTS curriculum, while the Delayed Intervention Group had not received the PACTS curriculum, serving as the control group. The cross cultural care survey was evaluated using a modified Likert type scale (with scale ranging from lowest to highest: very unprepared, somewhat unprepared, somewhat prepared, very well prepared). Resident scores were dichotomized into two groups, those reporting very unprepared and somewhat unprepared, and those reporting somewhat prepared and very well prepared. Here reported values are representative of the percentage of participants who reported somewhat prepared and very well prepared at time Period 2.
Time frame: Period 2 (18 months)
Population: Percentage of residents who reported somewhat prepared and very well prepared for the cross cultural survey in both the Early Intervention and Delayed Intervention groups at time period 2. Of the residents who completed the trial (141 for Early Intervention Group; 174 for Delayed Intervention Group), only 52 residents in the Early Intervention and 55 residents in the Delayed Intervention Group completed the Cross Cultural Care Survey at Period 2.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Early Intervention Group | Change in Residents' Cross Cultural Care Survey Scores From Pre- to Post-PACTS Curriculum | 88.2 percentage of participants |
| Delayed Intervention Group | Change in Residents' Cross Cultural Care Survey Scores From Pre- to Post-PACTS Curriculum | 88.2 percentage of participants |
Comparison: We conducted a superiority statistical test to assess if residents' preparation for caring for culturally diverse patients improved after exposure to the PACTS curriculum. For purposes of measuring an effect of the PACTS curriculum on resident preparedness assessed by the Cross-Cultural Care Survey, resident preparedness was compared at time Period 2 between the Early Intervention (intervention) and Delayed Intervention (control) groups.p-value: 1Chi-squared
Primary
Change in Residents' Questionnaire Scores Measuring Knowledge From Pre- to Post-PACTS Curriculum
The effect of PACTS curriculum on surgical residents' questionnaire scores measuring knowledge about caring for culturally diverse patients at time Period 2 (18 months). At this time, the Early Intervention Group had already received the PACTS curriculum. The Delayed Intervention Group had not received the PACTS curriculum, serving as the control group at this time period. Resident knowledge: Percent score out of 100, with range 0-100%. Higher values represent a better outcome, with 100% as the highest score possible. This is the average score for the Early Intervention and Delayed Intervention groups at Period 2.
Time frame: Period 2 (18 months)
Population: Mean resident knowledge scores (from 0-100%) for surgical residents in both the Early Intervention and Delayed Intervention groups at Period 2 (18 months). Of the residents who completed the trial (141 for Early Intervention Group; 174 for Delayed Intervention Group), only 52 residents in the Early Intervention and 55 residents in the Delayed Intervention Group participated in the resident assessment at Period 2.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Early Intervention Group | Change in Residents' Questionnaire Scores Measuring Knowledge From Pre- to Post-PACTS Curriculum | 74.3 score on a scale | Standard Deviation 8.96 |
| Delayed Intervention Group | Change in Residents' Questionnaire Scores Measuring Knowledge From Pre- to Post-PACTS Curriculum | 71.7 score on a scale | Standard Deviation 13.39 |
p-value: 0.2422t-test, 2 sided
Primary
Change in Residents' Questionnaire Scores Regarding Self-Assessed Skills From Pre- to Post-PACTS Curriculum
The effect of PACTS curriculum on surgical residents' self-assessed skills for caring for culturally diverse patients at time Period 2 (18 months). Self-assessed skills ranged from levels 1 to levels 4, with level 1 indicated less skilled, and level 4 indicating skillful. For purposes of comparison, resident scores were dichotomized into two groups: less skilled (referring to skill levels 1 and 2), and skillful (levels 3 and 4). Here reported values are representative of the percentage of participants who reported skill levels 3 or 4, indicating skillful. Results here demonstrate the proportion of residents in the Early Intervention (Intervention) group and Delayed Intervention (control group) who self-evaluated their skills as skillful at Period 2.
Time frame: Period 2 (18 months)
Population: Of the residents who completed the trial (141 for Early Intervention Group; 174 for Delayed Intervention Group), only 52 residents in the Early Intervention and 55 residents in the Delayed Intervention Group participated in the questionnaire regarding self-assessed skills.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Early Intervention Group | Change in Residents' Questionnaire Scores Regarding Self-Assessed Skills From Pre- to Post-PACTS Curriculum | 85.0 percentage of skillful participants |
| Delayed Intervention Group | Change in Residents' Questionnaire Scores Regarding Self-Assessed Skills From Pre- to Post-PACTS Curriculum | 84.1 percentage of skillful participants |
Comparison: We conducted a superiority statistical test to assess if residents' self-assessed skills improved after exposure to the PACTS curriculum. For purposes of measuring an effect of the PACTS curriculum on resident skills, resident skills were compared at time Period 2 between the Early Intervention (intervention) and Delayed Intervention (control) groups.p-value: 0.6295Chi-squared
Primary
Change in Residents' Questionnaire Scores Regarding Their Beliefs From Pre- to Post-PACTS Curriculum
The effect of PACTS curriculum on surgical residents' beliefs regarding caring for culturally diverse patients at time Period 2 (18 months). At this time, the Early Intervention Group had already received the PACTS curriculum. The Delayed Intervention Group had not received the PACTS curriculum, serving as the control group at this time period. The questionnaire was scored using a modified Likert type scale with a range from lowest to highest: strongly disagree, moderately disagree, mildly disagree, strongly agree, moderately agree, mildly agree. Answers were dichotomized into two groups: strongly disagree, moderately disagree, and mildly disagree; and strongly agree, moderately agree, and mildly agree. Here reported values are representative of the proportion of participants who answered strongly agree, moderately agree, and mildly agree.
Time frame: Period 2 (18 months)
Population: Of the residents who completed the trial (141 for Early Intervention Group; 174 for Delayed Intervention Group), only 52 residents in the Early Intervention and 55 residents in the Delayed Intervention Group completed the questionnaire on beliefs at time Period 2.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Early Intervention Group | Change in Residents' Questionnaire Scores Regarding Their Beliefs From Pre- to Post-PACTS Curriculum | 92.4 percentage of participants |
| Delayed Intervention Group | Change in Residents' Questionnaire Scores Regarding Their Beliefs From Pre- to Post-PACTS Curriculum | 89.9 percentage of participants |
Comparison: We conducted a superiority statistical test to assess if residents' beliefs improved after exposure to the PACTS curriculum. For purposes of measuring an effect of the PACTS curriculum on resident beliefs, beliefs were compared at time Period 2 between the Early Intervention (intervention) and Delayed Intervention (control) groups.p-value: 0.0199Fisher Exact
Primary
Objective Structured Clinical Examination Scores
Standardized Patient observers evaluated surgical residents on multiple dimensions of cultural dexterity and communication skills using Likert-type scales. The scale range, from lowest to highest was: Not at all; a little bit; somewhat; mostly; a great deal. Scores were put into two groups: 1) not at all, a little bit, and somewhat; 2) mostly and a great deal. The percentage of residents who received scores of mostly and a great deal in categories of trust, limited english proficiency, consent, and pain were reported.
Time frame: Period 2 (18 months)
Population: Of the residents who completed the trial (141 for Early Intervention Group; 174 for Delayed Intervention Group), only 59 residents in the Early Intervention and 111 residents in the Delayed Intervention Group completed the the OSCE at Period 2. Only 105 residents performed the OSCE on Limited English Proficiency in the Delayed Group
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Early Intervention Group | Objective Structured Clinical Examination Scores | Limited English Proficiency/Informed Consent Period 2 | 60.9 difference in the percentage |
| Early Intervention Group | Objective Structured Clinical Examination Scores | Trust/Pain Period 2 | 58.6 difference in the percentage |
| Delayed Intervention Group | Objective Structured Clinical Examination Scores | Limited English Proficiency/Informed Consent Period 2 | 63.1 difference in the percentage |
| Delayed Intervention Group | Objective Structured Clinical Examination Scores | Trust/Pain Period 2 | 64.8 difference in the percentage |
Comparison: We conducted a superiority statistical test to assess if residents' OSCE performance improved after exposure to the PACTS curriculum. OSCE performance was compared at time Period 2 between the Early Intervention (intervention) and Delayed Intervention (control) groups. We compared the difference in the percentage of residents designated mostly and a great deal on Limited English Proficiency and Informed Consent OSCE.p-value: 0.2665Chi-squared
Comparison: We conducted a superiority statistical test to assess if residents' OSCE performance improved after exposure to the PACTS curriculum. OSCE performance was compared at time Period 2 between the Early Intervention (intervention) and Delayed Intervention (control) groups. We compared the difference in the percentage of residents designated mostly and a great deal on Trust and Pain.p-value: 0.0001Chi-squared
Secondary
Median Hospital Length of Stay for Patient Participants
National Surgical Quality Improvement Program (NSQIP) metrics for each patient participant capturing hospital length of stay in days. Patients designated to Early Intervention Group were cared for by a resident enrolled in the Early Intervention group, where the PACTS curriculum was administered between period 1 (0 months) and period 2 (18 months). Patients designated to the Delayed Intervention group were cared for by a resident enrolled in the Delayed Intervention group, where the standard curriculum was administered between period 1 (0 months) and period 2 (18 months). We are comparing median length of stay at period 2.
Time frame: Period 2 (18 months)
Population: Comparison of length of stay for patients admitted to the hospital and cared for by residents in the early versus delayed intervention groups. The analysis population differs from the overall number of patients because not all patients had a recorded length of stay. Of those that we had length of stay data for, there were 255 participants in the Early Intervention group at Period 2, and 386 participants in the Delayed Intervention group at Period 2.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Early Intervention Group | Median Hospital Length of Stay for Patient Participants | 8.85 Days |
| Delayed Intervention Group | Median Hospital Length of Stay for Patient Participants | 14.16 Days |
Comparison: We conducted a superiority statistical test to assess if patients length of stay improved after resident exposure to the PACTS curriculum. Patient length of stay was compared at time Period 2 between the Early Intervention (intervention) and Delayed Intervention (control) groups to measure an effect of the PACTS intervention.p-value: 0.0028Wilcoxon (Mann-Whitney)
Secondary
Patients' Self-reported Satisfaction Scores
We used an adapted version of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) to assess patients' (1) satisfaction with pain management, (2) satisfaction with communication including specific measures for limited English proficiency (LEP), (3) trust, and (4) comprehension of informed consent. Patient satisfaction was captured using a modified Likert scale from lowest to highest: strongly disagree, disagree, neither agree nor disagree, agree, and strongly agree. The values reported below are the percentage of participants who reported agree or strongly agree.
Time frame: Period 2 (18 months)
Population: Patient reported satisfaction surveys at Periods 2 (18 months). Of the 1297 patients in the Early Intervention Group, and 1198 patients in the Delayed Intervention Group, only 436 patients and 392 patients, respectively, completed the survey at Period 2.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Early Intervention Group | Patients' Self-reported Satisfaction Scores | Consent Period 2 | 77.94 percentage of participants |
| Early Intervention Group | Patients' Self-reported Satisfaction Scores | Trust Period 2 | 72.06 percentage of participants |
| Early Intervention Group | Patients' Self-reported Satisfaction Scores | Pain Period 2 | 81.0 percentage of participants |
| Early Intervention Group | Patients' Self-reported Satisfaction Scores | Limited English Proficiency Period 2 | 53.48 percentage of participants |
| Delayed Intervention Group | Patients' Self-reported Satisfaction Scores | Pain Period 2 | 81.19 percentage of participants |
| Delayed Intervention Group | Patients' Self-reported Satisfaction Scores | Limited English Proficiency Period 2 | 51.56 percentage of participants |
| Delayed Intervention Group | Patients' Self-reported Satisfaction Scores | Consent Period 2 | 82.7 percentage of participants |
| Delayed Intervention Group | Patients' Self-reported Satisfaction Scores | Trust Period 2 | 75.25 percentage of participants |
Comparison: We conducted a superiority statistical test to assess if patient satisfaction improved after resident exposure to the PACTS curriculum. For purposes of measuring an effect of the PACTS curriculum, patient satisfaction was compared at time Period 2 between the Early Intervention (intervention) and Delayed Intervention (control) groups. We compared the difference in proportion of patients who reported agree and strongly agree for satisfaction as it relates to trust at time period 2.p-value: 0.5079Chi-squared
Comparison: We conducted a superiority statistical test to assess if patient satisfaction improved after resident exposure to the PACTS curriculum. For purposes of measuring an effect of the curriculum, patient satisfaction was compared at Period 2 between the Early Intervention (intervention) and Delayed Intervention (control) groups. We compared the difference in proportion of patients who reported agree and strongly agree for satisfaction as it relates to limited English proficiency at period 2.p-value: 0.1571Chi-squared
Comparison: We conducted a superiority statistical test to assess if patient satisfaction improved after resident exposure to the PACTS curriculum. For purposes of measuring an effect of the PACTS curriculum, patient satisfaction was compared at time Period 2 between the Early Intervention (intervention) and Delayed Intervention (control) groups. We compared the difference in proportion of patients who reported agree and strongly agree for satisfaction as it relates to consent at time period 2.p-value: 0.0001Chi-squared
Comparison: We conducted a superiority statistical test to assess if patient satisfaction improved after resident exposure to the PACTS curriculum. For purposes of measuring an effect of the PACTS curriculum, patient satisfaction was compared at time Period 2 between the Early Intervention (intervention) and Delayed Intervention (control) groups. We compared the difference in proportion of patients who reported agree and strongly agree for satisfaction as it relates to pain at time period 2.p-value: 0.2956Chi-squared