A Systematic Review of the Impact of Patient-Physician Non-English Language Concordance on Quality of Care and Outcomes

Treatment Disparities in Hispanic Patients with Chronic Pain: An Evidence-Based Narrative Review

PURPOSE OF REVIEW

The purpose of this narrative review is to summarize healthcare disparities experienced by Hispanic and Latino/Latinx patients with chronic pain, evaluate the existing literature exploring the specific therapeutic inequities affecting this patient population, and identify gaps in the literature requiring future study.

RECENT FINDINGS

Hispanic and Latino/Latinx patients experience disparities in chronic pain management. They are less likely to be prescribed pharmacologic therapies, including non-steroidal anti-inflammatory drugs and opioids. Hispanic and Latino/Latinx patients are also less likely to receive spinal cord stimulators and may be charged higher costs for them. There are no published studies specifically assessing Hispanic and Latino/Latinx patients' utilization and outcomes from other common interventional pain procedures (e.g., epidural steroid injections, radiofrequency ablation). Limited data suggest non-pharmacologic treatments, such as cognitive behavioral therapy and complementary/integrative health modalities, might have more benefit for this population, potentially because of greater utilization. Hispanic and Latino/Latinx patients experience disparities in chronic pain management. There is a paucity of data available pertaining specifically to pain-related outcomes and the utilization of pain treatment modalities, especially in regard to interventional procedures. Additional research is urgently needed in order to understand the full extent of these disparities and develop solutions to provide more equitable care.

Latino-White Disparities in Identification and Control of Elevated Blood Pressure Among Adults With Hypertension

BACKGROUND

Studies analyzing blood pressure (BP) management using the hypertension control cascade have consistently shown disparities in hypertension awareness, treatment, and BP control between Latino patients and non-Latino White patients. We analyze this cascade using electronic health record data from a multistate network of community health centers.

METHODS AND RESULTS

Data from 790 clinics in 23 US states from 2012 to 2020, including 1 270 174 patients, were analyzed to compare BP documentation in the electronic health record, clinician acknowledgment (diagnosis or treatment) of incident hypertension (BP ≥140/90), medication prescription, and BP control between non-Latino White patients, English-preferring Latino patients, and Spanish-preferring Latino patients, adjusted for patient-level covariates, and clustered on patients' primary clinics. Among the 429 182 patients with elevated BP (≥140/90) during ambulatory visits from 2012 to 2020, we found that clinician acknowledgment of hypertension was more likely in Spanish-preferring and English-preferring Latino patients versus non-Latino White patients (adjusted odds ratio [aOR], 1.17 [95% CI, 1.11-1.24]; aOR, 1.07 [95% CI, 1.02-1.12], respectively). In addition, Spanish-preferring Latino patients were more likely to receive a medication versus non-Latino White patients (aOR, 1.21 [95% CI, 1.16-1.28]). Among those receiving medication, Latino patients were as likely as non-Latino White patients to have their BP controlled (<140/90).

CONCLUSIONS

In a large retrospective study of community health center patients with incident hypertension, the expected disparities in hypertension management between Spanish-preferring Latino, English-preferring Latino, and non-Latino White patients were not identified. These findings add to the hypertension control cascade by examining robust electronic health record data from community health centers and may provide clues to reducing disparities in hypertension management.

The Importance of Cultural Awareness in the Management of Heart Failure: A Narrative Review

Heart failure is a commonly encountered clinical syndrome arising from a range of etiologic cardiovascular diseases and manifests in a phenotypic spectrum of varying degrees of systolic and diastolic ventricular dysfunction. Those affected by this life-limiting illness are subject to an array of burdensome symptoms, poor quality of life, prognostic uncertainty, and a relatively onerous and increasingly complex treatment regimen. This condition occurs in epidemic proportions worldwide, and given the demographic trend in societal ageing, the prevalence of heart failure is only likely to increase. The marked upturn in international migration has generated other demographic changes in recent years, and it is evident that we are living and working in ever more ethnically and culturally diverse communities. Professionals treating those with heart failure are now dealing with a much more culturally disparate clinical cohort. Given that the heart failure disease trajectory is unique to each individual, these clinicians need to ensure that their proposed treatment options and responses to the inevitable crises intrinsic to this condition are in keeping with the culturally determined values, preferences, and worldviews of these patients and their families. In this narrative review, we describe the importance of cultural awareness across a range of themes relevant to heart failure management and emphasize the centrality of cultural competence as the basis of appropriate care provision.

Is Primary Care Patient Experience Associated with Provider-Patient Language Concordance and Use of Interpreters for Spanish-preferring Patients: A Systematic Literature Review

BACKGROUND

Healthcare provided by a bilingual provider or with the assistance of an interpreter improves care quality; however, their associations with patient experience are unknown. We reviewed associations of patient experience with provider-patient language concordance (LC) and use of interpreters for Spanish-preferring patients.

METHOD

We reviewed articles from academic databases 2005-2023 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Joanna Briggs Institute Checklists to rate study quality. We reviewed 217 (of 2193) articles, yielding 17 for inclusion.

RESULTS

Of the 17 included articles, most articles focused on primary (n = 6 studies) or pediatric care (n = 5). All were cross-sectional, collecting data by self-administered surveys (n = 7) or interviews (n = 4). Most assessed the relationship between LC or interpreter use and patient experience by cross-sectional associations (n = 13). Two compared subgroups, and two provided descriptive insights into the conversational content (provider-interpreter-patient). None evaluated interventions, so evidence on effective strategies is lacking. LC for Spanish-preferring patients was a mix of null findings (n = 4) and associations with better patient experience (n = 3) (e.g., receiving diet/exercise counseling and better provider communication). Evidence on interpreter use indicated better (n = 2), worse (n = 2), and no association (n = 2) with patient experience. Associations between Spanish-language preference and patient experience were not significant (n = 5) or indicated worse experience (n = 4) (e.g., long waits, problems getting appointments, and not understanding nurses).

CONCLUSION

LC is associated with better patient experience. Using interpreters is associated with better patient experience but only with high-quality interpreters. Strategies are needed to eliminate disparities and enhance communication for all Spanish-preferring primary care patients, whether with a bilingual provider or an interpreter.

Psychometric properties of the Perceived Stress Scale (PSS-10) in silica-exposed workers from diverse cultural and linguistic backgrounds

BACKGROUND

The Perceived Stress Scale (PSS-10) has been used in a range of occupational cohorts, but only recently in stone benchtop workers undergoing screening for silicosis. The aim of this study was to compare psychometric properties of the PSS-10 in stone benchtop workers amongst those born overseas or who used an interpreter.

METHODS

Stone benchtop workers in Melbourne, Australia completed the PSS-10 as part of their occupational screening for silicosis. Internal consistency was assessed with Cronbach's α for the total score and the positive and negative subscales. Validity was assessed using confirmatory factor analysis (CFA). Analysis was performed for the total group and for subgroups according to sex, interpreter use, overseas-born, and language spoken at home.

RESULTS

The results of 682 workers with complete PSS-10 scores were included in analysis. Most participants were male (93%), with mean age 36.9 years (SD 11.4), with just over half (51.6%) born in Australia, 10.1% using an interpreter, and 17.5% using a language other than English at home. Cronbach's α for the overall group (α = 0.878) suggested good internal consistency.

DISCUSSION

CFA analysis for validity testing suggested PSS-10 performance was good for both sexes, moderate for country of birth and language spoken at home categories, but poorer for those who used an interpreter. Whilst professional interpreters provide a range of benefits in the clinical setting, the use of translated and validated instruments are important, particularly in cohorts with large numbers of migrant workers.

CONCLUSION

This study describes the psychometric properties of the PSS-10 in a population of stone benchtop workers, with good internal consistency, and mixed performance from validity testing across various subgroups.

Generative Artificial Intelligence to Transform Inpatient Discharge Summaries to Patient-Friendly Language and Format

Importance

By law, patients have immediate access to discharge notes in their medical records. Technical language and abbreviations make notes difficult to read and understand for a typical patient. Large language models (LLMs [eg, GPT-4]) have the potential to transform these notes into patient-friendly language and format.

Objective

To determine whether an LLM can transform discharge summaries into a format that is more readable and understandable.

Design, Setting, and Participants

This cross-sectional study evaluated a sample of the discharge summaries of adult patients discharged from the General Internal Medicine service at NYU (New York University) Langone Health from June 1 to 30, 2023. Patients discharged as deceased were excluded. All discharge summaries were processed by the LLM between July 26 and August 5, 2023.

Interventions

A secure Health Insurance Portability and Accountability Act-compliant platform, Microsoft Azure OpenAI, was used to transform these discharge summaries into a patient-friendly format between July 26 and August 5, 2023.

Main Outcomes and Measures

Outcomes included readability as measured by Flesch-Kincaid Grade Level and understandability using Patient Education Materials Assessment Tool (PEMAT) scores. Readability and understandability of the original discharge summaries were compared with the transformed, patient-friendly discharge summaries created through the LLM. As balancing metrics, accuracy and completeness of the patient-friendly version were measured.

Results

Discharge summaries of 50 patients (31 female [62.0%] and 19 male [38.0%]) were included. The median patient age was 65.5 (IQR, 59.0-77.5) years. Mean (SD) Flesch-Kincaid Grade Level was significantly lower in the patient-friendly discharge summaries (6.2 [0.5] vs 11.0 [1.5]; P < .001). PEMAT understandability scores were significantly higher for patient-friendly discharge summaries (81% vs 13%; P < .001). Two physicians reviewed each patient-friendly discharge summary for accuracy on a 6-point scale, with 54 of 100 reviews (54.0%) giving the best possible rating of 6. Summaries were rated entirely complete in 56 reviews (56.0%). Eighteen reviews noted safety concerns, mostly involving omissions, but also several inaccurate statements (termed hallucinations).

Conclusions and Relevance

The findings of this cross-sectional study of 50 discharge summaries suggest that LLMs can be used to translate discharge summaries into patient-friendly language and formats that are significantly more readable and understandable than discharge summaries as they appear in electronic health records. However, implementation will require improvements in accuracy, completeness, and safety. Given the safety concerns, initial implementation will require physician review.

Improving Assessment and Learning Environments for Graduate Medical Trainees to Advance Healthcare Language Equity

Language-appropriate care is critical for equitable, high-quality health care, but educational standards to assure graduate medical trainees are prepared to give such care are lacking. Detailed guidance for graduate medical education is provided by the Accreditation Council for Graduate Medical Education through the following: (1) an assessment framework for competencies, subcompetencies, and milestones for trainees and (2) the Clinical Learning Environment Review (CLER) Pathways for assessment of trainees' learning environments. These tools do not include a robust framework to evaluate trainees' abilities to offer language-appropriate care. They also do not address the learning environment's potential to support such care. A multidisciplinary group of linguistic, medical, and educational experts drafted a new subcompetency with milestones and an expanded CLER Pathway to highlight the importance of equitable care for patients who prefer languages other than English. These resources offer residency and fellowship programs tools to guide assessment, curriculum development, and learning-environment improvements related to language-appropriate care. Recognizing that programs have unique needs and resources, we propose a range of initial actions to address language equity. A focus on language diversity in the learning environment can have a broad and lasting impact on care quality, patient safety, and health equity.

Communication Preferences During Pregnancy Care Among Patients With Primary Spanish Language: A Scoping Review

BACKGROUND

Qualified language service providers (QLSPs)-professional interpreters or multilingual clinicians certified to provide care in another language-are critical to ensuring meaningful language access for patients. Designing patient-centered systems for language access could improve quality of pregnancy care.

OBJECTIVE

We synthesized and identified gaps in knowledge about communication preferences during pregnancy care among patients with Spanish primary language.

METHODS

We performed a scoping review of original research studies published between 2000 and 2022 that assessed communication preferences in Spanish-speaking populations during pregnancy care. Studies underwent title, abstract, and full-text review by three investigators. Data were extracted for synthesis and thematic analysis.

RESULTS

We retrieved 1,539 studies. After title/abstract screening, 36 studies underwent full-text review, and 13 of them met inclusion criteria. Two additional studies were included after reference tracing. This yielded a total of 15 studies comprising qualitative (n = 7), quantitative (n = 4), and mixed-methods (n = 4) studies. Three communication preference themes were identified: language access through QLSPs (n = 7); interpersonal dynamics and perceptions of quality of care (n = 9); and information provision and shared decision-making (n = 8). Although seven studies reported a strong patient preference to receive prenatal care from Spanish-speaking clinicians, none of the included studies assessed clinician Spanish language proficiency or QLSP categorization.

CONCLUSIONS

Few studies have assessed communication preferences during pregnancy care among patients with primary Spanish language. Future studies to improve communication during pregnancy care for patients with primary Spanish language require intentional analysis of their communication preferences, including precision regarding language proficiency among clinicians.

Sociodemographic Factors are Associated with Care Delivery and Outcomes in Pediatric Severe Sepsis

IMPORTANCE

Sepsis is a leading cause of morbidity and mortality in the United States and disparate outcomes exist between racial/ethnic groups despite improvements in sepsis management. These observed differences are often related to social determinants of health (SDoH). Little is known about the role of SDoH on outcomes in pediatric sepsis.

OBJECTIVE

This study examined the differences in care delivery and outcomes in children with severe sepsis based on race/ethnicity and neighborhood context (as measured by the social vulnerability index).

DESIGN SETTING AND PARTICIPANTS

This retrospective, cross-sectional study was completed in a quaternary care children's hospital. Patients 18 years old or younger who were admitted between May 1, 2018, and February 28, 2022, met the improving pediatric sepsis outcomes (IPSO) collaborative definition for severe sepsis. Composite measures of social vulnerability, care delivery, and clinical outcomes were stratified by race/ethnicity.

MAIN OUTCOMES AND MEASURES

The primary outcome of interest was admission to the PICU. Secondary outcomes were sepsis recognition and early goal-directed therapy (EGDT).

RESULTS

A total of 967 children met the criteria for IPSO-defined severe sepsis, of whom 53.4% were White/non-Hispanic. Nearly half of the cohort (48.7%) required PICU admission. There was no difference in illness severity at PICU admission by race (1.01 vs. 1.1, p = 0.18). Non-White race/Hispanic ethnicity was independently associated with PICU admission (odds ratio [OR] 1.35 [1.01-1.8], p = 0.04). Although social vulnerability was not independently associated with PICU admission (OR 0.95 [0.59-1.53], p = 0.83), non-White children were significantly more likely to reside in vulnerable neighborhoods (0.66 vs. 0.38, p < 0.001). Non-White race was associated with lower sepsis recognition (87.8% vs. 93.6%, p = 0.002) and less EGDT compliance (35.7% vs. 42.8%, p = 0.024).

CONCLUSIONS AND RELEVANCE

Non-White race/ethnicity was independently associated with PICU admission. Differences in care delivery were also identified. Prospective studies are needed to further investigate these findings.

Inter-Hospital Transfer Is an Independent Risk Factor for Hospital-Associated Infection

Background: Regionalization of surgical care shifts higher acuity patients to larger centers. Hospital-associated infections (HAIs) are important quality measures with financial implications. In our ongoing efforts to eliminate HAIs, we examined the potential role for inter-hospital transfer in our cases of HAI across a multihospital system. Hypothesis: Surgical patients transferred to a regional multihospital system have a higher risk of National Healthcare Safety Network (NHSN)-labeled HAIs. Patients and Methods: The analysis cohort of adult surgical inpatients was filtered from a five-hospital health system administration registry containing encounters from 2014 to 2021. The dataset contained demographics, health characteristics, and acuity variables, along with the NHSN defined HAIs of central line-associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridioides difficile infection (CDI). Univariable and multivariable statistics were performed. Results: The surgical cohort identified 92,832 patients of whom 3,232 (3.5%) were transfers. The overall HAI rate was 0.6% (528): 86 (0.09%) CLABSI, 133 (0.14%) CAUTI, and 325 (0.35%) CDI. Across the three HAIs, the rate was higher in transfer patients compared with non-transfer patients (CLABSI: n = 18 (1.3%); odds ratio [OR], 4.79; CAUTI: n = 25 (1.8%); OR, 4.20; CDI: n = 37 (1.1%); OR, 3.59); p < 0.001 for all. Multivariable analysis found transfer patients had an increased rate of HAIs (OR, 1.56; p < 0.001). Conclusions: There is an increased risk-adjusted rate of HAIs in transferred surgical patients as reflected in the NHSN metrics. This phenomenon places a burden on regional centers that accept high-risk surgical transfers, in part because of the downstream effects of healthcare reimbursement programs.

Demographics and clinical features associated with rates of electronic message utilization in the primary care setting

INTRODUCTION

Electronic messages are growing as an important form of patient-provider communication, particularly in the primary care setting. However, adoption of healthcare technology has been under-utilized by underserved patient populations. The purpose of this study was to describe how adoption and utilization of electronic messaging occurred within a large primary care urban-based patient population.

METHODS

In this retrospective study, the frequency of electronic messages initiated by adult outpatient primary care patients was observed. Patients were classified as either non-portal adopters, non-message utilizers, low message utilizers, and high message utilizers. Logistic regression modeling was used to compare factors associated with message utilization rates to determine disparities in access.

RESULTS

Among a sample of 27,453 ethnically diverse adult patients from the Houston, Texas Metropolitan area, 33,497 unique messages were sent (1.22 messages/patient). Message burden was predominantly derived by a small number of high utilizers (individuals who sent 3 or more messages), who comprised 15.7 % of the study population (n = 4302) but accounted for 77 % of the message volume (n = 25,776). These high utilizers were typically older, White, English speaking, from middle to upper income zip codes, had higher number of comorbidities, and a higher number of clinical visits.

CONCLUSIONS

Most inbox messages were generated by a small number of patients. While it was reassuring to see older and sicker individuals utilizing electronic messaging, patients from minority and/or lower income background utilized electronic messaging much less. This may propagate systematic bias and decrease the level of care for traditionally underserved patients.

The Impact of Patients' Primary Language on Inpatient Gastrointestinal Bleeding Outcomes

BACKGROUND

The impact of English proficiency on gastrointestinal bleeding (GIB) outcomes remains unclear. In this analysis, we compare inpatient GIB outcomes between patients with English as their primary language (EPL) and those with a primary language other than English (PLOE).

METHODS

Using the 2019 State Inpatient Databases for New Jersey, Maryland, and Michigan, we created an analysis cohort of GIB hospitalizations using International Classification of Diseases, 10th Revision codes. Patients were stratified by primary language (EPL vs PLOE) and type of bleeding (variceal upper GI bleeding [VUGIB], nonvariceal upper GI bleeding [NVUGIB], and lower GI bleeding (LGIB)]. Regression analyses were used to compare mortality, 30-day readmissions, and length of stay. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were reported. P < 0.05 was considered statistically significant.

RESULTS

In the cohort, 5.5%-10% of the patients spoke a primary language other than English. Endoscopy utilization was lower among patients with PLOE vs EPL for NVUGIB (17.2% vs 21.2%, P < 0.001) and LGIB (26.3% vs 29.2%, P = 0.027). Patients with PLOE had higher odds of dying of VUGIB (aOR 1.45, 95% CI 1.16-2.48) and LGIB (aOR 1.71, 95% CI 1.22-2.12). Patients with PLOE were also more likely to be readmitted after NVUGIB (aOR 1.75, 95% CI 1.64-1.81). However, after controlling for the percentage of patients with PLOE discharged from each hospital, the disparities in mortality and readmissions were no longer detected.

DISCUSSION

Disparities exist in GIB outcomes among patients with PLOE, but these gaps narrow at hospitals with higher percentages of patients with PLOE. Cultural and linguistic competence may improve outcomes in this vulnerable group.

Geospatial Analysis of the Proportion of Persons Defined as Underrepresented in Medicine for Each Medical School and Their Surrounding Core-Based Statistical Area

Background

The current approach to increasing diversity in medical education fails to consider local community demographics when determining medical school matriculation.

Purpose

We propose that medical schools better reflect their surrounding community, both because racially/ethnically concordant physicians have been shown to provide better care and to repair the historical and current racist impacts of these institutions that have criminalized, displaced, and excluded local Black and Brown communities.

Methods and Results

In this study, we used geospatial analysis to determine that medical school enrollments generally fail to reflect their surrounding community, represented as their core-based statistical area, within which the individual medical schools reside.

Interpreter resources for people who speak Spanish at dermatology residency programme clinics

Many residency programmes have inadequate interpreter services and health information available for patients. This cross-sectional study found that although most programme clinics had interpreter services, many were inapt, and five programme clinics (4.1%) had none. With regard to clinic paperwork, nearly half of the clinics did not have all of the paperwork available in Spanish.

Healthcare utilization for asthma exacerbation among children of migrant and seasonal farmworkers

Latino children of Migrant and Seasonal Farmworkers (MSFWs) with asthma are at risk for poor health outcomes due to medical access barriers. We compared differences in acute care utilization for asthma exacerbations among migrant and non-migrant Latino and non-Hispanic white (NHW) children at U.S. community health centers. A retrospective observational study utilizing electronic health record data from the ADVANCE Clinical Research Network of United States community health centers included 13,423 children ages 3-17 with a primary care visit between 2005 and 2017 from eight states. Emergency department (ED) and hospitalization data came from Oregon Medicaid claims. Outcomes included acute clinic visits, ED visits, and hospitalizations for asthma exacerbation. Regression analyses adjusted for patient-level covariates. Latino children had higher odds of acute clinic visits for asthma exacerbation compared to NHW children (MSFW odds ratio [OR] = 1.17, 95 % CI = 1.03-1.33; without migrant status OR = 1.13, 95 % CI = 1.03-1.23). MSFW children using Oregon Medicaid had fewer ED visits (rate ratio [RR] = 0.72, 95 % CI = 0.52-0.99) and hospitalizations (RR = 0.47, 95 % CI = 0.26-0.86) compared to NHW children. Increased community health center visits may help mitigate disparities in acute asthma care for MSFW children.

Racial and ethnic inequities in the quality of paediatric care in the USA: a review of quantitative evidence

Racial and ethnic inequities in paediatric care have received increased research attention over the past two decades, particularly in the past 5 years, alongside an increased societal focus on racism. In this Series paper, the first in a two-part Series focused on racism and child health in the USA, we summarise evidence on racial and ethnic inequities in the quality of paediatric care. We review studies published between Jan 1, 2017 and July 31, 2022, that are adjusted for or stratified by insurance status to account for group differences in access, and we exclude studies in which differences in access are probably driven by patient preferences or the appropriateness of intervention. Overall, the literature reveals widespread patterns of inequitable treatment across paediatric specialties, including neonatology, primary care, emergency medicine, inpatient and critical care, surgery, developmental disabilities, mental health care, endocrinology, and palliative care. The identified studies indicate that children from minoritised racial and ethnic groups received poorer health-care services relative to non-Hispanic White children, with most studies drawing on data from multiple sites, and accounting for indicators of family socioeconomic position and clinical characteristics (eg, comorbidities or condition severity). The studies discussed a range of potential causes for the observed disparities, including implicit biases and differences in site of care or clinician characteristics. We outline priorities for future research to better understand and address paediatric treatment inequities and implications for practice and policy. Policy changes within and beyond the health-care system, discussed further in the second paper of this Series, are essential to address the root causes of treatment inequities and to promote equitable and excellent health for all children.

Communication between healthcare providers and communicatively-vulnerable patients with associated health outcomes: A scoping review of knowledge syntheses

OBJECTIVE

Summarize literature on provider-patient communication linked to health outcomes in communicatively-vulnerable patient populations.

METHODS

Scoping review of reviews: systematically searched six databases.

INCLUSION CRITERIA

systematic searches and syntheses of literature; one or more providers and communicatively-vulnerable patients; synchronous in-person communication; intermediate or health outcome linked to communication.

RESULTS

The search yielded 14,615 citations; 47 reviews - with wide range of providers, communication vulnerabilities, communication practices, and health outcomes - met inclusion criteria. Methodology included qualitative, quantitative, and mixed approaches. Quality ranged from very low to high. Six categories of communication practices linked to health outcomes were identified: 1) motivation-based; 2) accommodation of language, culture, gender, sexual identity, and other concordance with the patient; 3) cultural adaptations of interventions; 4) use of interpreters; 5) other provider-patient communication practices; 6) patient communication practices.

CONCLUSION

Communication practices were studied in a wide range of providers, with common themes regarding best practices. A unique finding is the role of the patient's communication practices. The specificity of communication practices studied is heterogeneous, with many reviews providing insufficient details.

PRACTICE IMPLICATIONS

Motivation-based practices and culturally- and linguistically-appropriate care have impacts on patient outcomes across a range of settings with different professions and communicatively-vulnerable groups.

Inequitable access: factors associated with incomplete referrals to paediatric cardiology

OBJECTIVE

To assess the variables associated with incomplete and unscheduled cardiology clinic visits among referred children with a focus on equity gaps.

STUDY DESIGN

We conducted a retrospective chart review for patients less than 18 years of age who were referred to cardiology clinics at a single quaternary referral centre from 2017 to 2019. We collected patient demographic data including race, an index of neighbourhood socio-economic deprivation linked to a patient's geocoded address, referral information, and cardiology clinic information. The primary outcome was an incomplete clinic visit. The secondary outcome was an unscheduled appointment. Independent associations were identified using multivariable logistic regression.

RESULTS

There were 10,610 new referrals; 6954 (66%) completed new cardiology clinic visits. Black race (OR 1.41; 95% CI 1.22-1.63), public insurance (OR 1.29; 95% CI 1.14-1.46), and a higher deprivation index (OR 1.32; 95% CI 1.08-1.61) were associated with higher odds of incomplete visit compared to the respective reference groups of White race, private insurance, and a lower deprivation index. The findings for unscheduled visit were similar. A shorter time elapsed from the initial referral to when the appointment was made was associated with lower odds of incomplete visit (OR 0.62; 95% CI 0.52-0.74).

CONCLUSION

Race, insurance type, neighbourhood deprivation, and time from referral date to appointment made were each associated with incomplete referrals to paediatric cardiology. Interventions directed to understand such associations and respond accordingly could help to equitably improve referral completion.

Language Access Systems Improvement initiative: impact on professional interpreter utilisation, a natural experiment

OBJECTIVES

This study aims to evaluate the Language Access Systems Improvement (LASI) initiative's impact on professional interpreter utilisation in primary care and to explore patient and clinician perspectives on professional interpreter use.

DESIGN

Multi methods: Quantitative natural experiment pre-LASI and post-LASI, qualitative semistructured interviews with clinicians and focus groups with patients post-LASI.

SETTING

Large, academic primary care practice.

PARTICIPANTS

Cantonese, Mandarin, Spanish, English-speaking adult patients and their clinicians.

INTERVENTION

LASI initiative: Implementation of a clinician language proficiency test and simultaneous provision of on-demand access to professional interpreters via video medical interpretation.

MAIN OUTCOME MEASURES

Quantitative: Proportion of language discordant primary care visits which were professionally interpreted. Qualitative: Salient themes related to professional interpreter use and non-use.

RESULTS

The researchers categorised language concordance for 1475 visits with 152 unique clinicians; 698 were not fully language concordant (202 pre-LASI and 496 post-LASI). Professional interpreter utilisation increased (pre-LASI 57% vs post-LASI 66%; p=0.01); the visits with the lowest percentage of profssional interpreter use post-LASI were those in which clinicians and patients had partial language concordance. In inverse probability weighted analysis, restricting to 499 visits with strict estimated propensity score overlap (100% common support), post-LASI visits had higher odds of using a professional interpreter compared with pre-LASI visits (OR 2.39; 95% CI 1.04 to 5.48). Qualitative results demonstrate video interpretation was convenient and well liked by both clinicians and patients. Some partially bilingual clinicians reported frustration with patient refusal of interpreter services; others reported using the video interpreters as a backup during visits. Views of the care-partner role differed for clinicians and patients. Clinicians reported sometimes having family interpret out of convenience or habit, whereas patients reported wanting family members present for support and advocacy, not interpretation.

CONCLUSIONS

LASI increased utilisation of professional interpreters; however, this was least prominent for partially language concordant visits. Health systems wishing to implement LASI or similar interventions will need to support clinicians and patients with partial bilingual skills in their efforts to use professional interpreters.

TRIAL REGISTRATION NUMBER

HSRP20153367.

Medical Spanish Graphic Activity: A MeGA Deliberate Practice Approach to Reducing Jargon Use With Spanish-Speaking Acute Care Patients

Introduction

Medical Spanish courses in US medical schools aim to teach patient-centered communication, yet many existing resources focus on technical vocabulary and may inadvertently increase jargon use with patients. Graphic medicine presents an opportunity for interactive learning that centers the patient experience, yet it has never been explored in medical Spanish education.

Methods

We developed a Medical Spanish Graphic Activity (MeGA) for medical student deliberate practice of patient-centered verbal communication focused on three aspects: diagnosis, treatment, and follow-up care. Each 30-minute activity included a comics handout depicting a patient with a common problem. Students used voice-to-text technology to record their explanations in response to prompts. Transcripts were analyzed for jargon use, including total jargon, unexplained jargon, and problem words (non-Spanish words plus unexplained jargon), utilizing a previously published, reliable protocol for Spanish medical jargon classification. Participants voluntarily provided postactivity feedback.

Results

Twenty-nine fourth-year students with intermediate or greater Spanish skills participated in a series of 10 MeGA activities between January and April 2022. Unexplained jargon use and problem words progressively decreased for all transcripts (diagnosis, treatment, and follow-up; all ps < .001). Total jargon use also decreased, but this was not significant in follow-up transcripts (p = .38). All students agreed that MeGA helped them enhance communication skills applicable to patient care and self-identify strengths and limitations.

Discussion

MeGA is realistic to implement, engages students' active participation in the speaking domain, and reduces unexplained jargon use. Future studies should explore the broader application of this model and engage patient perspectives.

Hispanic/Latinx and Spanish Language Concordance Among Palliative Care Clinicians and Patients in Hospital Settings in California

Background: Members of racial or ethnic minority groups utilize palliative care (PC) services less than non-Hispanic White patients and multiple factors contribute to this disparity. The impact of racial, ethnic, and language (REL) concordance between patients and clinicians has been demonstrated in general medical populations, but not in PC populations. We characterized the racial and ethnic composition and languages spoken of California PC clinicians and patients to examine clinical impacts of REL concordance. Methods: Using Palliative Care Quality Network data, 15 inpatient teams were identified in California that had collected data on patient race/ethnicity and language. Patient and clinician data were analyzed using means and medians for continuous variables, and chi-squared tests to explore similarities and differences between clinician and patient data. Results: 51 clinicians from nine teams completed the survey. The largest non-White and non-English speaking groups among patients and clinicians identified as Hispanic/Latinx (31.5% of patients, 16.3% of clinicians) and as Spanish speakers (22.6% of patients, 7.5% of clinicians). There was a significantly higher proportion of Hispanic/Latinx patients compared to clinicians (p-value 0.01), with Southern California demonstrating the largest difference (30.4% of patients vs. 10.7 % of clinicians, p-value 0.01). Similar proportions of patients and clinicians reported Spanish fluency (22.6% vs 27.5%, p-value 0.31). Discussion: We found significant differences in the racial/ethnic distributions of Hispanic/Latinx patients and clinicians in California, prompting consideration of whether a lack of representation of Hispanic/Latinx clinicians relative to the patient population may contribute to lower palliative care utilization among Hispanic/Latinx patients.

Canadian French Translation and Validation of the Neck Dissection Impairment Index: A Quality of Life Measure for the Surgical Oncology Population

BACKGROUND

Neck dissections (ND) are a routine procedure in head and neck oncology. Given the postoperative functional impact that some patients experience, it is imperative to identify and track quality of life (QoL) symptomatology to tailor each patient's therapeutic needs. To date, there is no validated French-Canadian questionnaire for this patient-population. We therefore sought to translate and validate the Neck Dissection Impairment Index (NDII) in Canadian French.

METHODS

A 3-phased approach was used. Phase 1: The NDII was translated from English to Canadian French using a "forward and backward" translational technique following international guidelines. Phase 2: A cognitive debriefing session was held with 10 Canadian French-speaking otolaryngology patients to evaluate understandability and acceptability. Phase 3: The final version was administered prospectively to 30 patients with prior history of ND and 30 control patients. These patients were asked to complete the questionnaire 2 weeks after their first response. Test-retest reliability was calculated with Spearman's correlation. Internal consistency was elicited using Cronbach's alpha.

RESULTS

NDII was successfully translated and validated to Canadian French. Cronbach's alpha revealed high internal consistency (0.92, lower 95% confidence limit 0.89). The correlation for test-retest validity were strong or very strong (0.61-0.91).

CONCLUSION

NDII is an internationally recognized QoL tool for the identification of ND-related impairments. This validated Canadian French version will allow clinicians to adequately assess the surgery-related QoL effect of neck surgery in the French-speaking population, while allowing French institutions to conduct and/or participate in multisite clinical trials requiring the NDII as an outcome measure.

Patient Time Spent With Professional Medical Interpreters and the Care Experiences of Patients With Limited English Proficiency

INTRODUCTION/OBJECTIVES

More time spent with interpreters may support clinician-patient communication for patients with limited English proficiency (LEP), especially when interpreter support before and after clinical encounters is considered. We assessed whether more time spent with interpreters is associated with better patient-reported experiences of clinician-patient communication and interpreter support among patients with LEP.

METHODS

Patients with LEP (n = 338) were surveyed about their experiences with both the clinician and interpreter. Duration of interpreter support during the encounter (in min) and auxiliary time spent before and after encounters supporting patients (in min) were documented by interpreters. Multivariable linear regression models were estimated to assess the association of the time duration of interpreter support and patient experiences of (1) clinician-patient communication, and (2) interpreter support, controlling for patient and encounter characteristics.

RESULTS

The average encounter duration was 47.7 min (standard deviation, SD = 25.1), the average auxiliary time was 43.8 min (SD = 16.4), and the average total interpreter time was 91.1 min (SD = 28.6). LEP patients reported better experiences of interpreter support with a mean score of 97.4 out of 100 (SD = 6.99) compared to clinician-patient communication, with a mean score of 93.7 out of 100 (SD = 14.1). In adjusted analyses, total patient time spent with an interpreter was associated with better patient experiences of clinician-patient communication (β = 7.23, P < .01) when auxiliary time spent by interpreters supporting patients before and after the encounter was considered, but not when only the encounter time was considered.

CONCLUSIONS

Longer duration of time spent with an interpreter was associated with better clinician-patient communication for patients with LEP when time spent with an interpreter before and after the clinician encounter is considered. Policymakers should consider reimbursing health care organizations for time interpreters spend providing patient navigation and other support beyond clinical encounters.

A Review of Disparities in Outcomes of Hospitalized Patients with Limited English Proficiency: The Importance of Nursing Resources

Language barriers significantly affect communication between patients and health care staff and are associated with receipt of lower-quality care. Registered nurses are well positioned members of the health care team to reduce and eliminate disparities for patients with limited English proficiency (LEP). Current evidence recommends nurses use interpreters or translation devices to overcome language barriers; however, these recommendations fail to recognize that structural system-level factors, such as unsupportive work environments and poor nurse-to-patient staffing ratios, reduce nurses' ability to implement these recommendations. The Quality Health Outcomes Model (QHOM) is a useful framework for understanding relationships between hospital systems, the delivery of care interventions, and patient outcomes. The goal of this manuscript is to use the QHOM and existing empirical evidence to present a new perspective on the long-standing clinical challenge of reducing language-related health outcome disparities by considering the context in which nurses deliver patient care.

"Should I Say Something?": A Simulation Curriculum on Addressing Lapses in Professionalism to Improve Patient Safety

Introduction

Medical students may witness lapses in professionalism but lack tools to effectively address such episodes. Current professionalism curricula lack opportunities to practice communication skills in addressing professionalism lapses.

Methods

We designed a simulation curriculum to introduce professionalism expectations, provide communication tools using elements of the Agency for Healthcare Research and Quality TeamSTEPPS program, and address observed professionalism lapses involving patient safety in hierarchical patient care teams. Students were surveyed on knowledge, skills, and attitude regarding professionalism before, immediately after, and 6 months after participation.

Results

Of 253 students, 70 (28%) completed baseline and immediate postsurveys, and 39 (15%) completed all surveys. In immediate postsurveys, knowledge of communication tools (82% to 94%, p = .003) and empowerment to address residents (19% to 44%, p = .001) and attendings (15% to 39%, p < .001) increased. At 6 months, 96% of students reported witnessing a professionalism lapse.

Discussion

The curriculum was successful in reported gains in knowledge of communication tools and empowerment to address professionalism lapses, but few students reported using the techniques to address witnessed lapses in real life.

Social Determinants of Health and Perceived Barriers to Care in Diabetic Retinopathy Screening

Importance

Regular screening for diabetic retinopathy often is crucial for the health of patients with diabetes. However, many factors may be barriers to regular screening and associated with disparities in screening rates.

Objective

To evaluate the associations between visiting an eye care practitioner for diabetic retinopathy screening and factors related to overall health and social determinants of health, including socioeconomic status and health care access and utilization.

Design, Setting, and Participants

This retrospective cross-sectional study included adults aged 18 years or older with type 2 diabetes who answered survey questions in the All of Us Research Program, a national multicenter cohort of patients contributing electronic health records and survey data, who were enrolled from May 1, 2018, to July 1, 2022.

Exposures

The associations between visiting an eye care practitioner and (1) demographic and socioeconomic factors and (2) responses to the Health Care Access and Utilization, Social Determinants of Health, and Overall Health surveys were investigated using univariable and multivariable logistic regressions.

Main Outcome and Measures

The primary outcome was whether patients self-reported visiting an eye care practitioner in the past 12 months. The associations between visiting an eye care practitioner and demographic and socioeconomic factors and responses to the Health Care Access and Utilization, Social Determinants of Health, and Overall Health surveys in All of Us were investigated using univariable and multivariable logistic regression.

Results

Of the 11 551 included participants (54.55% cisgender women; mean [SD] age, 64.71 [11.82] years), 7983 (69.11%) self-reported visiting an eye care practitioner in the past year. Individuals who thought practitioner concordance was somewhat or very important were less likely to have seen an eye care practitioner (somewhat important: adjusted odds ratio [AOR], 0.83 [95% CI, 0.74-0.93]; very important: AOR, 0.85 [95% CI, 0.76-0.95]). Compared with financially stable participants, individuals with food or housing insecurity were less likely to visit an eye care practitioner (food insecurity: AOR, 0.75 [95% CI, 0.61-0.91]; housing insecurity: AOR, 0.86 [95% CI, 0.75-0.98]). Individuals who reported fair mental health were less likely to visit an eye care practitioner than were those who reported good mental health (AOR, 0.84; 95% CI, 0.74-0.96).

Conclusions and Relevance

This study found that food insecurity, housing insecurity, mental health concerns, and the perceived importance of practitioner concordance were associated with a lower likelihood of receiving eye care. Such findings highlight the self-reported barriers to seeking care and the importance of taking steps to promote health equity.

Strength in Numbers: A SWOT Analysis of Plastic Surgery

Background

Plastic surgeons comprise the minority of practicing surgeons, with an even smaller minority practicing in an academic setting. As the practice of medicine and the systems in which we operate continue to evolve, it is essential that plastic surgeons have a say in the changing landscape. This study conducted a strengths, weaknesses, opportunities, and threats (SWOT) analysis of plastic surgery to identify unifying strengths and common threats.

Methods

An electronic survey was distributed to American Council of Academic Plastic Surgeons' Winter Meeting attendees on three separate occasions preceding the meeting. Respondents were asked to provide demographic information and to identify the top three strengths, weaknesses, opportunities, and threats (SWOT analysis) for the specialty. Subgroup analyses were performed based on demographic characteristics.

Results

A total of 187 responses were received from meeting attendees, representing an 89.0% response rate. Most respondents were non-Hispanic (78.6%), White (66.8%), women (59.5%), and faculty/independent physicians (65.8%). The most identified strength in plastic surgery was our problem-solving abilities (62.0%). The most identified weakness was poor public perception of plastic surgery (54.0%). The most identified opportunity was demonstration of value to health systems (67.9%), and the most identified threat was scope of practice creep by other specialties (78.1%). The SWOT analysis identified lack of surgeon diversity as a key weakness, improvement of surgeon diversity as a key opportunity, and lack of diversity among plastic surgeons as a key threat to the specialty.

Conclusion

Only through a diverse but united front can we effectively use our strengths to face our threats and employ opportunities to overcome our weaknesses.

Association of language concordance and restraint use in adults receiving mechanical ventilation

PURPOSE

Clinician-patient language concordance improves patient outcomes in non-intensive care unit (ICU) settings. We sought to assess the association of ICU nurse-patient language concordance with delirium-related outcomes.

METHODS

We conducted a retrospective cohort study of adult English- or Spanish-speaking mechanically ventilated ICU patients admitted to ICUs at the University of Miami Hospital and Clinics (January 2021-September 2022). Our primary exposure was nurse-patient language concordance on each shift. We used mixed-effects multivariable regression to evaluate the association of language concordance with the primary outcome of restraint use, and secondary outcomes of agitation and identification of delirium, during each shift (with patient as a random effect).

RESULTS

Our cohort included 4326 shifts (3380 [78.1%] with language concordance) from 548 patients and 157 nurses. Spanish language was preferred by 269 (49.1%) of patients. English-speaking patients tended to be younger (65 [53, 75] vs 73 [61, 83], p < 0.001) and of non-Hispanic ethnicity (55.5% vs 7.1%, p < 0.001). English-speakers had restraints ordered on fewer of their included shifts (0 [0, 3] vs 1 [0, 3], p = 0.005). After adjustment, the odds of restraint use on shifts with language concordance was significantly lower (odds ratio [OR, 95% confidence interval [CI]]: 0.50 [0.39-0.63], p < 0.001). Agitation (18.6% vs 25.2%; OR [95% CI]: 0.71 [0.55-0.92], p = 0.009) and delirium identification (34.5% vs 41.3%; OR [95% CI]: 0.54 [0.34-0.88], p = 0.014) were also less common.

CONCLUSIONS

We identified a twofold reduction in the odds of restraint use among mechanically ventilated patients for language concordant nurse-patient dyads. Ensuring nurse-patient language concordance may improve ICU delirium, agitation, and restraint use.

Disparities in Postoperative Communication Patterns Among Spanish-speaking Pediatric Patients with Hydrocephalus

OBJECTIVE

To determine if differences exist in postoperative communication patterns or healthcare use among English-speaking patients (ESPs) and Spanish-speaking patients (SSPs) with childhood hydrocephalus.

STUDY DESIGN

A single-institution, retrospective cohort study was conducted. Through simple random sampling, 50 ESPs and 50 SSPs (<18 years old) who underwent a ventriculoperitoneal shunt or endoscopic third ventriculostomy were identified. Demographics, communication with clinic (eg, number of calls or messages postoperatively), and healthcare use were collected. Multiple linear regressions assessed the significance of predictors on communication frequency and use.

RESULTS

SSPs were more likely to have a comorbidity and ventriculoperitoneal shunt than ESPs. SSPs had longer median postoperative length of stay (P < .01) and 30-day readmission rate (P < .01) than ESPs. Only 18% of SSPs communicated with clinic; 11 total calls or messages were from SSPs vs 57 from ESPs (P < .01). The most common reason for outreach among both cohorts was a new symptom. ESP outreach most frequently resulted in reassurance or medical course changes on an outpatient basis (30% ESPs vs 0% SSPs; P = .04), whereas SSP outreach most frequently resulted in guidance to present to the emergency department (3% ESPs vs 36% SSPs; P < .01). Language remained a significant predictor for number of calls or messages, even after adjusting for comorbidity, operation type, and insurance (P < .01).

CONCLUSIONS

Despite having more complex disease, only 18% of SSPs communicated with the neurosurgical team postoperatively and were more frequently sent to the emergency department for management. Future research will explore communication barriers and preferences to ensure postoperative care is timely and patient centered.

Strategies Used by Healthcare Systems to Communicate with Hospitalized Patients and Families with Limited English Proficiency During the COVID-19 Pandemic: A Narrative Review

The COVID-19 pandemic disproportionately affected racial and ethnic minorities in the United States, including many with limited English proficiency (LEP). These patients face various communication barriers, including a shortage of available interpreters and the need for masks that exacerbated communication barriers. It is not known how hospitals responded to these unique challenges to providing language services for the large number of patients with LEP during COVID-19. This narrative review assessed literature and lay media to identify strategies utilized by hospitals to communicate with patients with LEP hospitalized during the COVID-19 pandemic. A search of APA PsychInfo, EBM Reviews, Embase, Ovid MEDLINE, Epub Ahead of Print, and Ebsco Megafile initially yielded 61 articles, 6 of which were ultimately included after reviewing abstracts and full texts. The identified interventions, which sought to increase accessibility of language-concordant care, increase accessibility of professional interpretation, and improve family communication and understanding, were described positively, though only one was tested for effectiveness.

Current State and Proposal of Best Practices of Standardized Patients for Spanish-Language Objective Structured Clinical Encounters in US Medical Schools

INTRODUCTION

Medical Spanish programs commonly engage Spanish-speaking standardized patients (SPs) for communication skills assessment, yet no studies address SP recruitment, selection, or training.

METHODS

We sent questionnaires to medical Spanish faculty at 20 US medical schools to gauge their practices in recruiting and selecting Spanish-language SPs. We invited faculty to distribute a separate questionnaire to Spanish-language SPs to gather SP language abilities, training, and experience. We analyzed data using descriptive statistics and qualitative content analysis. When available, we reviewed SP video encounters to formally assess participating SPs' linguistic performance using the SP Oral Language Observation Matrix, a rating tool adapted from the Physician Oral Language Observation Matrix to assess oral medical Spanish proficiency.

RESULTS

Eighty percent of faculty (16/20) responded. Standardized patient recruitment sources included institutional English-language SPs, Hispanic student groups and professional organizations, communities, and language professionals. Faculty-reported strategies to determine language readiness included interviewing SP candidates in Spanish and asking them to self-rate language skills using a validated scale. Fifteen SPs (54%, 15/28) from 5 schools responded to the SP questionnaire, and one third (5/15) reported that their Spanish was not assessed before being selected as an SP. In addition, one third (5/15) did not receive any initial training before performing a medical Spanish case. Raters assessed 11 different SPs using the SP Oral Language Observation Matrix, and 6 were rated as linguistically "ready" for the SP role.

CONCLUSIONS

Current approaches to recruitment, training, and language assessment of SPs vary. We propose strategies to ensure that medical Spanish encounters authentically reflect Spanish-speaking patients.

Understanding Professional Medical Interpreters' Perspectives on Advancing Accurate and Culturally Informed Patient-Provider Communication for Filipinos in Hawai'i: Qualitative Analysis

One in every eight persons in Hawai'i, USA, have limited English proficiency (LEP) and are entitled to free language assistance for federally funded services under Title IV of the Civil Rights Act of 1964. They also have the right to culturally and linguistically appropriate services (CLAS) provided by professional medical interpreters (PMIs). This study's goals were to uncover barriers and facilitators of CLAS from the perspective of PMIs. PMIs for Filipino languages (n = 10) participated in an online survey and semi-structured interviews. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed using conventional content analysis. Six themes emerged in the qualitative analysis: (1) cultural and social factors that can influence patient-provider communication; (2) barriers to effective patient-provider communication: patient, healthcare provider, and PMI levels; (3) facilitators of effective patient-provider communication: patient, healthcare provider, and PMI levels; (4) COVID-19 and remote interpreting barriers and facilitators; (5) strengths and weaknesses of in-person and stand-by interpreting appointments; and, (6) recommendations: system and provider levels. Proposed interventions could include advertising language services among Filipino communities and educating them about their language rights, providing additional resources for language assistance, employing more PMIs, training staff/providers, and supporting the use of PMIs versus untrained individuals.

The Impact of Standardized Recovery Pathways on Language Barriers and Inpatient Pain Management

BACKGROUND AND OBJECTIVES

Inpatient postoperative care is reliant upon clear, open communication between providers and patient-families, and thus is particularly vulnerable to disparities when discordant languages exist. It is not yet understood how standardized postoperative protocols may mitigate disparities related to language discordance.

METHODS

This is a retrospective cohort study among adolescent idiopathic scoliosis patients who underwent posterior spinal fusion at a tertiary care children's hospital in Bronx, New York after implementation of a postoperative pathway in 2017. Outcomes reliant upon communication between patient-families and providers were measured, including measures of pain management (number and type of pain medications requested, daily pain assessments, total opioids consumed), as well as outpatient pain scores.

RESULTS

A total of 160 patients were included (39 language other than English [LOE]). Between patient cohorts, there were no significant differences in demographic or operative characteristics. On univariate analyses, LOE patients were more likely to be given a basal dosing of patient-controlled analgesia or additional boluses (26% vs 12%, P = .03), consumed 0.53 fewer benzodiazepine medications per day (P = .01), and were more likely to have pain at outpatient follow-up (67% vs 43%, P = .03). On multivariate analyses, LOE patients were more likely to be placed on basally dosed or receive additional boluses of patient-controlled analgesia (odds ratio 3.19, 95% confidence interval 1.15-8.85).

CONCLUSIONS

As standardized pathways become more common in health care, it is critical to monitor for components of these protocols that may be vulnerable to language-related disparities, such as therapies reliant on symptom description and outpatient follow-up.

Do clinical and communication skills scores on credentialing exams predict potentially inappropriate antibiotic prescribing?

BACKGROUND

There is considerable variation among physicians in inappropriate antibiotic prescribing, which is hypothesized to be attributable to diagnostic uncertainty and ineffective communication. The objective of this study was to evaluate whether clinical and communication skills are associated with antibiotic prescribing for upper respiratory infections and sinusitis.

METHODS

A cohort study of 2,526 international medical graduates and 48,394 U.S. Medicare patients diagnosed by study physicians with an upper respiratory infection or sinusitis between July 2014 and November 2015 was conducted. Clinical and communication skills were measured by scores achieved on the Clinical Skills Assessment examination administered by the Educational Commission for Foreign Medical Graduates (ECFMG) as a requirement for entry into U.S residency programs. Medicare Part D data were used to determine whether patients were dispensed an antibiotic following an outpatient evaluation and management visit with the study physician. Physician age, sex, specialty and practice region were retrieved from the ECFMG databased and American Medical Association (AMA) Masterfile. Multivariate GEE logistic regression was used to evaluate the association between clinical and communication skills and antibiotic prescribing, adjusting for other physician and patient characteristics.

RESULTS

Physicians prescribed an antibiotic in 71.1% of encounters in which a patient was diagnosed with sinusitis, and 50.5% of encounters for upper respiratory infections. Better interpersonal skills scores were associated with a significant reduction in the odds of antibiotic prescribing (OR per score decile 0.93, 95% CI 0.87-0.99), while greater proficiency in clinical skills and English proficiency were not. Female physicians, those practicing internal medicine compared to family medicine, those with citizenship from the US compared to all other countries, and those practicing in southern of the US were also more likely to prescribe potentially unnecessary antibiotics.

CONCLUSIONS

Based on this study, physicians with better interpersonal skills are less likely to prescribe antibiotics for acute sinusitis and upper respiratory infections. Future research should examine whether tailored interpersonal skills training to help physicians manage patient expectations for antibiotics could reduce unnecessary antibiotic prescribing.

Experiences and Communication Preferences in Pregnancy Care Among Patients With a Spanish Language Preference: A Qualitative Study

OBJECTIVE

To explore Spanish-speaking patients' experiences and preferences regarding communication during pregnancy care with specific attention to language barriers.

METHODS

Patients with a Spanish language preference who gave birth between July 2022 and February 2023 at an academic medical center were invited to participate in focus groups. Focus groups were held over Zoom, audio-recorded, transcribed in Spanish, translated into English, and reviewed for translation accuracy. Thematic analysis was conducted with deductive and inductive approaches. Three investigators double-coded all transcripts, and discrepancies were resolved through team consensus.

RESULTS

Seven focus groups (27 total participants, range 2-6 per group) were held. Three key themes emerged regarding patient experiences and communication preferences when seeking pregnancy care: 1) language concordance and discordance between patients and clinicians are not binary-they exist on a continuum; 2) language-discordant care is common and presents communication challenges, even with qualified interpreters present; and 3) language discordance can be overcome with positive interpersonal dynamics between clinicians and patients.

CONCLUSION

Our findings highlight the importance of relationship to overcome language discordance among patients with limited English proficiency during pregnancy care. These findings inform potential structural change and patient-clinician dyad interventions to better meet the communication needs of patients with limited English proficiency.

The Impact of Surgeon Proficiency in Non-English-Speaking Patients' Primary Language on Outcomes After Total Joint Arthroplasty

Non-English-speaking patients face increased communication barriers when undergoing total joint arthroplasty (TJA). Surgeons may learn or have proficiency in languages spoken among their patients to improve communication. This study investigated the effect of surgeon-patient language concordance on outcomes after TJA. We conducted a single-institution, retrospective review of patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) whose preferred language was not English. Patients were stratified based on whether their surgeon spoke their preferred language (language concordant [LC]) or not (language discordant [LD]). Baseline characteristics, length of stay, discharge disposition, revision rate, readmission rate, and patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score for Joint Replacement [KOOS, JR], Hip disability and Osteoarthritis Outcome Score for Joint Replacement [HOOS, JR], and Patient-Reported Outcomes Measurement Information System [PROMIS]) were compared. A total of 3390 patients met inclusion criteria, with 855 receiving THA and 2535 receiving TKA. Among patients receiving THA, 440 (51.5%) saw a LC provider and 415 (48.5%) saw a LD provider. Those in the LC group had higher HOOS, JR scores at 1 year postoperatively (67.4 vs 49.3, P=.003) and were more likely to be discharged home (77.5% vs 69.9%, P=.013). Among patients receiving TKA, 1051 (41.5%) received LC care, whereas 1484 (58.5%) received LD care. There were no differences in outcome between the LC and LD TKA groups. Patients receiving THA with surgeons who spoke their language had improved patient-reported outcomes and were more commonly discharged home after surgery. Language concordance did not change outcomes in TKA. Optimizing language concordance for patients receiving TJA may improve postoperative outcomes. [Orthopedics. 2023;46(6):334-339.].

Language-Concordant Care: a Qualitative Study Examining Implementation of Physician Non-English Language Proficiency Assessment

BACKGROUND

Language concordance can increase access to care for patients with language barriers and improve patient health outcomes. However, systematically assessing and tracking physician non-English language skills remains uncommon in most health systems. This is a missed opportunity for health systems to maximize language-concordant care.

OBJECTIVE

To determine barriers and facilitators to participation in non-English language proficiency assessment among primary care physicians.

DESIGN

Qualitative, semi-structured interviews.

PARTICIPANTS

Eleven fully and partially bilingual primary care physicians from a large academic health system with a language certification program (using a clinician oral proficiency interview).

APPROACH

Interviews aimed to identify barriers and facilitators to participation in non-English language assessment. Two researchers independently and iteratively coded transcripts using a thematic analysis approach with constant comparison to identify themes.

KEY RESULTS

Most participants were women (N= 9; 82%). Participants reported proficiency in Cantonese, Mandarin, Russian, and Spanish. All fully bilingual participants (n=5) had passed the language assessment; of the partially bilingual participants (n=6), four did not test, one passed with marginal proficiency, and one did not pass. Three themes emerged as barriers to assessment participation: (1) beliefs about the negative consequences (emotional and material) of not passing the test, (2) time constraints and competing demands, and (3) challenging test format and structure. Four themes emerged as facilitators to increase assessment adoption: (1) messaging consistent with professional ethos, (2) organizational culture that incentivizes certification, (3) personal empowerment about language proficiency, and (4) individuals championing certification.

CONCLUSIONS

To increase language assessment participation and thus ensure quality language-concordant care, health systems must address the identified barriers physicians experience and leverage potential facilitators. Findings can inform health system interventions to standardize the requirements and process, increase transparency, provide resources for preparation and remediation, utilize messaging focused on patient care quality and safety, and incentivize participation.

Mammogram perceptions, communication, and gaps in care among individuals with non-English language preference in Oregon and Washington states

This study examined perceptions of and communication about mammography as drivers of gaps in screening among individuals with non-English language preference (NELP). A survey was fielded in fall 2021 in five languages (Cantonese, English, Russian, Spanish, or Vietnamese) to individuals identified using electronic medical records in Oregon and Washington. The analytic sample consisted of 420 respondents with a median age of 61; approximately 45% of respondents identified as Asian, 37% as Hispanic, Latino, or Spanish origin, and 18% as some other race, ethnicity, or origin. Logistic regression models examined associations between screening and perception and communication items. Individuals who believed mammograms are unnecessary when healthy (aRR = 0.72 [0.57, 0.91]) or absent symptoms (aRR = 0.85 [0.72, 1.00]) were less likely to report a mammogram within the past two years (i.e., be current). Having a provider recommend (aRR = 1.27 [1.09, 1.47]) and discuss mammography (aRR = 1.18 [1.05, 1.32]) were associated with a higher likelihood of being current. Few respondents received written or verbal information in their preferred language (35% and 28.3%, respectively). Financial and logistical support, including language services were most frequently identified as types of support needed to obtain a mammogram. Overall, misperceptions about mammography may act as a barrier but communication may act as a facilitator for individuals with NELP. Provider-patient communication could be an effective way to encourage mammography. Culturally-responsive health promotion materials and provider communication, available in patients' preferred language, are needed to combat misperceptions and support ongoing, on-time mammography for NELP patients.

Culture and language coaching for bilingual residents: the first 10 years of the CHiCoS model

ProblemIn the US, there are neither professional standards nor adequate formal training opportunities related to physician use of non-English languages, the most common of which is Spanish. To achieve safe, effective health care for culturally and linguistically diverse patients, the medical profession needs clear standards for physician language use and proven culture and language training models that include validated assessment of linguistic proficiency. InterventionThe authors describe the first decade of an innovative culture and language coaching program for bilingual (Spanish-English) pediatric residents, including the model's evolution and outcomes, as well as recommendations for implementing similar programs elsewhere. Over 10 years, the model has grown from a central innovation-the professional culture and language coach (CLC). The CLC provides 1:1 in-visit support and post-visit coaching to individual residents during three years of continuity clinic experience in a Spanish-language setting (Clínica Hispana de Cuidados de Salud-CHiCoS). They also provide a range of supplementary learning activities (e.g., simulations, immersion rotations, mock testing) and periodic formal assessment of language proficiency. Foundational program elements include cultural and linguistic humility, variations in language, pragmatic linguistics and trans-languaging, the inseparability of culture and language, health literacy, and a flat teaching hierarchy ("all teach, all learn"). ContextCHiCoS has been implemented continuously since 2009 in the primary care clinic of a stand-alone academic pediatric hospital in the Midwest, where pediatric residents have their continuity clinic experience over three years of residency. ImpactFifty-six residents have participated, reporting improved language skills, cultural knowledge, and ability to care for Spanish-speaking patients. Sixty-eight percent of residents not qualified bilingual upon program entry passed a validated physician language assessment by graduation. Spanish-speaking patients seen by CHiCoS residents and faculty reported higher satisfaction, trust, and communication scores than those seen in non-bilingual areas of the same clinic (p < .05 for all scores). The program increased bilingual faculty six-fold and changed attitudes and practices related to language supports throughout the residency program. Lessons LearnedCulture and language coaching provides effective preparation and assessment of bilingual physicians, leading to improved care for culturally and linguistically diverse patients. Our model offers an example for developing similar approaches for a variety of clinicians throughout health care. Such approaches should include professional standards for non-English language use, training supports customized to bilingual learners' proficiency levels, and a focus on integrating practical cultural and linguistic skills to achieve safe, effective clinical communication.

The Relationship of Ethnic, Racial, and Cultural Concordance to Physician-Patient Communication: A Mixed-Methods Systematic Review Protocol

The concept of racial, ethnic, or cultural concordance between a healthcare provider and a patient has emerged as a dimension of the patient-physician relationship that could influence health outcomes for minoritized patients, particularly through differences in the way physicians communicate with patients of various races and ethnicities. However, two decades of study on concordance and physician-patient communication have produced contradictory results. Although existing systematic reviews have addressed race, ethnicity, and culture as influences on medical encounters, only one review, published in 2006, has examined the effects of this concordance across multiple ethnicities, specifically focusing on physician-patient communication. Given the heightened societal awareness of racism and health disparities in recent years, there is a need for a comprehensive review of the current state of knowledge. This review, therefore, will seek to determine how communication patterns differ in ethnically, racially, and culturally concordant versus discordant patient-provider medical encounters, in the process identifying explanatory and outcome variables associated with those differences.

Effective communication with linguistically diverse patients: A concept analysis

OBJECTIVE

Effective communication is essential to providing high-quality healthcare. For linguistically diverse patients, communication remains a barrier to receiving equitable healthcare throughout the globe. It is necessary to examine the concept of effective communication with linguistically diverse patients.

METHODS

The Walker and Avant method was used to analyze the concept.

RESULTS

We define effective communication with linguistically diverse patients as any verbal or written communication between two or more individuals who do not speak the same language that utilizes accurate translation techniques to reach a shared message or understanding, where all parties involved are listened to and actively engaged. The antecedents, attributes, consequences, and empirical referents are mapped.

CONCLUSION

Effective communication with linguistically diverse patients is limited by a lack of access to professional language assistance, structural racism/discrimination, and policy barriers.

PRACTICE IMPLICATIONS

Healthcare workers hold the power to provide language assistance to patients and should therefore receive training in cultural competency, cultural humility, and how to work with professional medical interpreters and language access programs. Institutions should invest in multimodal approaches to provide equitable healthcare to linguistically diverse patients.

'Creating a culturally competent pharmacy profession': A qualitative exploration of pharmacy staff perspectives of cultural competence and its training in community pharmacy settings

INTRODUCTION

Cultural competence is an important attribute underpinning interactions between healthcare professionals, such as pharmacists, and patients from ethnic minority communities. Health- and medicines-related inequalities affecting people from underrepresented ethnic groups, such as poorer access to healthcare services and poorer overall treatment outcomes in comparison to their White counterparts, have been widely discussed in the literature. Community pharmacies are the first port of call for healthcare services accessed by diverse patient populations; yet, limited research exists which explores the perceptions of culturally competent care within the profession, or the delivery of cultural competence training to community pharmacy staff. This research seeks to gather perspectives of community pharmacy teams relating to cultural competence and identify possible approaches for the adoption of cultural competence training.

METHODS

Semistructured interviews were conducted in-person, over the telephone or via video call, between October and December 2022. Perspectives on cultural competence and training were discussed. Interviews were audio-recorded and transcribed verbatim. The reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Newcastle University Ethics Committee (reference: 25680/2022).

RESULTS

Fourteen participants working in community pharmacies were interviewed, including eight qualified pharmacists, one foundation trainee pharmacist, three pharmacy technicians/dispensers and two counter assistants. Three themes were developed from the data which centred on (1) defining and appreciating cultural competency within pharmacy services; (2) identifying pharmacies as 'cultural hubs' for members of the diverse, local community and (3) delivering cultural competence training for the pharmacy profession.

CONCLUSION

The results of this study offer new insights and suggestions on the delivery of cultural competence training to community pharmacy staff, students and trainees entering the profession. Collaborative co-design approaches between patients and pharmacy staff could enable improved design, implementation and delivery of culturally competent pharmacy services.

PATIENT OR PUBLIC CONTRIBUTION

The Patient and Public Involvement and Engagement group at Newcastle University had input in the study design and conceptualisation. Two patient champions inputted to ensure that the study was conducted, and the findings were reported, with cultural sensitivity.

The STAR-MAMA RCT: Bilingual Mobile Health Coaching for Postpartum Weight Loss

INTRODUCTION

Gestational diabetes and overweight during pregnancy are associated with future type 2 diabetes. Postpartum weight loss can reduce diabetes risk. However, effective interventions for postpartum weight loss are lacking, in particular for Latina populations, despite their disproportionate burdens of gestational diabetes, overweight, and diabetes.

STUDY DESIGN

This was a community-based RCT.

SETTING/PARTICIPANTS

Researchers recruited pregnant individuals with gestational diabetes or BMI>25 kg/m2 from safety-net health care settings and Women, Infants, and Children offices in Northern California in 2014-2018. Of 180 individuals randomized to intervention (n=89) or control (n=91), 78% identified as Latina, 61% were primarily Spanish speaking, and 76% perceived their diabetes risk to be low.

INTERVENTION

The intervention consisted of a 5-month postpartum telephone-based health coaching intervention delivered in English or Spanish.

MAIN OUTCOME MEASURES

Data were collected through surveys at enrollment and 9-12 months after delivery and chart review up to 12 months after delivery. The primary outcome, weight change from prepregnancy to 9-12 months after delivery, was compared between the groups, overall and within strata defined a priori according to language (Spanish or English) and diabetes risk perception (none/slight or moderate/high).

RESULTS

The intent-to-treat estimated intervention effect was +0.7 kg (95% CI= -2.4 kg, +3.8 kg; p=0.67). In stratified analyses, intervention effects remained nonsignificant but varied in direction: effects were favorable among English speakers and those with higher perceived diabetes risk, and unfavorable among Spanish speakers and those with lower perceived risk. Analyses were conducted in 2021-2022.

CONCLUSIONS

A postpartum health coaching intervention, designed for low-income Latina women at increased risk for diabetes, did not reduce postpartum weight gain. Intervention effects were nonsignificantly more favorable among English speakers versus Spanish speakers, and among those who perceived their diabetes risk to be high versus low.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT02240420.

Health Disparities for Immigrant Children: Focus on Epilepsy

Although health and health care disparities between immigrant and native-born adult populations in the United States are well documented, the pediatric literature is limited. Data suggest first- and second- generation immigrant children have worse health outcomes when compared with their native-born counterparts because of factors such as socioeconomic status, insurance and language barriers, authorization status, and bias/xenophobia. This article takes a broad look at existing research regarding health barriers for immigrant children, then focuses on the pediatric epilepsy literature to highlight the complex interplay of these disparity factors. Finally, we review the literature on existing interventions, including language concordance, community-driven educational efforts, and broad-scale policy changes that can be used to promote health equity in pediatric epilepsy and beyond. Research gaps are also identified. [Pediatr Ann. 2023;52(10):e373-e380.].