Influence of language barriers on outcomes of hospital care for general medicine inpatients

Completeness and readability of GPT-4-generated multilingual discharge instructions in the pediatric emergency department

Objectives

The aim of this study was to assess the completeness and readability of generative pre-trained transformer-4 (GPT-4)-generated discharge instructions at prespecified reading levels for common pediatric emergency room complaints.

Materials and Methods

The outputs for 6 discharge scenarios stratified by reading level (fifth or eighth grade) and language (English, Spanish) were generated fivefold using GPT-4. Specifically, 120 discharge instructions were produced and analyzed (6 scenarios: 60 in English, 60 in Spanish; 60 at a fifth-grade reading level, 60 at an eighth-grade reading level) and compared for completeness and readability (between language, between reading level, and stratified by group and reading level). Completeness was defined as the proportion of literature-derived key points included in discharge instructions. Readability was quantified using Flesch-Kincaid (English) and Fernandez-Huerta (Spanish) readability scores.

Results

English-language GPT-generated discharge instructions contained a significantly higher proportion of must-include discharge instructions than those in Spanish (English: mean (standard error of the mean) = 62% (3%), Spanish: 53% (3%), P = .02). In the fifth-grade and eighth-grade level conditions, there was no significant difference between English and Spanish outputs in completeness. Readability did not differ across languages.

Discussion

GPT-4 produced readable discharge instructions in English and Spanish while modulating document reading level. Discharge instructions in English tended to have higher completeness than those in Spanish.

Conclusion

Future research in prompt engineering and GPT-4 performance, both generally and in multiple languages, is needed to reduce potential for health disparities by language and reading level.

Addressing disparities in health outcomes for patients with advanced pancreatic cancer and limited English proficiency

INTRODUCTION

There are significant challenges and a lack of data related to culturally and linguistically diverse (CALD) cancer patients. We compared patient characteristics, treatment patterns, and outcomes of patients with advanced pancreatic cancer that required an interpreter.

METHODS

Registry data was extracted for advanced pancreatic cancer patients from a single health institution with a comprehensive Transcultural and Language Service (TALS). Demographic and clinicopathologic characteristics were compared. Kaplan-Meier survival estimates with log-rank testing, and univariate and multivariable regression analysis were performed to compare the group with limited English proficiency (LEP) to the English proficient (EP) group.

RESULTS

Of 155 patients, 32.9% (n = 51) required the TALS. The LEP group had a higher mean age (71.2 vs. 76.8 years; p = 0.005) and received less chemotherapy (42.3% vs. 31.4%, p = 0.220). Univariate analysis revealed a shorter median overall survival (OS) in the LEP group (3.6 vs. 5.0 months), with a hazard ratio [HR] of 1.51 (95% confidence interval [CI]: 1.03-2.21, p = 0.033). Upon multivariable analysis, adjusting for Eastern Cooperative Oncology Group (ECOG) performance scale, the number of sites of metastatic disease and chemotherapy use, the strength of association between LEP and OS reduced marginally (HR 1.42, 95% CI: 0.93-2.16), and was no longer statistically significant (p = 0.103).

CONCLUSIONS

In patients with advanced pancreatic cancer utilizing a comprehensive TALS, there was a trend to poorer survival with limited English proficiency, although this association was not statistically significant. An ongoing research commitment to the CALD experience is necessary to build a granular understanding of this population and ensure equitable outcomes.

Assessing for differences in opioid administration during inpatient end-of-life care for patients with limited English proficiency

BACKGROUND

Patients with limited English proficiency (LEP) may have worse health outcomes and differences in processes of care. Language status may particularly affect situations that depend on communication, such as symptom management or end-of-life (EOL) care.

OBJECTIVE

The objective of this study was to assess whether opioid prescribing and administration differs by English proficiency (EP) status among hospitalized patients receiving EOL care.

METHODS

This single-center retrospective study identified all adult patients receiving "comfort care" on the general medicine service from January 2013 to September 2021. We assessed for differences in the quantity of opioids administered (measured by oral morphine equivalents [OME]) by patient LEP status using multivariable linear regression, controlling for other patient and medical factors.

RESULTS

We identified 2652 patients receiving comfort care at our institution during the time period, of whom 1813 (68%) died during the hospitalization. There were no significant differences by LEP status in terms of mean OME per day (LEP received 30.8 fewer OME compared to EP, p = .91) or in the final 24 h before discharge (LEP received 61.7 more OME compared to EP, p = .80).

CONCLUSION

LEP was not associated with differences in the amount of opioids received for patients whose EOL management involved standardized order sets for symptom management at our hospital.

Effect of Language Barriers and Use of Interpreters on Hope Among Patients With Central Nervous System Malignancies and Bone Metastases

PURPOSE

Hope is important in serious illnesses, as it has been linked to patient quality of life. We aimed to determine factors associated with lower hope scores among patients with central nervous system disease or bone metastases.

METHODS AND MATERIALS

The Adult Dispositional Hope Scale (AHS) is a 12-item questionnaire that measures hope through 2 qualities: agency (goal-directed energy) and pathways (plan to meet goals). Total scores range from 8 to 64, with higher scores reflecting higher agency and pathways thinking. We prospectively collected scores from patients seen in 2 radiation oncology clinics at our institution from October 2022 to April 2023. The method of least squares to fit general linear models and Pearson's correlation coefficients was used to determine relationships between AHS score and socioeconomic and disease factors.

RESULTS

Of the 197 patients who responded, the median age was 60.5 years (range, 16.9-92.5 years) and most patients were male (60.9%), were White (59.4%), and had malignant disease (59.4%). The median overall AHS score was 54 (range, 8-64), and median pathway and agency thinking scores were 27 (range, 4-32) and 27 (range, 4-32), respectively. Patients who needed an interpreter compared with those who did not had significantly lower overall AHS scores (mean score, 45.4 vs 51.2, respectively; P = .0493) and pathway thinking scores (mean score, 21.5 vs 25.7, respectively; P = .0085), and patients with poorer performance status had significantly worse overall AHS scores (Pearson's correlation coefficient = -0.2703, P = .0003).

CONCLUSIONS

Patients with central nervous system disease or bone metastases requiring the use of an interpreter had lower AHS scores, highlighting the possible association of language barriers to hope. Addressing patient language barriers and further studies on the possible association of language barriers to hope may improve hope, quality of life, and outcomes among these patients.

NPCC4: Climate change and New York City's health risk

This chapter of the New York City Panel on Climate Change 4 (NPCC4) report considers climate health risks, vulnerabilities, and resilience strategies in New York City's unique urban context. It updates evidence since the last health assessment in 2015 as part of NPCC2 and addresses climate health risks and vulnerabilities that have emerged as especially salient to NYC since 2015. Climate health risks from heat and flooding are emphasized. In addition, other climate-sensitive exposures harmful to human health are considered, including outdoor and indoor air pollution, including aeroallergens; insect vectors of human illness; waterborne infectious and chemical contaminants; and compounding of climate health risks with other public health emergencies, such as the COVID-19 pandemic. Evidence-informed strategies for reducing future climate risks to health are considered.

Are medical history data fit for risk stratification of patients with chest pain in emergency care? Comparing data collected from patients using computerized history taking with data documented by physicians in the electronic health record in the CLEOS-CPDS prospective cohort study

OBJECTIVE

In acute chest pain management, risk stratification tools, including medical history, are recommended. We compared the fraction of patients with sufficient clinical data obtained using computerized history taking software (CHT) versus physician-acquired medical history to calculate established risk scores and assessed the patient-by-patient agreement between these 2 ways of obtaining medical history information.

MATERIALS AND METHODS

This was a prospective cohort study of clinically stable patients aged ≥ 18 years presenting to the emergency department (ED) at Danderyd University Hospital (Stockholm, Sweden) in 2017-2019 with acute chest pain and non-diagnostic ECG and serum markers. Medical histories were self-reported using CHT on a tablet. Observations on discrete variables in the risk scores were extracted from electronic health records (EHR) and the CHT database. The patient-by-patient agreement was described by Cohen's kappa statistics.

RESULTS

Of the total 1000 patients included (mean age 55.3 ± 17.4 years; 54% women), HEART score, EDACS, and T-MACS could be calculated in 75%, 74%, and 83% by CHT and in 31%, 7%, and 25% by EHR, respectively. The agreement between CHT and EHR was slight to moderate (kappa 0.19-0.70) for chest pain characteristics and moderate to almost perfect (kappa 0.55-0.91) for risk factors.

CONCLUSIONS

CHT can acquire and document data for chest pain risk stratification in most ED patients using established risk scores, achieving this goal for a substantially larger number of patients, as compared to EHR data. The agreement between CHT and physician-acquired history taking is high for traditional risk factors and lower for chest pain characteristics.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT03439449.

Association between language discordance and unplanned hospital readmissions or emergency department revisits: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Studies conflict about whether language discordance increases rates of hospital readmissions or emergency department (ED) revisits for adult and paediatric patients. The literature was systematically reviewed to investigate the association between language discordance and hospital readmission and ED revisit rates.

DATA SOURCES

Searches were performed in PubMed, Embase and Google Scholar on 21 January 2021, and updated on 27 October 2022. No date or language limits were used.

STUDY SELECTION

Articles that (1) were peer-reviewed publications; (2) contained data about patient or parental language skills and (3) included either unplanned hospital readmission or ED revisit as one of the outcomes, were screened for inclusion. Articles were excluded if: unavailable in English; contained no primary data or inaccessible in a full-text form (eg, abstract only).

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data using Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping reviews guidelines. We used the Newcastle-Ottawa Scale to assess data quality. Data were pooled using DerSimonian and Laird random-effects models. We performed a meta-analysis of 18 adult studies for 28-day or 30-day hospital readmission; 7 adult studies of 30-day ED revisits and 5 paediatric studies of 72-hour or 7-day ED revisits. We also conducted a stratified analysis by whether access to interpretation services was verified/provided for the adult readmission analysis.

MAIN OUTCOMES AND MEASURES

Odds of hospital readmissions within a 28-day or 30-day period and ED revisits within a 7-day period.

RESULTS

We generated 4830 citations from all data sources, of which 49 (12 paediatric; 36 adult; 1 with both adult and paediatric) were included. In our meta-analysis, language discordant adult patients had increased odds of hospital readmissions (OR 1.11, 95% CI 1.04 to 1.18). Among the 4 studies that verified interpretation services for language discordant patient-clinician interactions, there was no difference in readmission (OR 0.90, 95% CI 0.77 to 1.05), while studies that did not specify interpretation service access/use found higher odds of readmission (OR 1.14, 95% CI 1.06 to 1.22). Adult patients with a non-dominant language preference had higher odds of ED revisits (OR 1.07, 95% CI 1.004 to 1.152) compared with adults with a dominant language preference. In 5 paediatric studies, children of parents language discordant with providers had higher odds of ED revisits at 72 hours (OR 1.12, 95% CI 1.05 to 1.19) and 7 days (OR 1.02, 95% CI 1.01 to 1.03) compared with patients whose parents had language concordant communications.

DISCUSSION

Adult patients with a non-dominant language preference have more hospital readmissions and ED revisits, and children with parents who have a non-dominant language preference have more ED revisits. Providing interpretation services may mitigate the impact of language discordance and reduce hospital readmissions among adult patients.

PROSPERO REGISTRATION NUMBER

CRD42022302871.

Social accountability challenges and recommendations by community service rehabilitation therapists

BACKGROUND

 Social accountability entails providing equitable and accessible services that are tailor-made for the community's healthcare needs and enable rehabilitation therapists to improve the efficiency and efficacy of healthcare delivery and their response. Enabling them to provide optimal care during their community service year requires understanding the gaps in their knowledge, experience and the support they provide to the communities they service.

METHODS

 Four in-depth individual interviews and four focus group discussions were conducted via Zoom. The qualitative responses to the questions related to the challenges and recommendations associated with social accountability in clinical settings were analysed using an inductive thematic approach via NVIVO.

RESULTS

 Four sub-themes emerged for each of the two areas of interest: the challenges relating to (1) budget and equipment constraints, (2) staff shortages, (3) cultural and language barriers and (4) scope of practice limitations. The recommendations related to (5) collaboration with community caregivers, (6) service inclusion in primary health care clinics, (7) improved executive management support and (8) continuing professional development.

CONCLUSION

 Equipping graduates with the knowledge, skills and support needed to work in an under-resourced setting is essential for community service rehabilitation therapists to ensure social accountability, given that they often work alone, specifically in rural settings.Contribution: Being aware of the challenges that face community service rehabilitation therapists, having the necessary tools and health facility management support will enable ongoing improvements in their ability to provide socially accountable services.

Rate of Primary Cesarean Delivery by Language Preference among Nulliparas

OBJECTIVE

Sociodemographic factors such as race/ethnicity and socioeconomic status affect primary cesarean delivery rates. Language is associated with disparate health care outcomes but has not been well studied in obstetrics. We examined the association between primary unscheduled cesarean delivery rate and preferred patient language.

STUDY DESIGN

A retrospective cohort study was conducted at an urban medical center between January 2017 and January 2020. Nulliparous women with early or full-term gestation and having no obstetric or medical contraindication to vaginal delivery were included. We used multivariable linear and logistic regressions to evaluate language differences in cesarean delivery odds and indication for cesarean.

RESULTS

Of the 1,314 eligible women, 76.8% of patients preferred English, 17.8% Spanish, and 5.4% other languages. Overall cesarean delivery rate was 27.6%. Controlling for age, race/ethnicity, body mass index, insurance, gravidity, pregnancy comorbidities, labor induction, and infant birth weight, Spanish- and other language-speaking women had significantly higher odds of undergoing cesarean compared with English-speaking women (adjusted odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.25, 2.46). Relative proportions of indications for cesarean did not differ by language group. Documented interpreter use was an effect modifier on the relationship between language preference and cesarean (OR with interpreter use: 2.89, 95% CI: 1.90, 4.39).

CONCLUSION

Primary cesarean delivery rates were significantly higher among nulliparous women who prefer languages other than English. This difference may reflect lack of communication, provider bias or discrimination, or other factors, and should be further studied. Interpreter services should be routinely utilized and documented effectively.

KEY POINTS

· Women who prefer languages other than English had higher odds of cesarean.. · Indication for cesarean did not differ by language.. · Interpreter use did not reduce risk for cesarean..

Limited English Proficiency and Outcomes in the Intensive Care Unit: An Integrated Review

INTRODUCTION

Language barriers place patients at risk of substandard care. Hospitalized patients with limited English proficiency (LEP) face unique challenges, especially in the intensive care unit (ICU). The purpose of this review is to critique and synthesize quantitative evidence on LEP and ICU outcomes.

METHODOLOGY

Quantitative studies published in English between 1999 and 2022 were queried using intentional terminology.

RESULTS

Searches yielded 138 results, with 12 meeting inclusion criteria. The analysis resulted in the extrapolation of five themes pertinent to outcomes of ICU patients or families with LEP: (a) knowledge deficit relating to conditions and care; (b) lack of language-appropriate care; (c) alienation from care process; (d) decreased confidence and ownership of care; and (e) relationship to clinical quality indicators.

DISCUSSION

Outcomes associated with LEP were largely negative and revealed unmet needs for ICU patients with LEP. More research is needed to improve linguistically and culturally congruent care in the ICU.

Ascertaining the Francophone population in Ontario: validating the language variable in health data

BACKGROUND

Language barriers can impact health care and outcomes. Valid and reliable language data is central to studying health inequalities in linguistic minorities. In Canada, language variables are available in administrative health databases; however, the validity of these variables has not been studied. This study assessed concordance between language variables from administrative health databases and language variables from the Canadian Community Health Survey (CCHS) to identify Francophones in Ontario.

METHODS

An Ontario combined sample of CCHS cycles from 2000 to 2012 (from participants who consented to link their data) was individually linked to three administrative databases (home care, long-term care [LTC], and mental health admissions). In total, 27,111 respondents had at least one encounter in one of the three databases. Language spoken at home (LOSH) and first official language spoken (FOLS) from CCHS were used as reference standards to assess their concordance with the language variables in administrative health databases, using the Cohen kappa, sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV).

RESULTS

Language variables from home care and LTC databases had the highest agreement with LOSH (kappa = 0.76 [95%CI, 0.735-0.793] and 0.75 [95%CI, 0.70-0.80], respectively) and FOLS (kappa = 0.66 for both). Sensitivity was higher with LOSH as the reference standard (75.5% [95%CI, 71.6-79.0] and 74.2% [95%CI, 67.3-80.1] for home care and LTC, respectively). With FOLS as the reference standard, the language variables in both data sources had modest sensitivity (53.1% [95%CI, 49.8-56.4] and 54.1% [95%CI, 48.3-59.7] in home care and LTC, respectively) but very high specificity (99.8% [95%CI, 99.7-99.9] and 99.6% [95%CI, 99.4-99.8]) and predictive values. The language variable from mental health admissions had poor agreement with all language variables in the CCHS.

CONCLUSIONS

Language variables in home care and LTC health databases were most consistent with the language often spoken at home. Studies using language variables from administrative data can use the sensitivity and specificity reported from this study to gauge the level of mis-ascertainment error and the resulting bias.

Navigating linguistic barriers: a case for and against medical Spanish certification for medical students in border states

Limited English proficiency poses a significant barrier to health care, particularly in US border states, exacerbated by a nationwide shortage of interpreters. This growing disparity in language-concordant care underscores the need for solutions like integrating Medical Spanish Certification (MSC) into medical school curricula, a topic of considerable debate. Various arguments exist for and against including MSC in medical education, especially considering the increasing Hispanic/Latino patient population. This paper aims to present a balanced perspective on officially including MSC in medical school curricula. After discussing the various arguments, the authors suggest a balanced approach that addresses the challenges while leveraging the potential benefits of MSC in medical education.

Dementia-Related Disparities in Adult Day Centers: Results of a Bivariate Analysis

PURPOSE

Adult day services (ADS) are a valuable resource for people living with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD) and serve a large population of late-life immigrants, often with limited English proficiency (LEP). This secondary data analysis examined potential disparities in diagnosis, dementia severity, medical complexity, and dementia-related behavioral problems in persons with AD/ADRD with LEP within the ADS setting.

METHOD

The current study used data from TurboTAR, the electronic health record for ADS in California. Bivariate analyses were conducted to examine differences in clinical management for those with and without LEP.

RESULTS

Of 3,053 participants included in the study, 42.3% had LEP. Participants with LEP had higher rates of emergency department use and medication mismanagement. However, due to non-standard data collection, there was a significant amount of missing data on language preference (38.1%) and race/ethnicity (46.5%). Although these findings suggest LEP may play a role in the clinical management of persons with AD/ADRD in ADS, missing data caused by lack of standardized collection compromise the results.

CONCLUSION

It is essential to improve data collection practices in ADS on language, race, and ethnicity to help identify health disparities and promote equitable care for marginalized older adults. [Journal of Gerontological Nursing, 50(4), 42-47.].

Limited English Proficiency and Graves' Disease at an Urban Safety Net Hospital

INTRODUCTION

Decision-making regarding definitive therapy for Graves' disease requires effective patient-provider communication. We investigated whether patients with limited English proficiency have differences in thyroidectomy outcomes or perioperative management when compared to English proficient (EP) patients at a safety net hospital with high-volume endocrine surgery practice.

METHODS

Retrospective study of patients who underwent thyroidectomy (2012-2021) for Graves' disease within a tertiary referral system. Demographics, preoperative factors, and postoperative outcomes were abstracted via chart review and compared between EP and limited English proficient (LEP) patients in univariate analyses. Odds of postoperative complications were assessed via multivariable logistic regression. Time metrics such as time from endocrinology consultation to surgery were compared via Kaplan-Meier analysis and adjusted Cox proportional regression models.

RESULTS

Of 236 patients, 85 (36%) had LEP. Low and equivalent complication rates occurred across language groups (<1% permanent). LEP patients had similar odds of thyroidectomy-specific complications (odds ratio = 1.2; 95% confidence interval 0.6-2.4). Adjusted Cox proportional hazards ratios showed that LEP patients experienced significantly shorter time from endocrinology consultation to surgery compared to EP patients [hazard ratio = 0.7; 95% confidence interval 0.5-0.9].

CONCLUSIONS

Thyroidectomy-specific complication rate for patients with Graves' disease was low, and we detected no independent association between complications and English language proficiency. Non-English primary language was independently associated with reduced time from endocrinology consultation to surgery. This finding must be interpreted with nuance and is likely multifactorial. It may reflect a well-organized, efficient system for under-resourced patients, or it may derive from communication barriers that limit robust shared decision-making, thus accelerating time to surgery.

Using artificial intelligence to promote equitable care for inpatients with language barriers and complex medical needs: clinical stakeholder perspectives

OBJECTIVES

Inpatients with language barriers and complex medical needs suffer disparities in quality of care, safety, and health outcomes. Although in-person interpreters are particularly beneficial for these patients, they are underused. We plan to use machine learning predictive analytics to reliably identify patients with language barriers and complex medical needs to prioritize them for in-person interpreters.

MATERIALS AND METHODS

This qualitative study used stakeholder engagement through semi-structured interviews to understand the perceived risks and benefits of artificial intelligence (AI) in this domain. Stakeholders included clinicians, interpreters, and personnel involved in caring for these patients or for organizing interpreters. Data were coded and analyzed using NVIVO software.

RESULTS

We completed 49 interviews. Key perceived risks included concerns about transparency, accuracy, redundancy, privacy, perceived stigmatization among patients, alert fatigue, and supply-demand issues. Key perceived benefits included increased awareness of in-person interpreters, improved standard of care and prioritization for interpreter utilization; a streamlined process for accessing interpreters, empowered clinicians, and potential to overcome clinician bias.

DISCUSSION

This is the first study that elicits stakeholder perspectives on the use of AI with the goal of improved clinical care for patients with language barriers. Perceived benefits and risks related to the use of AI in this domain, overlapped with known hazards and values of AI but some benefits were unique for addressing challenges with providing interpreter services to patients with language barriers.

CONCLUSION

Artificial intelligence to identify and prioritize patients for interpreter services has the potential to improve standard of care and address healthcare disparities among patients with language barriers.

Underlying Causes of Ethnocultural Inequality in Pregnancy Outcomes: Role of Hospital Proximity

We evaluated the contribution of place of birth to ethnocultural inequality in pregnancy outcomes. We analyzed a cohort of 1,487,723 births between 1998 and 2019 among minority Anglophones and majority Francophones in Quebec, Canada. We estimated the association (adjusted risk ratio, RR; 95% confidence interval, CI) of language with preterm birth and stillbirth, and incorporated interaction terms to determine the contribution of place of birth and distance traveled. Compared with Francophones, minority Anglophones had a greater risk of preterm birth (RR 1.03; 95% CI 1.01-1.06) and were less likely to deliver farther from home (RR 0.95; 95% CI 0.94-0.95). Anglophones who delivered close to home had a higher risk of preterm birth (RR 1.07; 95% CI 1.04-1.11), whereas Anglophones who delivered farther had a lower risk (RR 0.69; 95% CI 0.64-0.75). Patterns were similar for stillbirth. Ethnocultural inequality in adverse birth outcomes may be influenced by place of birth.

The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the U.S.: A Scoping Review

A majority of individuals with limited English proficiency (LEP) in the U.S. are foreign-born, creating a complex intersection of language, socio-economic, and policy barriers to healthcare access and achieving good outcomes. Mapping the research literature is key to addressing how LEP intersects with healthcare. This scoping review followed PRISMA-ScR guidelines and included PubMed/MEDLINE, CINAHL, Sociological Abstracts, EconLit, and Academic Search Premier. Study selection included quantitative studies since 2000 with outcomes specified for adults with LEP residing in the U.S. related to healthcare service access or defined health outcomes, including healthcare costs. A total of 137 articles met the inclusion criteria. Major outcomes included ambulatory care, hospitalization, screening, specific conditions, and general health. Overall, the literature identified differential access to and utilization of healthcare across multiple modalities with poorer outcomes among LEP populations compared with English-proficient populations. Current research includes inconsistent definitions for LEP populations, primarily cross-sectional studies, small sample sizes, and homogeneous language and regional samples. Current regulations and practices are insufficient to address the barriers that LEP individuals face to healthcare access and outcomes. Changes to EMRs and other data collection to consistently include LEP status and more methodologically rigorous studies are needed to address healthcare disparities for LEP individuals.

Non-English Primary Language: A Growing Population's Access to Cholecystectomy

OBJECTIVE

To examine access to cholecystectomy and postoperative outcomes among non-English primary-speaking patients.

BACKGROUND

The population of U.S. residents with limited English proficiency is growing. Language affects health literacy and is a well-recognized barrier to health care in the United States of America. Historically marginalized communities are at greater risk of requiring emergent gallbladder operations. However, little is known about how primary language affects surgical access and outcomes of common surgical procedures, such as cholecystectomy.

METHODS

We conducted a retrospective cohort study of adult patients after receipt of cholecystectomy in Michigan, Maryland, and New Jersey utilizing the Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery and Services Database (2016-2018). Patients were classified by primary spoken language: English or non-English. The primary outcome was admission type. Secondary outcomes included operative setting, operative approach, in-hospital mortality, postoperative complications, and length of stay. Multivariable logistics and Poisson regression were used to examine outcomes.

RESULTS

Among 122,013 patients who underwent cholecystectomy, 91.6% were primarily English speaking and 8.4% were non-English primary language speaking. Primary non-English speaking patients had a higher likelihood of emergent/urgent admissions (odds ratio: 1.22, 95% CI: 1.04-1.44, P = 0.015) and a lower likelihood of having an outpatient operation (odds ratio: 0.80, 95% CI: 0.70-0.91, P = 0.0008). There was no difference in the use of a minimally invasive approach or postoperative outcomes based on the primary language spoken.

CONCLUSIONS

Non-English primary language speakers were more likely to access cholecystectomy through the emergency department and less likely to receive outpatient cholecystectomy. Barriers to elective surgical presentation for this growing patient population need to be further studied.

A Case Study of the Impact of Language Concordance on Patient Care, Satisfaction, and Comfort with Sharing Sensitive Information During Medical Care

Linguistic barriers continue to be a source of difficulty and inappropriate treatment in our healthcare system. Several studies have shown the importance of language concordance, which leads to increased trust and higher patient satisfaction. The aim of this is study is to determine patients' satisfaction and comfort levels with sharing sensitive information in Spanish with either the health care provider or an interpreter, respectively, and to compare the results to find out if there is an option that patients prefer. There were two different groups of participants in the study. The experimental group was directly seen by Spanish-speaking student doctors while the control group was seen by English-speaking student doctors that had the aid of an interpreter. Several questions were asked to participants via survey in order to measure their comfort levels during the encounter. The results of this study demonstrate that having Spanish-speaking healthcare providers providing health care to Hispanic patients can raise patients' comfort levels and satisfaction in contrast to having the aid of an interpreter. Providing second language training to student doctors can potentially improve patient care and reduce health inequities facing LEP patients. Given the small sample size of our study, future projects should expand the study to include more participants.

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.

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.].

Enhancing Medical Spanish Education and Proficiency to Bridge Healthcare Disparities: A Comprehensive Assessment and Call to Action

This article highlights the critical importance of linguistic and cultural concordance in health care, particularly in addressing the shortage of proficient Spanish-speaking healthcare providers in California. It advocates for standardized curricula, qualified instructors, and mandatory medical Spanish courses while stressing the significance of interdisciplinary training that integrates language skills with clinical experience and acknowledges the interplay between language and culture in health care. The article calls for proactive efforts from medical schools, faculty, and healthcare providers, emphasizing standardized curricula, culturally sensitive training, and reliable assessment tools. Additionally, it underscores the need to enhance the representation of underrepresented minority healthcare providers to ensure equitable health care for linguistic minorities, emphasizing the shared responsibility of healthcare and education stakeholders.

The roles and experiences of medical interpreters in palliative care: A narrative review

OBJECTIVES

Skilled medical interpreters are essential to providing high-quality, culturally sensitive palliative care and addressing health-care disparities for patients with limited English proficiency (LEP). While the benefits of utilizing medical interpreters are well documented, interpreter roles and experiences in palliative care are unique and poorly defined. This narrative review examines the extant literature on medical interpreters in palliative care to define their unique roles and describe their experiences and recommendations.

METHODS

A narrative literature review was completed through systematically searching the following databases: Medline, Embase, Web of Science, and CINHAL. Title and abstract screening was completed, followed by full-text review.

RESULTS

Ten articles met inclusion criteria and were included in the review. Medical interpreters play several roles in palliative care for patients with LEP including interpreting language and meaning, acting as a cultural broker, and advocating for patients and families. Medical interpreters report being comfortable interpreting palliative care discussions; however, they face challenges in navigating their complex roles and the emotional impact of palliative care encounters. Their recommendations to improved palliative care encounters involving medical interpreters are careful language choice, holding pre- and post-meetings, education for interpreters and health-care professionals, and further integrating the medical interpreter into the interprofessional team.

SIGNIFICANCE OF RESULTS

Medical interpreters play several complex roles when participating in palliative care encounters for patients with LEP. Understanding these roles and the experiences allows medical interpreters to be better integrated into the interprofessional team and enhances the ability to provide quality, culturally sensitive palliative care for patients with LEP. Further research is required to understand how implementing the recommendations of medical interpreters impacts patient outcomes.

Electronic Health Interventions for Type 2 Diabetes and Obesity in Hispanic or Latino Adults: A Systematic Review of English and Spanish Studies

Objective

The objective of this study was to synthesize English and Spanish literature to determine whether electronic health interventions (EHIs) such as telehealth, telemedicine, digital health, and mobile health (mHealth) improve A1C, blood glucose, BMI, and/or weight among Hispanic/Latino adults with type 2 diabetes or overweight/obesity in the Americas.

Design and methods

Searches were conducted in June 2021 using the Scientific Electronic Library Online, Cumulative Index of Nursing and Allied Health Literature, PubMed, and PsycInfo literature databases. Studies were identified that investigated the effect of an EHI on A1C, blood glucose, BMI, or weight in populations that were ≥12% Hispanic/Latino adults with type 2 diabetes or overweight/obesity, were conducted in the Americas, and were published in English or Spanish. Study quality was determined using the Quality Index Score. Data were extracted and synthesized, and themes were identified.

Results

Twenty-five studies met inclusion criteria, including 23 in English (from the United States) and two in Spanish (from Chile). A total of 22 investigated type 2 diabetes, and three investigated overweight/obesity. The studies encompassed 6,230 participants, including 3,413 Hispanic/Latino adults. Sixty-three percent of studies demonstrated significant improvements in A1C or blood glucose and 67% in weight. Thirteen studies offered an EHI in both English and Spanish, and six offered the intervention in either English or Spanish alone. All EHIs involving mHealth exclusively and most (90%) involving more than one electronic modality demonstrated a higher number of significant findings compared with those having only one EHI modality, especially telehealth (44.4%). EHIs lasting ≤12 months had more significant findings (72.7%) than those lasting >12 months (50%). Six studies had industry-related funding, with 83.3% of those demonstrating significant improvements in outcomes.

Conclusion

EHIs improved A1C and weight in adults (n = 4,355), including 45.5% Hispanic/Latino adults. mHealth and EHIs using more than one electronic modality and those lasting ≤12 months were especially effective. However, overall study quality was modest. Future research should be conducted in Spanish-speaking countries in Latin America and should compare the effectiveness of different EHI modalities.

Reproductive inequity and inferior intrauterine insemination outcomes in patients with limited English proficiency: a retrospective cohort study

OBJECTIVE

To evaluate if language preference influences intrauterine insemination outcomes.

DESIGN

Retrospective cohort.

SETTING

The study was conducted at an urban medical center in New York from January 2016 to August 2021.

PATIENT(S)

All women older than 18 years undergoing their first IUI cycle with an infertility diagnosis were included.

INTERVENTION(S)

Intrauterine insemination after ovarian stimulation.

MAIN OUTCOME MEASURE(S)

Primary outcomes were intrauterine insemination success rate and duration of infertility before seeking infertility care. The primary outcomes used the Kaplan-Meier estimator to investigate the difference in duration of infertility before specialty consultation and logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) of clinical pregnancy among English speakers vs. those with limited English proficiency (LEP) undergoing initial IUI. Secondary outcomes included final IUI outcomes compared by language preference. Adjusted analyses controlled for race/ethnicity.

RESULTS

A total of 406 patients were included in this study, of which 86% preferred English, 7.6% preferred Spanish, and 5.2% preferred other. Patients with LEP have longer duration of infertility before seeking infertility care than English-proficient women (mean 4.53 ± 3.65 years vs. 2.01 ± 1.58 years). Although clinical pregnancy rate of initial IUI did not significantly vary (OR, 2.92; 95% CI, 0.68-12.47 unadjusted and OR, 2.88; 95% CI, 0.67-12.35 adjusted), the cumulative pregnancy rate was significantly higher in English-proficient patients than in LEP patients at the time of final IUI (22.32% vs. 15.38%). This is despite a similar number of total IUIs (2.40 English vs. 2.70 LEP). Additionally, LEP patients were significantly more likely to discontinue care after unsuccessful IUI, instead of proceeding to further fertility treatments such as in vitro fertilization.

CONCLUSIONS

Limited English proficiency is associated with longer duration of infertility before initiating care as well as poorer IUI outcomes, including lower cumulative pregnancy rate. Further research is needed to assess what clinical and socioeconomic factors are contributing to lower IUI success rates and lower continuation in infertility care in LEP patients.

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.].

Association of Primary Language with Very Low Birth Weight Outcomes in Hispanic Infants in California

OBJECTIVE

To determine the association of Spanish as a primary language for a family with the health outcomes of Hispanic infants with very low birth weight (VLBW, <1500g).

STUDY DESIGN

Data from the California Perinatal Quality Care Collaborative (CPQCC) linked to hospital discharge records were analyzed. Hispanic infants with VLBW born between 2009 and 2018 with a primary language of English or Spanish were included. Outcomes selected were hypothesized to be sensitive to language barriers. Multivariable logistic regression models and mixed models estimated associations between language and outcomes.

RESULTS

Of 18 364 infants meeting inclusion criteria, 27% (n = 4976) were born to families with Spanish as a primary language. In unadjusted analyses, compared with infants of primarily English-speaking families, these infants had higher odds of hospital readmission within 1 year (OR 1.11 [95% CI 1.02-1.21]), higher odds to receive human milk at discharge (OR 1.32 [95% CI 1.23-1.42]), and lower odds of discharge home with oxygen (OR 0.83 [95% CI 0.73-0.94]). In multivariable analyses, odds of readmission and home oxygen remained significant when adjusting for infant but not maternal and hospital characteristics. Higher odds for receipt of any human milk at discharge were significant in all models. Remaining outcomes did not differ between groups.

CONCLUSIONS

Significant differences exist between Hispanic infants with VLBW of primarily Spanish-vs English-speaking families. Exploration of strategies to prevent readmissions of infants of families with Spanish as a primary language is warranted.

Transitional care of older ethnic minority patients: An integrative review

AIMS

To critically synthesize the empirical literature on practice in transitional care and how to meet the care needs of older ethnic minority populations who discharged from hospital to community.

DESIGN

An integrative literature review integrating empirical studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

PubMed, Web of Science, PsycINFO, EBSCO (including CINAHL and MEDLINE) and Scopus were searched for papers published between 2012 and September 2022.

REVIEW METHODS

Full-text papers were screened against inclusion and exclusion criteria subsequent to screening titles and abstracts. All included papers were evaluated for methodological quality using the Critical Appraisal Skills Programme Checklists. After extracting findings, themes were created by critically examining and synthesizing of findings.

RESULTS

The search yielded a total of 1180 studies, 1153 after removing duplicates and 27 papers meeting the inclusion criteria and exclusion criteria were included in the review. The main findings were categorized into four themes: (i) intervention-related outcomes; (ii) unmet needs of older minority people; (iii) transitional care-related characteristics of older minority people and (iv) challenges for healthcare providers. Findings indicated that the transitional care experience of ethnic minority older populations differed from natives to some extent which revealed unmet needs addressing how to provide culturally appropriate transitional care for this population.

CONCLUSION

This review gave insight into facilitators in the transitional care of ethnic minority older adults. Future transitional care interventions should incorporate needs of ethnic minority population.

IMPACT

This review highlighted the defined gaps between existing transitional care programmes and transitional care needs of older ethnic minority. Increasing follow-up completion, evidence defining deeply of ethnic phenomenon in the transitional care process, developing interventions that meet transitional care needs and increasing healthcare providers' cultural competency were featured headlines. No Patient or Public Contribution.

A Pilot Randomized Trial of a Purposeful and Stimulating Volunteer Opportunity: Program Satisfaction and Potential Impacts on Perceived Cognitive Change in a Neurologically Mixed Sample of Older Adults

BACKGROUND

Purposeful social interactions are important for healthy aging. We conducted a pilot trial of SPEAK! (Seniors Promoting English Acquisition and Knowledge), an intervention providing older volunteers with a safe, accessible opportunity to converse via webcam with English-language learners.

METHODS

A neurologically mixed sample of older adults was randomized to 8 weekly, webcam conversations with English-language learners or a waitlist control. Outcomes included the Cognitive Change Index (CCI) and surveys of program satisfaction. Here, we report on session completion, intervention satisfaction, and follow-up CCI scores. Exploratory analyses of CCI intervention effects controlled for baseline CCI scores and the interaction between group and baseline CCI.

RESULTS

Participants (N=38) were on average 70.8 years of age, 28/38 were White, and 16/38 demonstrated possible cognitive impairment on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Pairs completed 115/136 sessions (85%) and all volunteers said they would recommend the program. Controlling for the interaction between baseline CCI and randomization group, SPEAK! volunteers had better follow-up CCI scores than controls (P=0.018). Improvements in CCI were greater among participants with fewer baseline memory problems.

CONCLUSIONS

SPEAK! was feasible and appreciated by older adults with and without cognitive impairment. Larger studies should confirm benefits for memory and other determinants of quality of life.

Navigating Cultural Diversity in the Selection of Cardiovascular Device Treatments: A Comprehensive Review

In cardiology, patients' cultural beliefs, linguistic differences, lack of knowledge, and socioeconomic status can create barriers to choosing device treatment. To address this issue, we conducted a thorough literature review using online databases such as PubMed, Google Scholar, and Texas Tech University Health Sciences Center's research portal. Our review found that cultural, religious, and linguistic barriers can contribute to patients' apprehension and reservations about device placement. These barriers can also impact patients' adherence to treatment and clinical outcomes. Patients from lower socioeconomic backgrounds may have difficulty accessing and affording device-based treatments. Additionally, fear and inadequate understanding of surgical procedures can deter patients from accepting device treatment in cardiology. To overcome these cultural barriers, healthcare providers must raise awareness about the benefits of device treatment and provide better training to overcome these challenges. It is crucial to address the unique needs of patients from different cultural backgrounds and socioeconomic statuses to ensure they receive the care they need.

A Multilingual Chatbot Can Effectively Engage Arthroplasty Patients with Limited English Proficiency

BACKGROUND

In the United States, English language proficiency is widely accepted as a key social determinant of health. For patients with limited English proficiency (LEP), language barriers can make the delivery of perioperative instructions challenging. The purpose of this study was to evaluate whether a multilingual chatbot could effectively engage LEP patients and improve their outcome after total joint arthroplasty (TJA).

METHODS

We identified 1,282 TJA patients (705 knees, 577 hips) who enrolled in a Short Message Service (SMS) chatbot from 2020-2022. 47 patients enrolled in the chatbot received their messages in a language other than English. A historical control of 68 LEP patients not enrolled in the chatbot was identified. Chi-squared, Fisher's Exact, and t-tests were performed to measure the effect that conversational engagement had on ED visits, hospital readmissions, and reoperations.

RESULTS

There was no difference in the conversational engagement between LEP patients and those with English as their primary language (EPL) (12.3 vs. 12.2 text responses, p=0.959). The LEP cohort who enrolled in the chatbot had fewer readmissions (0% vs. 8.3%, p=0.013) and a near significant reduction in ED visits (0.9% vs. 8.0%, p=0.085) compared to those not enrolled. There was no difference in reoperations between the two cohorts.

CONCLUSIONS

LEP and EPL patients engaged equally with the multilingual chatbot. LEP patients who enrolled in the chatbot had fewer readmissions and a near significant reduction in ED visits. Multilingual platforms such as this chatbot may provide more equitable care to our frequently encountered LEP patients.

Impact of Socioeconomic Demographics and Race on Laryngotracheal Stenosis Etiology and Outcomes

OBJECTIVE

Certain sociodemographic variables are known to result in health care disparities. This study investigates potential differences in outcomes for patients with laryngotracheal stenosis (LTS) based on racial backgrounds and socioeconomic variables including insurance status and English language-Proficiency.

METHODS

Patients with LTS from 2016 to 2021were identified by relevant ICD codes. Variables including race, age, gender, language preference and insurance status were collected from medical records. Risk factors for LTS including COPD, smoking history, diabetes, GERD, and BMI were obtained. Etiology of LTS was categorized as autoimmune, traumatic, iatrogenic, or idiopathic. Need for temporary tracheostomy and tracheostomy dependence were determined at last follow-up visit.

RESULTS

129 patients were included for review. 70% of Black patients had iatrogenic LTS, whereas 65% of the White patient cohort had autoimmune or idiopathic LTS. Black patients were more strongly associated with temporary tracheostomy and tracheostomy dependence compared to White patients. Public health insurance and co-morbid GERD were associated with tracheostomy dependence for White patients only.

CONCLUSION

This study identified a disproportionate representation of Black patients in the iatrogenic etiology of LTS. Although controlling for risk factors of LTS, this cohort had an increased need for temporary tracheostomy and tracheostomy dependence compared to White and Latinx cohorts. This finding merits further study.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:908-913, 2023.

Understanding the Role of Caseworker-Cultural Mediators in Addressing Healthcare Inequities for Patients with Limited-English Proficiency: a Qualitative Study

BACKGROUND

Patients with limited-English proficiency (LEP) face multiple barriers to equitable healthcare. Interventions that go beyond interpretation, such as the use of bicultural-bilingual patient navigators, hold promise for addressing multi-level barriers. However, data about how to operationalize the tasks that are key to such interventions across diverse LEP communities are lacking.

OBJECTIVE

Using our health system's bicultural-bilingual caseworker-cultural mediator (CCM) program serving Amharic-, Cambodian/Khmer-, Somali-, Spanish-, and Vietnamese-speaking patients, we sought to understand the key tasks that comprise the CCMs' role and how these tasks enable them to address barriers to healthcare for patients with LEP.

DESIGN

Semi-structured interviews were conducted in 2019 with a purposive sample (n=23) of clinicians, CCMs, and patients with LEP or their family members from all language groups.

PARTICIPANTS

Patients or family members receiving CCM services, CCMs, and clinicians who referred patients to the program.

APPROACH

Content analysis consisting of a hybrid deductive-inductive qualitative approach.

KEY RESULTS

Seven CCM tasks were identified: advocacy, care coordination, navigation, interpretation, education, mediation, and emotional support. Additionally, four key impacts emerged that described the ways in which these tasks enabled the CCMs to facilitate equitable care: bridging the patient, family, community, clinical team, and healthcare system; impacting knowledge of cultural issues and of the healthcare system; troubleshooting cultural barriers and problem solving; and enhancing relationship building.

CONCLUSIONS

We identified several tasks and impacts that enabled CCMs to address multi-level barriers to care experienced by patients with LEP and their families across diverse cultural and linguistic groups. Findings suggest opportunities for the generalizability of programs such as ours for multiple LEP populations. Additionally, interventions having a greater scope than interpretation and including relationships with communities may be more successful in addressing barriers to equitable care at the individual, system, and community levels.

Effects of Language, Age, and Hearing Loss on Health-Related Quality of Life

Objective

To understand the effect of age on health-related quality of life (HRQoL) in patients with hearing loss and determine how primary language mediates this relationship.

Study Design

Cross-sectional study.

Setting

General otolaryngology clinic in Los Angeles.

Methods

Demographics, medical records, and HRQoL data of adult patients presenting with otology symptoms were reviewed. HRQoL was measured using the Short-Form 6-Dimension utility index. All patients underwent audiological testing. A path analysis was performed to generate a moderated path analysis with HRQoL as the primary outcome.

Results

This study included 255 patients (mean age = 54 years; 55% female; 27.8% did not speak English as a primary language). Age had a positive direct association with HRQoL (p < .001). However, the direction of this association was reversed by hearing loss. Older patients exhibited significantly worse hearing (p < .001), which was negatively associated with HRQoL (p < .05). Primary language moderated the relationship between age and hearing loss. Specifically, patients who did not speak English as a primary language had significantly worse hearing (p < .001) and therefore worse HRQoL (p < .01) than patients who spoke English as a primary language with hearing loss. Increasing age was associated with bilateral hearing loss compared to unilateral hearing loss (p < .001) and subsequently lower HRQoL (p < .001). Polypharmacy (p < .01) and female gender (p < .01) were significantly associated with lower HRQoL.

Conclusion

Among otolaryngology patients with otology symptoms, older age and not speaking English as a primary language were associated with worse hearing and subsequently lower HRQoL.

A sequential, multiple assignment randomized trial comparing web-based education to mobile video interpreter access for improving provider interpreter use in primary care clinics: the mVOCAL hybrid type 3 study protocol

BACKGROUND

Individuals who use a language other than English for medical care are at risk for disparities related to healthcare safety, patient-centered care, and quality. Professional interpreter use decreases these disparities but remains underutilized, despite widespread access and legal mandates. In this study, we compare two discrete implementation strategies for improving interpreter use: (1) enhanced education targeting intrapersonal barriers to use delivered in a scalable format (interactive web-based educational modules) and (2) a strategy targeting system barriers to use in which mobile video interpreting is enabled on providers' own mobile devices.

METHODS

We will conduct a type 3 hybrid implementation-effectiveness study in 3-5 primary care organizations, using a sequential multiple assignment randomized trial (SMART) design. Our primary implementation outcome is interpreter use, calculated by matching clinic visits to interpreter invoices. Our secondary effectiveness outcome is patient comprehension, determined by comparing patient-reported to provider-documented visit diagnosis. Enrolled providers (n = 55) will be randomized to mobile video interpreting or educational modules, plus standard interpreter access. After 9 months, providers with high interpreter use will continue as assigned; those with lower use will be randomized to continue as before or add the alternative strategy. After another 9 months, both strategies will be available to enrolled providers for 9 more months. Providers will complete 2 surveys (beginning and end) and 3 in-depth interviews (beginning, middle, and end) to understand barriers to interpreter use, based on the Theoretical Domains Framework. Patients who use a language other than English will be surveyed (n = 648) and interviewed (n = 75) following visits with enrolled providers to understand their experiences with communication. Visits will be video recorded (n = 100) to assess fidelity to assigned strategies. We will explore strategy mechanism activation to refine causal pathway models using a quantitative plus qualitative approach. We will also determine the incremental cost-effectiveness of each implementation strategy from a healthcare organization perspective, using administrative and provider survey data.

DISCUSSION

Determining how these two scalable strategies, alone and in sequence, perform for improving interpreter use, the mechanisms by which they do so, and at what cost, will provide critical insights for addressing a persistent cause of healthcare disparities.

TRIAL REGISTRATION

NCT05591586.

Improving Professional Spiritual Care to Persons With Limited English Proficiency: The Cross-Language Chaplaincy Introduction Guidebook

Hospitalized individuals in the United States with limited English proficiency (LEP) may experience complications when receiving hospital care. Grounded in the ethical principles of chaplaincy and motivated by the desire to address inequitable health service provision, we developed the Cross-Language Chaplaincy Introduction Guidebook. The Guidebook introduces chaplaincy in 20 different languages with the goal of improving chaplain accessibility. We report on the rigorous development of the Guidebook and how to integrate the resource clinically.

Pharmacists, nurses, and physicians' perspectives and use of formal and informal interpreters during medication management in the inpatient setting

OBJECTIVE

Language barriers during inpatient medication management can occur during medication reconciliation on admission and discharge, and during the hospitalization. Understanding inpatient clinicians' experiences with language barriers and use of interpreters can help inform interventions aimed at improving medication management with Limited English Proficient (LEP) patients. Our objective was to examine clinicians' experiences with language barriers around inpatient medication management.

METHODS

We used semi-structured interviews with pharmacist technicians, pharmacists, nurses, and physicians working in a tertiary care hospital. We used the constant comparison method to guide data collection and analysis.

RESULTS

We interviewed 14 providers. Nurses and physicians perceived lack of time to use formal interpreters, particularly during busy or night shifts. Clinicians strongly preferred virtual and in-person interpreter services over telephonic services, and highlighted communication challenges with patients with low health literacy, concerns about the quality of interpretation, and inconsistencies in the use of translated materials.

CONCLUSIONS

Ensuring access to formal interpreters during all shifts, translation of materials into the patient/caregiver's language, and access to in-person/virtual services would improve quality of care for LEP patients.

PRACTICE IMPLICATIONS

Current laws require use of interpreters, but do not provide for their reimbursement, resulting in suboptimal use. Reimbursement for interpreter services may increase their availability.

Evaluation of consent forms for clinical practice in Spanish Public Hospitals

OBJECTIVE

To evaluate the access, development, and quality of consents forms for clinical practice within the Spanish Public Hospitals.

METHOD

A cross-sectional study was conducted in a two-stage process (January 2018-September 2021). In stage 1, A nationwide survey was undertaken across all public general hospitals (n=223) in the Spanish Healthcare System. In stage 2, Data was taken from the regional health services websites and Spanish regulations. Health Regional Departments were contacted to verify the accuracy of the findings. Data was analyzed using a descriptive and inferential statistics (frequencies, percentages, Chi-square & Fisher's exact tests).

RESULTS

The response rate was 123 (55.16%) of Spanish Public Hospitals. The results revealed a range of hospital departments involved in the development of consent documents and the absence of a standardized approach to consent forms nationally. Consent audits are undertaken in 43.09% hospitals and translation of written consents into other languages is limited to a minority of hospitals (35.77%). The validation process of consent documentation is not in evidence in 13% of Spanish Hospitals. Regional Informed Consent Committees are not place in the majority (70.7%) of hospitals. Citizens can freely access to consent documents through the regional websites of Andalusia and Valencia only.

CONCLUSION

Variability is found on access, development and quality of written consent across the Spanish Public Hospitals. This points to the need for a national informed consent strategy to establish policy, standards and an effective quality control system. National audits at regular intervals are necessary to improve the consistency and compliance of consent practice.

Investigating Racial and Socioeconomic Characteristics in Pediatric Sepsis Using Electronic Health Data

BACKGROUND AND OBJECTIVES

Racial/ethnic and socioeconomic disparities are reported in sepsis, with increased mortality for minority and low socioeconomic status groups; however, these studies rely on billing codes that are imprecise in identifying sepsis. Using a previously validated algorithm to detect pediatric sepsis using electronic clinical data, we hypothesized that racial/ethnic and socioeconomic status disparities would be evident in this group.

METHODS

We performed a retrospective study from a large, quaternary academic center, including sepsis episodes from January 20, 2011, to May 20, 2021, identified by an algorithm indicative of bacterial infection with organ dysfunction (cardiac, respiratory, renal, or hematologic). Multivariable logistic regression was used to measure association of race/ethnicity, insurance status, and social disorganization index, with the primary outcome of mortality, adjusting for age, sex, complex chronic conditions, organ dysfunction on day 1, source of admission, and time to hospital. Secondary outcomes were ICU admission, readmission, organ dysfunction-free days, and sepsis therapies.

RESULTS

Among 4532 patient episodes, the mortality rate was 9.7%. There was no difference in adjusted odds of mortality on the basis of race/ethnicity, insurance status, or social disorganization. There was no significant association between our predictors and ICU admission. Hispanic patients and publicly insured patients were more likely to be readmitted within 1 year (Hispanic odds ratio 1.28 [1.06-1.5]; public odds ratio 1.19 [1.05-1.35]).

CONCLUSIONS

Previously described disparities were not observed when using electronic clinical data to identify sepsis; however, data were only single center. There were significantly higher readmissions in patients who were publicly insured or identified as Hispanic or Latino, which require further investigation.

Comparative costs for critically ill patients with limited English proficiency versus English proficiency

OBJECTIVES

To conduct comparative cost analysis of hospital care for critically ill patients with Limited English Proficiency (LEP) versus patients with English proficiency (controls).

PATIENTS AND METHODS

We conducted a historical cohort study using propensity matching at Mayo Clinic Rochester, a quaternary care academic center. We included hospitalized patients who had at least one admission to ICU during a 10-year period between 1/1/2008-12/31/2017.

RESULTS

Due to substantial differences in baseline characteristics of the groups, propensity matching for the covariates age, sex, race, ethnicity, APACHE 3 score, and Charlson Comorbidity score was used, and we achieved the intended balance. The final cohort included 80,404 patients, 4,246 with LEP and 76,158 controls. Patients with LEP had higher costs during hospital admission to discharge, with a mean cost difference of $3861 (95% CI $822 to $6900, p = 0.013) and also higher costs during index ICU admission to hospital discharge, with a mean cost difference of $3166 (95% CI $231 to $6101, p = 0.035). A propensity matched cohort including only those that survived showed those with LEP had significantly greater mean costs for all outcomes. Sensitivity analysis revealed that international patients with LEP had significantly greater overall hospital costs of $9,240 than patients with LEP who resided in the US (95% CI $3341 to $15,140, p = 0.002).

CONCLUSION

This is the first study to demonstrate significantly higher costs for patients with LEP experiencing a critical illness. The causes for this may be increased healthcare utilization secondary to communication deficiencies that impede timely decision making about care.

End-of-life healthcare utilization and palliative care use among older adults with limited English proficiency

BACKGROUND

Little is known about end-of-life healthcare utilization and palliative care use among older adults with serious illness and limited English proficiency (LEP).

METHODS

We conducted a retrospective analysis of seriously-ill older adults (65+) with and without LEP, from a large health system, who died between 2010 and 2018. Primary outcomes were measures of healthcare utilization in the last 30 and 180 days of life: hospitalization, emergency department (ED) visits, intensive care unit (ICU) admission, and 30-day readmission. Secondary outcomes were palliative care consultation and advance care planning documents. We used multivariate analyses adjusted for sociodemographic factors including race and ethnicity.

RESULTS

Among 18,490 decedents, 1363 had LEP. Patients with LEP were older at time of death (median age 80 vs 77 years), more likely to be female (48% vs 44%), of Asian descent (64% vs 4%), of Hispanic ethnicity (10% vs 2%), with <12th grade education (38% vs 9%), and Medicaid (36% vs 6%). In the last 30 days of life, patients with LEP had higher odds of ED visits (33% vs 20%; aOR 1.41, 95% CI 1.26-1.72; p < 0.001), readmission (12% vs 8%; aOR 1.64, 95% CI 1.30-2.07; p < 0.001), and in-hospital death (45% vs 37%; aOR 1.24, 95% CI 1.07-1.44; p = 0.005) compared to patients without LEP. Findings were similar in the last 180-days of life. Only 14% of patients with LEP and 10% of those without LEP received palliative care consultation in the last month of life. Patients with LEP were less likely to have advance care planning documents than patients without LEP (36% vs 40%; aOR 0.68, 95% CI 0.50-0.80; p < 0.001).

CONCLUSIONS

Older adults with serious illness and LEP have higher rates of end-of-life healthcare utilization. Additional research is needed to identify drivers of these differences and inform linguistically- and culturally-appropriate interventions to improve end-of-life care in this population.

Academics versus the Internet: Evaluating the readability of patient education materials for cerebrovascular conditions from major academic centers

Background:

Health literacy profoundly impacts patient outcomes as patients with decreased health literacy are less likely to understand their illness and adhere to treatment regimens. Patient education materials supplement in-person patient education, especially in cerebrovascular diseases that may require a multidisciplinary care team. This study aims to assess the readability of online patient education materials related to cerebrovascular diseases and to contrast the readability of those materials produced by academic institutions with those of non-academic sources.

Methods:

The readability of online patient education materials was analyzed using Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) assessments. Readability of academic-based online patient education materials was compared to nonacademic online patient education materials. Online patient education materials from 20 academic institutions and five sources from the web were included in the analysis.

Results:

Overall median FKGL for neurovascular-related patient online education documents was 11.9 (95% CI: 10.8–13.1), reflecting that they are written at a 12th grade level, while the median FRE was 40.6 (95% CI: 34.1–47.1), indicating a rating as “difficult” to read. When comparing academic-based online patient education materials to other internet sources, there was no significant difference in FRE and FKGL scores (P = 0.63 and P = 0.26 for FKGL and FRE, respectively).

Conclusion:

This study demonstrates that online patient education materials pertaining to cerebrovascular diseases from major academic centers and other nonacademic internet sites are difficult to understand and written at levels significantly higher than that recommended by national agencies. Both academic and nonacademic sources reflect this finding equally. Further study and implementation are warranted to investigate how improvements can be made.

Forgotten in the crowd: A qualitative study of medical interpreters' role in medical teams

BACKGROUND

Patients with limited English proficiency (LEP) experience worse outcomes compared with native English speakers. Communication errors are partly responsible for the disparities among this population. Medical interpreters improve communication and often assume multiple roles during clinical encounters. We sought to explore the perspectives of medical interpreters regarding their role within medical teams and ways to improve communication.

METHODS

We conducted a qualitative study using semistructured interviews with inpatient and outpatient medical interpreters at an academic medical center between March and August 2021. Interview questions explored interpreters' perceptions of their roles within the medical team and best practices to improve communication during encounters. Interview transcripts were analyzed using thematic analysis.

RESULTS

Our sample consisted of 20 interpreters with a mean age of 48 years (SD: 14.3) and a mean experience of 16.3 years (SD: 10.6). Two main themes emerged from interviews: (1) the full spectrum of medical interpreters' role and (2) factors acting as barriers and facilitators of interpretation. Interpreters described their role as language interpreters, cultural mediators, and patient advocates. They also identified several factors that may enhance encounters, such as utilizing the teach-back method with patients and debriefing with interpreters.

CONCLUSIONS

Interpreters view their role as extending beyond interpretation to include cultural mediation and patient advocacy. Addressing commonly encountered challenges and adopting some of the proposed solutions highlighted in this study may facilitate improved communication with LEP patients receiving care in healthcare systems.

Limited English Proficiency and Clinical Outcomes After Hospital-Based Care in English-Speaking Countries: a Systematic Review

BACKGROUND

Limited English proficiency (LEP) is common among hospitalized patients and may impact care. We synthesized the literature comparing clinical outcomes after in-hospital care for English-proficient(EP) versus LEP patients.

METHODS

This systematic review searched PubMed, Embase, and Web of Science from database inception through June 7, 2020, to identify research investigating clinical outcomes in patients receiving hospital-based care (in the emergency department, inpatient ward, surgical/procedural suite, or intensive care unit) that compared patients with LEP to an EP group. We assessed mortality, length of stay (LOS), readmissions/revisits, and complications. Study quality was evaluated using the Newcastle-Ottawa Scale.

RESULTS

Twenty-six studies met eligibility criteria. Study settings and populations were heterogeneous. Determination of primary language varied; a majority of studies (16/26) used patient self-report directly or via hospital records. Of 16 studies examining LEP and all-cause mortality, 13 found no significant association. Of 17 studies measuring LOS, 9 found no difference, 4 found longer LOS, 3 found shorter LOS, and 1 had mixed LOS results among patients with LEP. Several investigations suggested that LOS differences may be mediated at the hospital level. Nine studies evaluated inpatient readmissions. Among patients with LEP, there was evidence for increased readmissions in the setting of chronic medical conditions such as heart failure, but no evidence for increased readmissions among cohorts undergoing surgeries/procedures or with acute medical conditions. Five studies evaluated complications or harm related to a hospitalization, and no differences were found between language groups.

DISCUSSION

The research community lacks a standardized definition of LEP. Most studies did not find an association between English proficiency and mortality or complications. LOS findings were mixed and may be influenced at the hospital level. Differences in readmissions by language were concentrated in chronic medical conditions. Given the paucity of studies examining LEP populations, additional research is imperative.

PROSPERO REGISTRATION NUMBER

CRD42020143477.