Daniel Hernandez, MD, on Assessment of RA Care Among Hispanic Patients

Dr Hernandez discusses an abstract he presented at EULAR on validation of a Spanish-language patient-provider questionnaire and assessments of health care visits among Hispanic/Latinx patients with rheumatoid arthritis and their rheumatologists.

Daniel Hernandez, MD, is director of medical affairs and Hispanic outreach at the Global Healthy Living Foundation.

TRANSCRIPT:

RALN:  Welcome to this podcast from the Rheumatology & Arthritis Learning Network. We're joined today by Dr. Daniel Hernandez, Director of Medical Affairs and Hispanic Outreach for the Global Healthy Living Foundation. He's going to discuss an abstract presented at EULAR on the validation of a Spanish language patient provider questionnaire, and the assessments of healthcare visits among Hispanic and Latinx patients with rheumatoid arthritis and the rheumatologists. Thank you for being with us today, Dr. Hernandez.

Dr. Daniel Hernandez: Thank you so much for having me.

RALN: Your abstract reports that RA screening tools typically have lower sensitivity and specificity for Hispanic Latinx patients than for white patients, and that there's very little research to explain these differences or how to address them. Did your study shed some light on these differences?

Dr. Hernandez: The biggest difference that we saw was that there was a huge concordance between physicians and patients, but concordance that we didn't expect, which was overly optimistic and overly positive, where after interviewing the patients and the physicians, we saw that it was completely opposite of what they were reporting on these questionnaires. So that was the biggest difference, seeing that there was a nonconcordance between what was actually happening in the office and what these patients and physicians were answering in the PPQ. The PPQ is a survey that was developed and validated in Sweden first, and it's made the rounds in Europe, but it's a physician patient questionnaire where patients and physicians answer a series of questions with a Likert score 1 through 5. And they ask them about the visit and how that went.

So that's what we saw. We saw a huge nonconcordance between what was happening in the office and what was actually being reported. Therefore, what we concluded was that there are these cultural norms within the Hispanic community in the United States and Puerto Rico, which is where we did this, that is causing this. We're suggesting that this is part of social desirability bias, where there's more positive responses when that's not what's actually happening. So we really have to dig deeper, and figure out a better tool to analyze what is happening within the clinic with these patients.

RALN: How did you determine what was actually happening? Did you interview caregivers and patients separately?

Dr. Hernandez: Right. We did was we interviewed patients and we interviewed the physicians that were part of the study. But what we also did was we developed an advisory board of patients, RA Hispanic patients within the United States and Puerto Rico, and also an advisory board of Hispanic rheumatologists separately, completely. And we interviewed them, and we tried to analyze the landscape and what was going on within the office. Those were very telling on what actually happens versus what our results we're presenting.

RALN: The cultural imperative that you mentioned — is this on both sides with physicians and patients? Are patients reluctant to criticize physicians, or did it work both ways?

Dr. Hernandez: It seemed to be working both ways. It seemed to be working within the physicians' side, but our theory is that these physicians are getting the answers that they want to hear from the patients because of this social desirability bias. The patient comes in, and instead of advocating for themselves, or really being frank with what is going on during their treatment process, they're trying to appease the physician. So the physician might think that the patient is doing amazingly well. And there are some issues with seeing what the laboratory results are saying and what the patient is actually saying. But within these questionnaires, where it was only about what the patient was communicating to the doctor, it seemed like it was overly positive. That is what we need to analyze, and we need a better tool in order to actually get insight on what is happening with the patient before and during the patient physician visit.

RALN: And is this one of the reasons you said that one of your objectives was to determine if you could use the physician responses as proxy?

Dr. Hernandez: That's correct.

RALN: And your results showed you that, no, you're not going to be able to do that, correct?

Dr. Hernandez: Not in the original iteration of the PPQ. What we did was we modified that PPQ and we submitted to the IRB. And the way that we modified it, we believe that is the way that we will be able to actually gain insight on what the physician is actually observing and actually using the other tools that they have at their disposal to analyze and assess how the patient is doing within that visit.

RALN: So how did you modify the PPQ?

Dr. Hernandez: Basically, happened was we did away with the Likert scores, and we modified these questions in order for them to be a little bit more telling on what's happening within the office.

RALN: And you've tested this now?

Dr. Hernandez: We are currently testing it as we speak.

RALN: It's interesting that you noted that there was a distinct set of subset of respondents that accounted for almost all of the responses that were below the top rating on that Likert scale. Did you notice any specific characteristics of that subset that shed any light on why they were being a little less positive than the rest?

Dr. Hernandez: That was very interesting. The analysis was a bit difficult to do because since the Likert score is only 1 through 5, that's the only thing that you can actually analyze. And what we saw, this accordance or nonconcordance, was sometimes the physician would answer with a 5 scale or a 5 score, and the patient would answer with a 4 score, and vice versa. So that is what we noticed. We are currently analyzing or trying to put the dots back together in order to see what that difference was.

RALN: You said you're in the process of testing this revised PPQ right now. Once you get that done, what's the next step?

Dr. Hernandez: Once we get that done, we'll analyze that. We'll see if there is a change between how the physicians were answering with the original PPQ compared to this one. We'll continue doing interviews. And based on that, and based on our analysis, and strongly we feel that this tool actually works, we'd like to start developing it into a larger study where we can then iterate it into different disease states. That would be the end goal.

RALN: Well, this has been very interesting, and we thank you for sharing your results with us. And look forward to hearing through you as this project continues.

Dr. Hernandez: Thank you so much, Rebecca, for taking the time to speak about this. And I'm looking forward to sharing more results with you.