Gives Unconditional Attention and Regard for Patients/family/community Needs.
J Natl Med Assoc. Author manuscript; available in PMC 2010 Feb 18.
Published in last edited class as:
PMCID: PMC2824588
NIHMSID: NIHMS174354
Patient Centeredness, Cultural Competence and Healthcare Quality
Abstract
Cultural competence and patient centeredness are approaches to improving healthcare quality that accept been promoted extensively in recent years. In this newspaper, we explore the historical development of both cultural competence and patient centeredness. In doing and then, nosotros demonstrate that early conceptual models of cultural competence and patient centeredness focused on how healthcare providers and patients might interact at the interpersonal level and that later conceptual models were expanded to consider how patients might be treated by the healthcare arrangement as a whole. We then compare conceptual models for both cultural competence and patient centeredness at both the interpersonal and healthcare organization levels to demonstrate similarities and differences. Nosotros conclude that, although the concepts have had different histories and foci, many of the core features of cultural competence and patient centeredness are the same. Each approach holds promise for improving the quality of healthcare for individual patients, communities and populations.
Keywords: cultural competence, patient–doc relationship, quality of intendance
INTRODUCTION
Cultural competence and patient centeredness are approaches to enhancing healthcare delivery that accept been promoted extensively in recent years. As they have gained recognition and popularity, yet, considerable ambivalence has evolved in their definition and use across settings. Proponents of patient centeredness speak of cultural competence equally merely one attribute of patient-centered care, while proponents of cultural competence often assert the antipodal. The purpose of this paper is to nowadays and compare the ideals of patient centeredness and cultural competence, to define their similarities and differences, and to discuss their implications for improving healthcare quality at the interpersonal and wellness system levels.
THE Evolution OF PATIENT CENTEREDNESS
Early on Conceptions of Patient Centeredness
Originally coined by Balint in 1969 to express the belief that each patient "has to exist understood as a unique human-existence,"1 patient-centered medicine began as a descriptive account of how physicians should interact and communicate with patients. In 1984, Lipkin and colleagues described the patient-centered interview equally one which "approaches the patient equally a unique man being with his ain story to tell, promotes trust and confidence, clarifies and characterizes the patient's symptoms and concerns, generates and tests many hypotheses that may include biological and psychosocial dimensions of illness, and creates the basis for an ongoing relationship."2 Co-ordinate to Lipkin, practitioners who are patient centered have specific knowledge (e.thou., ascertain countertransference, place different types of interview questions), attitudes (east.one thousand., unconditional positive patient regard, willingness to join with patients as partners) and skills (east.chiliad. arm-twist patient'southward "story" of illness, overcome barriers to communication).two
Levenstein and colleagues subsequently described the patient-centered clinical method as 1 in which the doctor aims to gain an agreement of the patient too as the illness—as opposed to an approach focusing strictly on the disease—through a process of addressing both the patient's and the dr.'s agendas—as opposed to addressing but the physician's agenda.iii Later, Stewart outlined half-dozen dimensions of patient-centered care: ane) exploring the affliction feel, two) understanding the whole person, iii) finding common ground regarding management, 4) incorporating prevention and wellness promotion, 5) enhancing the dr.–patient relationship, and 6) being realistic about personal limitations.4
More than recently, Mead and Bower proposed a similar conceptual framework with five dimensions: one) adopting the biopsychosocial (equally opposed to narrowly biomedical) perspective; 2) understanding the patient equally a person in his or her own right, not simply as a body with an illness; 3) sharing power and responsibility between the doctor and the patient; iv) building a therapeutic brotherhood; and 5) understanding the doctor every bit a person, not merely as a skilled technician.5 Noticeably absent from this framework is any mention of illness prevention or health promotion. Mead and Bower focused their framework of patient centeredness as a fashion of interaction and advice with patients, while Stewart construed patient centeredness as a more than comprehensive arroyo to patient care.
Summarizing patient centeredness most succinctly, McWhinney described the patient-centered arroyo as 1 where the "dr. tries to enter the patient's world, to see the illness through the patient's eyes."half-dozen This notion of "seeing through the patient's eyes" has become maybe the near curtailed description of patient centeredness, and has led to several outgrowths of the early patient-centered movement. It may have been, by sincerely looking through the patient'southward optics, that it became clear there is a slap-up deal more than to set up in the healthcare organization than the interaction way of its practitioners.
Expansion of the Scope of Patient Centeredness
The Picker-Commonwealth Program for Patient-Centered Care was begun in 1987 to promote a patient-centered approach to infirmary and health services focusing on the patient's needs and concerns. Seven dimensions of patient-centered care were identified: 1) respect for patients' values, preferences and expressed needs; ii) coordination and integration of care; three) information, communication and education; iv) physical comfort; v) emotional back up and consolation of fright and anxiety; 6) interest of friends and family; and 7) transition and continuity.7 The Picker-Commonwealth Program clearly went beyond the more narrow interpretation of patient centeredness every bit a guide for individual practitioners interacting with individual patients, and moved towards the consideration of patient centeredness equally a comprehensive mode of delivering wellness services. Figure 1 details the fundamental features of patient centeredness inside organizations and interpersonal interactions between patients and providers.
Key features of patient centeredness
The shift in focus of patient centeredness is subsequently reflected in the National Library of Medicine's MED-LINE bailiwick heading (MeSH) definition of patient-centered intendance, introduced in 1995, which states, "Blueprint of patient care wherein institutional resources and personnel are organized around patients rather than around specialized departments." About notably, the Found of Medicine (IOM) endorsed patient-centered care as one of six aims for wellness arrangement comeback in the groundbreaking 2001 report, "Crossing the Quality Chasm." The IOM divers patient-centered care every bit "intendance that is respectful and responsive to private patient preferences, needs and values, and ensuring that patient values guide all clinical decisions."8 Further descriptions of patient-centered intendance in the IOM report depict on the earlier Picker-Commonwealth dimensions described past Gerteis and colleagues, and include the dimensions of coordination and integration, the provision of information and education to patients, attention to concrete comfort, emotional support, and involvement of family and friends.vii
Information technology is worth noting, both from a semantic and substantive point of view, that there are a variety of terms used to draw patient centeredness. The term "patient-centered interview" describes the original model of interaction and communication between patients and providers. Patient-centered communication is frequently used to describe patient–practitioner interactions as well, but could include other modes of advice. For case, patients may experience patient-centered communication when attempting to interface with the health system; patients may take the ability to e-mail their practitioners if they prefer, to have the phone answered by a pleasant and responsive receptionist when they telephone call their practitioner's office and receive timely returned phone calls. Similarly, written advice, such as signage and patient education materials, may be patient centered to the extent that they run into patients' needs, are written in a style that patients can understand, and raise patients' agreement and power to participate in medical care.
Patient-centered care is not limited to communication and frequently focuses on other aspects of care such as convenience of function hours, ability to get appointments when needed, being seen on time for appointments and having services near one's place of residence. The term "patient-centered access" distinctly does not include the interpersonal aspects of care and is more clearly focused on the delivery of wellness services such that patients can secure services when and where they are needed.9 Patient-centered outcomes refer to the measurement or consideration of outcomes that patients might care about, but which accept traditionally been ignored by the medical establishment, such as patient satisfaction, quality of life and functional status.ten The terms "patient-centered approach" and "patient centeredness" are the most broad and vague, since at that place is no particular content specified.
Finally, because of the number of ways patient centeredness has been construed, it is also worth noting that there is >1 model of care that can be regarded equally antithetical to patient centeredness. Some take contrasted patient-centered medicine with care that is focused on affliction rather than on people, or so-chosen illness-oriented medicine.1 This has led to a greater focus on the biopyschosocial model, wellness promotion, attention to concrete comfort and coordinated transition between care settings. Others have argued that patient centeredness is at ane end of a continuum, with "doc-centeredness" at the opposite end.11 This has led to a greater focus on the provision of same-24-hour interval appointments and patient–provider email correspondence. Still others have identified medical paternalism as the opposite of patient centeredness, considering it may fail to acknowledge the preferences, needs and values of individual patients.12 This has led to a greater focus on the provision of data and education to patients. In short, information technology is fair to say that any of these culling conceptions of patient-provider interactive styles are not patient centered and that patient centeredness could be envisioned as a strategy to correct for all of these tendencies in medicine simultaneously.
THE Development OF CULTURAL COMPETENCE
The ascension of cultural competence in healthcare has been somewhat less prominent but more than precipitous than that of patient centeredness. The term "cultural competence" did not begin to appear consistently in the healthcare literature until the early 1990s. Past May 2007, >1,000 articles mentioning the terms "cultural competence" or "cultural competency" in their titles or abstracts had been published in medical and nursing journals, more than than three-quarters of them since 2000. Within the final 10 years, myriad programs addressing cultural competence in healthcare have been adult,13 national standards for health systems take been published,fourteen a recurring national conference devoted to the issue has been established (www.diversityrx.org/CCCONF/) and federal mandates to increment cultural competence take been issued.15 The chief impetus for the cultural competence movement of the terminal decade has been the demonstration of and publicity surrounding widespread racial and ethnic disparities in healthcare.sixteen , 17 But the principles of cultural competence are rooted in efforts that precede the high visibility the outcome has received in recent years.
Early Conceptions of Cultural Competence
For decades, healthcare leaders and educators have recognized that cultural and linguistic barriers between healthcare providers and patients might interfere with the effective delivery of health services. Advocacy for greater attending to these barriers gave rising to programs and curricula begetting the monikers cross-cultural medicine, cultural sensitivity, transcultural nursing and multicultural counseling. Programs largely focused on populations "whose health beliefs may be at variance with biomedical models."18 Although the principles underlying these programs were best-selling to exist universally applicable, the targeted groups included primarily immigrant populations with limited English proficiency and limited exposure to western cultural norms. Programs sought to bridge the "cultural distance" that existed between healthcare providers and these immigrant patients, focusing on the advisable use of interpreters and "cultural brokers" and on learning the history and cultural norms of different minority populations.
A number of frameworks and guidelines were proposed to help healthcare practitioners consider patients' cultural context and comport cultural assessments.eighteen – 21 These models acknowledged that, while awareness of and respect for dissimilar cultural traditions were valued, familiarity with all cultural perspectives a healthcare provider might encounter in clinical do was impractical. Additionally, viewing patients every bit members of indigenous or cultural groups, rather than as individuals with unique experiences and perspectives, might lead providers to stereotype patients and brand inappropriate assumptions about their beliefs and behaviors. To business relationship for these concerns, approaches to cross-cultural healthcare incorporated a balance, betwixt acquiring some background knowledge of the specific cultural groups encountered in clinical practice, and developing attitudes and skills that were not specific to any particular civilisation but were universally relevant. As outlined in the late 1970s and early 1980s by pioneers in cross-cultural medicine—including Berlin and Fowkes, Kleinman and colleagues, and Leininger— these "generic" attitudes and skills included: 1) respecting the legitimacy of patients' health beliefs and recognizing their office in effective healthcare delivery; 2) shifting from a paradigm of viewing patients' complaints as stemming from a disease occurring inside their organ systems to that of an illness occurring within a biopsy-chosocial context; 3) eliciting patients' explanations of the illness and its perceived causes (patient's explanatory model of illness); 4) explaining the clinician's understanding of the illness and its perceived causes (clinician's explanatory model of illness) in language attainable to patients; and 5) negotiating an understanding within which a safe, effective and mutually amusing treatment programme could be implemented.18 , 19 , 22 Substantially, this individualized approach entailed clinicians' seeing the illness experience through patients' eyes, helping patients to see the procedure through the clinicians' eyes and reaching common basis.
Inherent in early formulations of cross-cultural healthcare was the importance of recognizing that both patients and providers brought cultural perspectives to the encounter. Equally such, healthcare providers were encouraged to admit and explore their ain cultural influences, including those caused through their training in western biomedicine and entry into the health professions. This included reflecting on the privilege and power associated with their status equally professionals. This process of critically questioning and deconstructing the "medicocentric" perspective was considered central to the ability to evangelize effective care across cultural boundaries.22
It should be readily apparent that many of the principles of cross-cultural care were the same every bit those for patient-centered intendance. These included respect for patients equally individuals; date of patients as partners; effective communication of illness models and treatment goals; and holistic consideration of the sociocultural context and consequences of patients' disease experience. Just equally patient centeredness was construed as i cease of a continuum (with physician centeredness on the other end), cultural competence was also characterized in terms of continua ranging from ethnocentric to ethnosensitive23 or from cultural destructiveness to cultural proficiency.24
Expansion of the Telescopic of Cultural Competence
From its roots in early models of cross-cultural healthcare, cultural competence expanded in the late 1980s through the 1990s in 3 means. First, the populations to whom cross-cultural care was applied expanded from primarily immigrants to essentially all minority groups, especially those nigh affected by racial disparities in the quality of healthcare. Second, the conceptual purview of cultural competence expanded across civilisation per se and encompassed problems such as prejudice, stereotyping and social determinants of health. Finally, as occurred with patient centeredness, the scope of cultural competence expanded beyond the interpersonal domain of cross-cultural care to include health systems and communities.
This expansion in scope was driven largely by accumulating research demonstrating that racial and ethnic minority groups received lower quality healthcare than the majority population, fifty-fifty afterward accounting for differences in access to intendance.16 , 17 Studies further suggested that social and cultural barriers between healthcare providers and nonimmigrant people of colour might exist affecting the quality of care.25 – 27 The expansion of the population base for whom cultural barriers were now felt to be a potentially important outcome, and the urgency to address documented racial inequities, gave rise to an explosion of new interest and activity in cross-cultural healthcare, which adopted from other disciplines the more modern label of cultural competence.
Proponents of cultural competence acknowledged that the principles and approaches of cantankerous-cultural healthcare were in and of themselves necessary simply not sufficient to address racial disparities in healthcare quality. The observed inequities were non yet fully explicated, but few disagreed with the notion that while cultural barriers might be contributing, other factors also needed to be considered. For case, some minority patients might distrust healthcare providers or institutions, maybe related to historical or ongoing experiences of discrimination. Providers might harbor either overt or unconscious biases about people of color that influence their interactions and decision-making. Champions of the cultural competence motion took these problems on, incorporating into their grooming programs a broad-ranging set up of issues: the concepts of race and class and their touch on on health and healthcare experiences; the relevance of trust in patient–provider relationships and the historical contributors to potential distrust among certain minority populations; the importance of social factors, including support systems and literacy; and reflection on one's own racial attitudes and stereotypes. While some of these issues might be seen as overlapping with a liberally interpreted definition of civilisation, near would not consider them to correspond "cultural" barriers per se. In fact, some consider addressing these issues under the rubric of "cultural" competence to be dangerously dismissive of the interpersonal and institutional racism that they more than accurately reverberate.28 Notwithstanding, all of these efforts were mostly folded into cultural competence programs. Cultural competence, therefore, grew from the relatively focused set of principles that defined cross-cultural healthcare, into a concept encompassing a wide assortment of topics relevant to racial and indigenous disparities in healthcare quality.
Several dissimilar models have been proposed to describe cultural competence in wellness intendance. Nearly all of them include dimensions of cognition (east.1000., understanding the meaning of civilization and its importance to healthcare commitment), attitudes (eastward.g., having respect for variations in cultural norms) and skills (e.g., eliciting patients' explanatory models of illness). Many aspects of the cultural competence conception are also central aspects of patient centeredness; some have consequently argued that the essence of cultural competence is a "patient-centered approach."29
Pioneers of the cultural competence movement recognized that disparities in healthcare quality may result from cultural and other barriers not only between patients and healthcare providers but also between communities and health systems. Nearly of the American healthcare infrastructure was adult in the pre-Civil Rights era and is therefore at risk of propagating "institutionalized" discrimination against people of color. Even modern wellness systems were largely designed with the bulk population in mind. These realities, coupled with the increasing racial and ethnic multifariousness in the United States, have fabricated irresolute health systems to accommodate the preferences and values of various populations an essential part of the cultural competence agenda. One of the earliest proposals for more culturally competent systems of care was outlined in a monograph by Cross and colleagues.24 They defined cultural competence as "a prepare of congruent behaviors, attitudes and policies that come together in a organisation, agency or amongst professionals and enables that organization, agency or those professionals to work effectively in cross-cultural situations." They described the culturally competent organisation as: 1) valuing diverseness, 2) having the capacity for cultural self-assessment, 3) being conscious of the dynamics inherent when cultures collaborate, 4) having institutionalized cultural knowledge, and v) having developed adaptations to diversity.24
Methods of operationalizing these principles of "system- level" cultural competence have included efforts such as the National Standards on Culturally and Linguistically Appropriate Services in Health Intendance (CLAS Standards), which include recommendations such as having healthcare practitioners, leaders and staff that are ethnically similar to the community served; collecting and tracking data on quality of care, stratified by race; and engaging communities in the design and delivery of healthcare facilities and services.14 Many take based arguments for these changes non only on the moral imperative to reduce healthcare disparities but on the "business instance" for catering to an ever-expanding segment of the healthcare market.30 Primal features of cultural competence within healthcare organizations and patient-provider interactions are detailed in Effigy 2.
Key features of cultural competence
In summary, the cultural competence movement grew out of early on efforts to bridge the divide between the largely biomedical, white, middle-class American cultural perspectives of clinicians, and the perspectives of patients, mainly immigrants, whose experiences and language put them at a substantial cultural distance from American healthcare. Cultural competence evolved from these efforts into an extensive arroyo to address interpersonal and institutional sources of racial and ethnic disparities in healthcare. Though the concept of cultural competence has changed over time and con tinues to evolve, it has ever independent at its core the principles of patient-centered healthcare delivery.
PATIENT CENTEREDNESS AND CULTURAL COMPETENCE: OVERLAPPING AND DISTINCT CONTRIBUTIONS TO HEALTHCARE QUALITY
Apparent from the development of patient centeredness and cultural competence is the fact that both began every bit guides for interpersonal interaction and afterward expanded to consider health systems. Because frameworks for understanding quality in interpersonal interactions are substantively unlike from frameworks for quality in health systems, nosotros consider each separately while comparing patient centeredness and cultural competence at both levels.
Interpersonal Interactions in Healthcare
The power or preparedness of healthcare providers to engage in effective interactions with patients depends in large office on the providers' knowledge, attitudes, skills and behaviors (Figure three). While the features of patient centeredness and cultural competence in Figure 3 are not intended to be a comprehensive business relationship of all important facets, they are representative of the corresponding traditions.
Overlap between patient-centered care and cultural competence at the interpersonal level
At the core of both patient centeredness and cultural competence is the ability of the healthcare provider to run into the patient as a unique person; to maintain unconditional positive regard; to build effective rapport; to use the bio-psychosocial model; to explore patient beliefs, values and meaning of affliction; and to find common ground regarding handling plans. The patient-centered model additionally includes a detailed set of noesis and skills that healthcare providers should possess in society to accomplish these tasks, such as agreement the stages and functions of a medical interview and attending to patients' physical comfort. While such detail is generally not explicit in accounts of cultural competence, most of these additional characteristics of patient-centered care might be endorsed every bit traits of a culturally competent provider.
Patient centeredness has non been straight responsive to racial and indigenous disparities in healthcare, but it has the theoretical potential to reduce such disparities considering it addresses some of the hypothesized mechanisms by which patient race/ethnicity impacts healthcare providers.31 For case, provider controlling appears in some cases to exist biased by patient race.31 , 32 Since patient-centered intendance aims to equalize power between patients and providers, information technology is possible that disparities in clinical decisions would be reduced by increasing patient involvement. Providers also brandish differential interpersonal behavior, characterized by more affective altitude (less warmth, empathy, respect), when interacting with people of color.31 , 33 Here as well, patient centeredness emphasizes fostering these positive qualities within all patient–practitioner encounters.
In addition to the core features that cultural competence shares with patient centeredness, it has been suggested that the culturally competent healthcare provider exhibits other, distinct qualities, such equally understanding the meaning and importance of culture, and effectively using interpreter services when needed (Figure three). Only as proponents of cultural competence might cover most aspects of patient centeredness, it is likely that proponents of patient centeredness would also embrace these additional features of cultural competence. Because cultural context and effective communication are relevant to the care of patients in full general, not only people of color, cultural competence has the capacity to enhance patient centeredness and better quality for all patients.
Healthcare Quality at the Organisation Level
Elements of patient-centered and culturally competent health systems include structures and processes intended to improve patient-centered outcomes and promote equity (Figure 4).34 , 35 Once more, these features are non intended every bit an exhaustive itemize simply rather as representative facets of the corresponding traditions.
Overlap between patient-centered intendance and cultural competence at the health system level
The features of patient-centered and culturally competent approaches to quality in health systems practice not overlap as substantially every bit at the interpersonal level. The overlapping features include the general endorsement that services should exist aligned to meet patient needs and preferences; that healthcare should exist bachelor in communities and user-friendly to patients' homes; that educational materials should exist tailored to patients' needs, health literacy and preferred language; and that information on performance should be publicly available (though the sort of information varies slightly in that patient centeredness calls for general data to be recorded and available and cultural competence standards call for race/ethnicity-specific data to be recorded and available).
Patient-centered health systems offer additional features, such as the ability to get same-day appointments and maintaining continuity and secure transitions across healthcare settings. There are likewise features of culturally competent health systems that are not explicitly mentioned in accounts of patient centeredness, such as an accent on a various workforce that reflects the patient population, and partnering with communities in setting priorities and planning. In examining the singled-out aspects of cultural competence at the system level, it is articulate that these features hold promise for enhancing patient centeredness. For instance, the utilize of community health workers might help healthcare systems achieve out and bring care to the patient, rather than always relying on the patient to come to the system for intendance. Also, the distinct aspects of patient centeredness have the potential to improve care for people of color and to reduce disparities in care. Enhancing provider availability might improve care most dramatically for minority groups who tend to exist disadvantaged in terms of access to intendance. Some patient centeredness initiatives, however, if not crafted carefully, might actually increment disparities. For instance, promoting provider availability through due east-mail contact or spider web portals might unduly benefit patients with piece of cake admission to and familiarity with computers, and thereby exacerbate disparities for low-income and minority patients on the less fortunate side of the "digital divide." This highlights the wisdom of integrating patient centeredness and cultural competence when considering initiatives to promote quality of care.
Decision
Patient centeredness and cultural competence are movements in healthcare that have garnered a cracking deal of attention and momentum in the concluding decade. Both aim to improve healthcare quality, only the accent of each is on dissimilar aspects of quality (Effigy 5). The chief aim of patient centeredness has been to individualize quality, to complement the healthcare quality movement's focus on process measures and performance benchmarks with a return to accent on personal relationships and "customer service." As such, patient centeredness aims to elevate quality for all patients. The primary aim of the cultural competence movement has been to balance quality, to improve disinterestedness and reduce disparities by specifically improving treat people of color and other disadvantaged populations. Because of these different emphases, patient centeredness and cultural competence accept targeted different aspects of healthcare commitment. Despite these dissimilar focuses, however, at that place is substantial overlap in how patient centeredness and cultural competence are operationalized, and consequently in what they have the potential to achieve. Individualizing intendance must accept into account the multifariousness of patient values and perspectives; to the extent that patient-centered care is delivered universally, care should become more equitable. Conversely, attending to the specific needs of people of color and other disadvantaged populations must have into account the broad range of worldviews inside a given group, and the multifaceted nature of "culture;" to the extent that cultural competence enhances the power of health systems and providers to address individual patients' preferences and goals, care should become more than patient centered.
Patient centeredness, cultural competence and healthcare quality
Considering the cultural competence and patient-centered care movements both aim to improve healthcare quality in similar ways, one might reasonably inquire whether it is better to keep the movements split or to combine efforts into a single agenda. While many features are similar, of import aspects of each remain that have not been formally adopted by the other. Since these nonoverlapping features too have the potential to improve healthcare quality, we suggest that the concepts should remain distinct, at least in the curt term. While the concepts remain singled-out, all the same, efforts to contain them into provider practices and health systems should occur in concert. Separating patient centeredness and cultural competence initiatives will duplicate effort, since so many of the principles are the same. In improver, equally mentioned above, efforts to enhance patient centeredness, without acceptable attention to the needs of minority and other disadvantaged groups, have the potential to exacerbate existing disparities in intendance.
A variety of specific recommendations can therefore be made. Healthcare organizations and providers should adopt principles of both patient centeredness and cultural competence jointly, so that services are aligned to meet the needs of all patients, including people of color and other disadvantaged groups, whose needs and preferences may be overshadowed by those of the majority. Wellness services researchers should develop measures of cultural competence and patient centeredness and explore the bear upon of their unique and overlapping components on patient outcomes. Medical educators should partner with social scientists, anthropologists and researchers to develop and evaluate educational programs to improve the patient centeredness and cultural competence of health professionals. Those responsible for ensuring health organization quality should employ measurement of both patient centeredness and cultural competence as part of the process of delivering high-quality care. Finally, all patients should take advantage of every opportunity to provide feedback (due east.g., participate in surveys and focus groups) to improve the design and evaluation of healthcare systems that reverberate patients' diverse needs and preferences.
ACKNOWLEDGEMENTS
The authors would like to thank Dr. Anne Beal of The Republic Fund for her back up and guidance of this projection.
Financial support: This study was supported by The Democracy Fund, a New York City-based individual, independent foundation. Dr. Saha was supported by an Advanced Research Career Development Award from the Health Services Enquiry and Development Service of the Department of Veterans Affairs. Drs. Saha and Beach were supported by Generalist Doc Faculty Scholar Awards from the Robert Wood Johnson Foundation. Dr. Cooper was supported by the National Middle Lung and Blood Institute (grant #K24HL083113). The views expressed in this paper are those of the authors and not necessarily those of The Commonwealth Fund, the Department of Veterans Affairs, the National Institutes of Health or the Robert Wood Johnson Foundation.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824588/
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