Influence of English proficiency on patient-provider communication and shared decision-making

Shared decision-making before prostate cancer screening decisions

Decisions around prostate-specific antigen screening require a patient-centred approach, considering the benefits and risks of potential harm. Using shared decision-making (SDM) can improve men's knowledge and reduce decisional conflict. SDM is supported by evidence, but can be difficult to implement in clinical settings. An inclusive definition of SDM was used in order to determine the prevalence of SDM in prostate cancer screening decisions. Despite consensus among guidelines endorsing SDM practice, the prevalence of SDM occurring before the decision to undergo or forgo prostate-specific antigen testing varied between 11% and 98%, and was higher in studies in which SDM was self-reported by physicians than in patient-reported recollections and observed practices. The influence of trust and continuity in physician-patient relationships were identified as facilitators of SDM, whereas common barriers included limited appointment times and poor health literacy. Decision aids, which can help physicians to convey health information within a limited time frame and give patients increased autonomy over decisions, are underused and were not shown to clearly influence whether SDM occurs. Future studies should focus on methods to facilitate the use of SDM in clinical settings.

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

OBJECTIVES

In order to improve the degree of shared decision making (SDM) experienced by patients, it is necessary to gain insight into the explanations for the differences in these degrees.

METHODS

A scoping review of the literature on the explanations for differences in the degree of SDM experienced by patients was conducted. We assessed 21,329 references. Ultimately, 308 studies were included. The explanations were divided into micro, meso, and macro levels.

RESULTS

The explanations are mainly related to the micro level. They include explanations related to the patient and healthcare professionals, the relationship between the patient and the physician, and the involvement of the patient's relatives. On the macro level, explanations are related to restrictions within the healthcare system such as time constraints, and adequate information about treatment options. On the meso level, explanations are related to the continuity of care and the involvement of other healthcare professionals.

CONCLUSIONS

SDM is not an isolated process between the physician and patient. Explanations are connected to the macro, meso, and micro levels.

PRACTICE IMPLICATIONS

This scoping review suggests that there could be more focus on explanations related to the macro and meso levels, and on how explanations at different levels are interrelated.

Case-Based Immigrant Health Ethics Curriculum: A Pathway to Improve Care and Advocacy

Introduction Immigrants comprised a significant portion of the total population in the United States (US), and a considerable number of children in the US live with at least one immigrant parent, which has continued to increase over the past decades. However, healthcare providers (HPs) in the US report lack of comfort in interacting with immigrant and refugee populations. Methods The authors, in partnership with the Midwest Consortium of Global Health Educators, developed an innovative, interactive ethics curriculum within the Immigrant Partnership Advocacy and Curricular Kit (I-PACK). They sought to increase HPs' confidence in navigating complex encounters with immigrant families by teaching a relevant ethical framework, highlighting the importance of cultural humility, and equipping learners with an ethics tool (five-box Method) for use in clinical encounters. They piloted the curriculum during three workshop sessions in 2020-2021, and this curriculum continues to be used nationally as a part of I-PACK. Results Pre- and post-session surveys indicated that all participants (100%, n=22) reported acquisition of new skills/knowledge and 19 (86%) felt confident applying this to their clinical practice. The participants reported appreciation for an ethical framework with which to analyze cases, enjoyment of active participation in small group discussions, and utility of the five-box method tool. Some areas of improvement offered were to have more cases and more time dedicated to small-group discussions. Conclusions Given the success of the I-PACK ethics curriculum pilot, the authors plan to incorporate immigrant health cases in the general ethics training in medical school classes and pediatric residency training. Furthermore, they will advocate for the importance of including immigrant health ethics across graduate medical education, as fluency and competence in navigating the ethics of immigrant health are required to provide patient-centered, culturally informed care to all populations.

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.

Association of Language Barriers With Process Outcomes After Craniotomy for Brain Tumor

BACKGROUND

Little is known about the independent association of language barriers on postoperative process outcomes after craniotomies.

OBJECTIVE

To evaluate the association of limited English proficiency (LEP) with length of stay (LOS), discharge disposition, hospitalization costs, and rate of 30-day readmission after craniotomy for brain tumor.

METHODS

This is a retrospective cohort study of adult patients who underwent craniotomies for brain tumor from 2015 to 2019 at a high-volume neurosurgical center. Multivariable logistic regression was used to evaluate the association of LEP with discharge disposition and 30-day readmission. Negative binomial regression was used to evaluate the association of LEP with LOS and hospitalization cost.

RESULTS

Of the 2232 patients included, 7% had LEP. LEP patients had longer LOS (median [IQR] 5 [3-8] days vs 3 [2-5] days, P < .001), higher costs of hospitalization (median [IQR] $27 000 [$21 000-$36 000] vs $23 000 [$19 000-$30 000], P < .001), and were more likely to be discharged to skilled care facilities (37% vs 21%, P < .001) compared with English proficient patients. In multivariable models, the association between LEP and longer LOS (incidence rate ratio 1.11, 95% CI 1.00-1.24), higher hospitalization costs (incidence rate ratio 1.13, 95% CI 1.05-1.20), and discharge to skilled care (OR 1.76, 95% CI 1.13-2.72) remained after adjusting for confounders. There was no difference in 30-day readmission rates by language status.

CONCLUSION

LEP is an independent risk factor for extended LOS, higher hospitalization cost, and discharge to skilled care in neurosurgical patients who undergo craniotomy for brain tumor. Future research should seek to understand mediators of these observed disparities.

Association of Patient and Family Reports of Hospital Safety Climate With Language Proficiency in the US

IMPORTANCE

Patients with language barriers have a higher risk of experiencing hospital safety events. This study hypothesized that language barriers would be associated with poorer perceptions of hospital safety climate relating to communication openness.

OBJECTIVE

To examine disparities in reported hospital safety climate by language proficiency in a cohort of hospitalized children and their families.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study conducted from April 29, 2019, through March 1, 2020, included pediatric patients and parents or caregivers of hospitalized children at general and subspecialty units at 21 US hospitals. Randomly selected Arabic-, Chinese-, English-, and Spanish-speaking hospitalized patients and families were approached before hospital discharge and were included in the analysis if they provided both language proficiency and health literacy data. Participants self-rated language proficiency via surveys. Limited English proficiency was defined as an answer of anything other than "very well" to the question "how well do you speak English?"

MAIN OUTCOMES AND MEASURES

Primary outcomes were top-box (top most; eg, strongly agree) 5-point Likert scale ratings for 3 Children's Hospital Safety Climate Questionnaire communication openness items: (1) freely speaking up if you see something that may negatively affect care (top-box response: strongly agree), (2) questioning decisions or actions of health care providers (top-box response: strongly agree), and (3) being afraid to ask questions when something does not seem right (top-box response: strongly disagree [reverse-coded item]). Covariates included health literacy and sociodemographic characteristics. Logistic regression was used with generalized estimating equations to control for clustering by site to model associations between openness items and language proficiency, adjusting for health literacy and sociodemographic characteristics.

RESULTS

Of 813 patients, parents, and caregivers who were approached to participate in the study, 608 completed surveys (74.8% response rate). A total of 87.7% (533 of 608) of participants (434 [82.0%] female individuals) completed language proficiency and health literacy items and were included in the analyses; of these, 14.1% (75) had limited English proficiency. Participants with limited English proficiency had lower odds of freely speaking up if they see something that may negatively affect care (adjusted odds ratio [aOR], 0.26; 95% CI, 0.15-0.43), questioning decisions or actions of health care providers (aOR, 0.19; 95% CI, 0.09-0.41), and being unafraid to ask questions when something does not seem right (aOR, 0.44; 95% CI, 0.27-0.71). Individuals with limited health literacy (aOR, 0.66; 95% CI, 0.48-0.91) and a lower level of educational attainment (aOR, 0.59; 95% CI, 0.36-0.95) were also less likely to question decisions or actions.

CONCLUSIONS AND RELEVANCE

This cohort study found that limited English proficiency was associated with lower odds of speaking up, questioning decisions or actions of providers, and being unafraid to ask questions when something does not seem right. This disparity may contribute to higher hospital safety risk for patients with limited English proficiency. Dedicated efforts to improve communication with patients and families with limited English proficiency are necessary to improve hospital safety and reduce disparities.

Exploring motivations and resistances for implementing shared decision-making in clinical practice: A systematic review based on a structure-process-outcome model

OBJECTIVE

Shared decision-making (SDM) as a multicollaborative approach is vital for facilitating patient-centred care. Considering the limited clinical practice, we attempted to synthesize the motivations and resistances, and investigate their mutual relationships for advancing the implementation of SDM.

METHODS

A comprehensive systematic review using Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines was performed. 'Shared decision making' was searched as the mesh term through PubMed, Web of Science and EBSCO from 2000 to 2021, and the quality of literature was appraised using the QualSyst Tool. Motivations and resistances were categorized based on content analysis and the 'structure-process-outcome' model.

RESULTS

From 8319 potential citations, 105 were included, comprising 53 qualitative studies (the average quality score is 0.92) and 52 quantitative studies (the average quality score is 0.95). A total of 42 categories of factors were identified into 11 themes and further grouped into three dimensions: structure, process and outcome. The structure dimension comprised six themes (71.43%), the process dimension contained four themes (11.01%) and the outcome dimension covered only one theme. Across all categories, decision-making time and patients' decision preparedness in the process dimension were the most reported, followed by physicians' communication skills and health care environment in the structure dimension. Analysis of implementation of SDM among various types of diseases showed that more influencing factors were extracted from chronic diseases and unspecified disease decisions.

CONCLUSIONS

The major determinants for the implementation of SDM are focused on the structural dimension, which challenges the health systems of both developed and low- and middle-income countries. Furthermore, we consider it important to understand more about the interactions among the factors to take integrated measures to address the problems and to ensure the effectiveness of implementing SDM.

PATIENT OR PUBLIC CONTRIBUTION

Patients, healthcare professionals and other stakeholders articulated their perspectives on the implementation of SDM actively, and these were adopted and analysed in this study. However, the above-mentioned individuals were not directly involved in the process of this study. Protocol was registered on PROSPERO (CRD42021259309).

Social vulnerability and fragmentation of postoperative surgical care among patients undergoing hepatopancreatic surgery

BACKGROUND

Regionalization of hepatopancreatic surgery to high-volume hospitals has been associated with fragmentation of postoperative care and, in turn, inferior outcomes after surgery. The objective of this study was to examine the association of social vulnerability with the likelihood of experiencing fragmentation of postoperative care (FPC) after hepatopancreatic surgery.

METHODS

Patients who underwent hepatopancreatic surgery and had at least 1 readmission within 90 days were identified using Medicare 100% Standard Analytical Files between 2013 and 2017. Fragmentation of postoperative care was defined as readmission at a hospital other than the index institution where the initial surgery was performed. The association of social vulnerability index and its components with fragmentation of postoperative care was examined.

RESULTS

Among 11,142 patients, 8,053 (72.3%) underwent pancreatectomy, and 3,089 (27.7%) underwent hepatectomy. The overall incidence of fragmentation of postoperative care was 32.9% (n = 3,667). Patients who experienced fragmentation of postoperative care were older (73 years [interquartile range: 69-77]_FPC vs 72 years [interquartile range: 68-77]_non-FPC) and had a higher Charlson comorbidity score (4 [interquartile range: 2-8]_FPC vs 3 [interquartile range: 2-8]_non-FPC) (both P < .001). Median overall social vulnerability index was higher among patients who experienced fragmentation of postoperative care (52.5 [interquartile range: 29.3-70.4]_FPC vs 51.3 [interquartile range: 27.9-69.4]_non-FPC, P = .02). On multivariable analysis, the odds of experiencing fragmentation of postoperative care was higher with increasing overall social vulnerability index (odds ratio: 1.14; 95% confidence interval 1.01-1.30). Additionally, the odds of experiencing fragmentation of postoperative care were higher among patients with high vulnerability owing to their socioeconomic status (odds ratio: 1.28; 95% confidence interval 1.12-1.45) or their household composition and disability (odds ratio: 1.35; 95% confidence interval 1.19-1.54), whereas high vulnerability owing to minority status and language was inversely associated with fragmentation of postoperative care (odds ratio: 0.73; 95% confidence interval 0.64-0.84).

CONCLUSION

Social vulnerability was strongly associated with the odds of experiencing fragmented postoperative care after hepatopancreatic surgery.

Association of shared decision making with inpatient satisfaction: a cross-sectional study

BACKGROUND

We assessed inpatient perceived shared decision making (SDM) and tested the association of SDM with inpatient satisfaction in public tertiary hospitals in Shanghai, China.

METHODS

A cross-sectional survey of 2585 inpatients in 47 public tertiary hospitals in Shanghai in July and August 2018 was conducted. We assessed overall SDM and 4 aspects of SDM and tested the factors influencing SDM and the association of SDM with patient satisfaction (patient satisfaction with physician services, medical expenses, outcomes and overall inpatient care), by adopting linear or two-level regression models.

RESULTS

The positive response rate (PRR) and high positive response rate (HPRR) to overall SDM among the inpatients of public tertiary hospitals in Shanghai were relatively high (95.30% and 87.86%, respectively), while the HPRR to "My physician informed me of different treatment alternatives" was relatively low (80.09%). In addition, the inpatients who underwent surgery during admission had higher HPRRs and adjusted HPRRs to overall SDM than those who did not undergo surgery. The study showed that the adjusted high satisfaction rates (HSRs) with physician services, medical expenses, outcomes and overall inpatient care among the inpatients with high level of overall SDM were higher (96.50%, 68.44%, 89.50% and 92.60%) than those among the inpatients without a high level of overall SDM (71.77%, 35.19%, 57.30% and 67.49%). The greatest differences in the adjusted HSRs between the inpatients with and without a high level of SDM were found in inpatient satisfaction with medical expenses and informed consent in SDM. Moreover, 46.22% of the variances in the HSRs with overall inpatient care across the hospitals were attributed to the hospital type (general hospitals vs. specialty hospitals).

CONCLUSIONS

Inpatient PRRs and HPRRs to SDM in public tertiary hospitals in Shanghai are relatively high overall but lower to information regarding alternatives. SDM can be affected by the SDM preference of both the patients and physicians and medical condition. Patient satisfaction can be improved through better SDM and should be committed at the hospital level.

Association Between Parent Comfort With English and Adverse Events Among Hospitalized Children

IMPORTANCE

Children of parents expressing limited comfort with English (LCE) or limited English proficiency may be at increased risk of adverse events (harms due to medical care). No prior studies have examined, in a multicenter fashion, the association between language comfort or language proficiency and systematically, actively collected adverse events that include family safety reporting.

OBJECTIVE

To examine the association between parent LCE and adverse events in a cohort of hospitalized children.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter prospective cohort study was conducted from December 2014 to January 2017, concurrent with data collection from the Patient and Family Centered I-PASS Study, a clinician-family communication and patient safety intervention study. The study included 1666 Arabic-, Chinese-, English-, and Spanish-speaking parents of general pediatric and subspecialty patients 17 years and younger in the pediatric units of 7 North American hospitals. Data were analyzed from January 2018 to May 2020.

EXPOSURES

Language-comfort data were collected through parent self-reporting. LCE was defined as reporting any language besides English as the language in which parents were most comfortable speaking to physicians or nurses.

MAIN OUTCOMES AND MEASURES

The primary outcome was adverse events; the secondary outcome was preventable adverse events. Adverse events were collected using a systematic 2-step methodology. First, clinician abstractors reviewed patient medical records, solicited clinician reports, hospital incident reports, and family safety interviews. Then, review and consensus classification were completed by physician pairs. To examine the association of LCE with adverse events, a multivariable logistic regression was conducted with random intercepts to adjust for clustering by site.

RESULTS

Of 1666 parents providing language-comfort data, 1341 (80.5%) were female, and the mean (SD) age of parents was 35.4 (10.0) years. A total of 147 parents (8.8%) expressed LCE, most of whom (105 [71.4%]) preferred Spanish. Children of parents who expressed LCE had higher odds of having 1 or more adverse events compared with children whose parents expressed comfort with English (26 of 147 [17.7%] vs 146 of 1519 [9.6%]; adjusted odds ratio, 2.1; 95% CI, 1.2-3.7), after adjustment for parent race and education, complex chronic conditions, length of stay, site, and the intervention period. Similarly, children whose parents expressed LCE were more likely to experience 1 or more preventable adverse events (adjusted odds ratio, 2.3; 95% CI, 1.2-4.2).

CONCLUSIONS AND RELEVANCE

Hospitalized children of parents expressing LCE were twice as likely to experience harms due to medical care. Targeted strategies are needed to improve communication and safety for this vulnerable group of children.

Provider-patient Language Discordance and Cancer Operations: Outcomes from a Single Center Linked to a State Vital Statistics Registry

INTRODUCTION

Patterns of worldwide immigration have resulted in high rates of discordance between medical providers and the patients they treat. For example, in the USA, 25 million individuals in the USA self-identified that they speak English less than "very well." Previous studies have generated mixed results regarding differences in postoperative outcomes between English proficient (EP) and limited English proficient (LEP) patients. Our objective was to determine whether a difference in outcomes exists for non-English-speaking patients compared to English-speaking patients after operations commonly performed to treat cancer.

STUDY DESIGN

A retrospective cohort study was performed in an urban, safety net and tertiary referral medical center over a five-year period. Adult patients undergoing cancer operations were stratified as EP and LEP. We evaluated 30-day revisit to the ED, length of stay (LOS), long-term all-cause mortality, and any major complication on index admission. Regression was used to adjust for baseline comorbidities, case risk, and socioeconomic factors.

RESULTS

A total of 2467 patients were included. There was no difference in case risk between language groups, but EP had a larger proportion of high comorbidity scores. Patients in the non-English group were more likely to be uninsured/self-pay and live in neighborhoods with lower median income. After adjustment, we found no difference in long-term mortality [hazard ratio: 0.87 (95% CI 0.52-1.45)]. LEP patients had the same LOS compared to primary EP patients with an IRR of 0.99 (95% CI 0.88-1.10). There was no difference in the odds of revisit to hospital for LEP versus EP, with an OR of 1.08, 95% CI [0.75-1.53] and no difference in major complication (OR 0.76 (95% CI 0.39-1.45).

CONCLUSIONS

We found no association between language and outcomes after cancer operations. This lack of difference may reflect local efficacy at treating non-English-speaking patients, and health systems with fewer services for LEP patients might show different results.

The Limited English Proficient Population: Describing Medicare, Medicaid, and Dual Beneficiaries

Purpose: The Limited English Proficient (LEP) population experiences well-documented suboptimal health outcomes and substandard provider experiences. The lack of national estimates on the size of the LEP population relative to the healthcare setting makes examining health outcomes for this population very difficult. This analysis addresses this limitation by publishing population estimates for LEP persons enrolled in Medicare, Medicaid, and Duals (enrolled in Medicare and Medicaid). Focusing on the Medicare and Medicaid programs provides an important foundation as these programs are not only the largest insurers in the United States but are also governed by legislation that requires LEP persons to receive equitable access to care.

Methods: Data from the 2014 American Community Survey Public Use Microdata Sample (ACS PUMS) were used to produce national estimates and measures of statistical accuracy for the LEP population enrolled in Medicare and/or Medicaid (LEPMM).

Results: In 2014, there were approximately 8.7 million LEP persons enrolled in Medicare, Medicaid, or both programs (Duals). The LEPMM was concentrated along the western and eastern coastlines and the southwestern region, with California and New York each containing more than 1 million LEPMMs. The LEPMM was also highly diverse with varying disability status, and most were racial or ethnic minorities and elderly.

Conclusion: These findings provide a foundation for measuring an understudied and at-risk population that will enable population health professionals to develop effective culturally and linguistically, and appropriate services and policies that address health disparities in the LEPMM.