Patient centeredness in medical encounters requiring an interpreter

Lived experiences of palliative care physicians on the impacts of language and cultural discordance on end-of-life care across Ontario, Canada: a qualitative study using the intersectionality-based policy framework

BACKGROUND

Language and cultural discordance refer to when a physician and patient do not share the same language or culture. This can create barriers to providing high-quality care at the end-of-life (EoL). This study explores the intersections of language, culture, geography, and care model in EoL care from the perspectives of palliative care physicians.

METHODS

In this exploratory-descriptive qualitative study, semi-structured interviews (1-h) were conducted virtually between July and November 2023. We interviewed 16 family physicians with experience providing linguistic and/or culturally discordant palliative/EoL care in various urban, suburban, and rural regions of Ontario, who practiced at community and hospital outpatient clinics, home-based care, or long-term care homes. We used reflexive thematic analysis to identify themes across the interviews guided by the intersectionality theoretical framework.

RESULTS

We identified three themes 1) Visible barriers to care access due to the inability to communicate accurate information and insufficient time spent during appointments with patients; 2) Invisible barriers to care access, shaped by the Eurocentric approach to palliative care and physicians' lack of awareness on cultural discordance; 3) Workplace supports that currently exist and interventions that physicians would like to see. Community physicians following fee-for-service models were less likely to have access to professional interpreter services. Physicians in long-term care emphasized resource limitations to providing culturally-appropriate care environments.

CONCLUSION

Cultural discordance required awareness of personal biases, while language discordance hindered basic communication. These findings will be useful in informing clinical practice guidelines and mobilizing policy-level change to improve palliative/EoL care for patients from linguistic and cultural minority groups.

Medical Team Practices and Interpreter Alterations on Family-Centered Rounds

BACKGROUND

Robust evidence demonstrates inequities in communication during family-centered rounds for families who use a language other than English (LOE) for health care. This study aimed to characterize the type of interpreter alterations occurring on family-centered rounds and identify medical team communication practices associated with alterations.

METHODS

In this observational study of interpreter-supported family-centered rounds, we recorded and transcribed family-centered rounds encounters for Spanish-speaking families. We assessed measures of medical team communication behaviors and interpreter alterations (omissions, additions, and substitutions) using previously described instruments. We used a content analysis approach to apply defined codes to each interpreted segment and to characterize the nature of interpreter alterations. We assessed the association between medical team communication behaviors and interpreter alterations using χ2 tests.

RESULTS

We recorded, transcribed, and coded 529 interpreted segments of 10 family-centered rounds encounters. At least 1 alteration was present in 72% (n = 382/529) of interpreted segments. Omissions were the most common alteration (n = 242/529, 46%) followed by substitutions (n = 177/529, 34%) and additions (n = 71/529, 13%). Interpretation resulted in a potentially negative alteration in 29% (n = 155/529) and a positive alteration in 9% (n = 45/529) of segments. Greater number of sentences in the segment preceding interpretation was associated with an increase in loss of information (P < .001), loss of social support (P = .003), and loss of partnership (P = .020).

CONCLUSIONS

To improve communication with families that use an LOE, medical teams must abide by best practices for using an interpreter such as frequent pausing to prevent loss of both biomedical and psychosocial information.

Challenges in the Transition from Acute Hospital Care to Home for Spanish-Speaking Latino Patients with TBI and Families: Perspectives of Healthcare Providers and Interpreters

Language-based disparities negatively impact patient outcomes. Spanish-speaking Latino patients with traumatic brain injury (TBI) transitioning home from acute hospital care and their families have poor TBI-related outcomes; further, they have significant difficulties navigating the healthcare system due to care fragmentation and limited provider support. These challenges are exacerbated by language barriers. There are disproportionately fewer bilingual providers and interpreters in the U.S. healthcare system for patients with TBI for whom English is not their primary language. Although Spanish-speaking Latino patients with TBI and their families communicate with healthcare providers using interpreters on a regular basis, limited research has explored the healthcare delivery perspective. The purpose of this study was to understand the perspectives of healthcare providers and interpreters regarding their experience caring for or supporting Spanish-speaking Latino patients with TBI and their families during the transition home from acute hospital care. This qualitative descriptive study included 10 bilingual (English and Spanish-speaking) participants: 7 interdisciplinary providers and 3 interpreters; findings were analyzed using rapid qualitative analysis to inform intervention adaptation. Four themes were identified: 1) language misalignment decreases health literacy and increases length of stay; 2) TBI-related cognitive impairments, coupled with language differences, make communication challenging; 3) unique social contributors to health directly decrease health equity; and 4) recommendations to improve access and justice in transitional care. There are multiple opportunities to improve transitional care support provided to Spanish-speaking Latino patients with TBI and their families in a manner that is not currently being addressed in research or in practice.

Medical Interpreting Services for Refugees in Canada: Current State of Practice and Considerations in Promoting this Essential Human Right for All

Language barriers, specifically among refugees, pose significant challenges to delivering quality healthcare in Canada. While the COVID-19 pandemic accelerated the emergence and development of innovative alternatives such as telephone-based and video-conferencing medical interpreting services and AI tools, access remains uneven across Canada. This comprehensive analysis highlights the absence of a cohesive national strategy, reflected in diverse funding models employed across provinces and territories, with gaps and disparities in access to medical interpreting services. Advocating for medical interpreting, both as a moral imperative and a prudent investment, this article draws from human rights principles and ethical considerations, justified in national and international guidelines, charters, codes and regulations. Substantiated by a cost-benefit analysis, it emphasizes that medical interpreting enhances healthcare quality and preserves patient autonomy. Additionally, this article illuminates decision-making processes for utilizing interpreting services; recognizing the pivotal roles of clinicians, interpreters, patients and caregivers within the care circle; appreciating intersectional considerations such as gender, culture and age, underscoring the importance of a collaborative approach. Finally, it provides recommendations at provider, organizational and system levels to ensure equitable access to this right and to promote the health and well-being of refugees and other individuals facing language barriers within Canada's healthcare system.

Association between English Proficiency and Kidney Disease Knowledge and Communication Quality among Patients with ESKD

Key Points

In one hospital-based safety-net dialysis unit, only one half of patients with ESKD knew their cause of kidney failure, which did not differ by English proficiency status. Patients with limited English proficiency (versus English-proficient patients) reported poorer communication with the dialysis care team (less listening, fewer clear explanations, less time spent). We highlight the need for tailored, patient-centered communication between limited English-proficient patients and dialysis care team members.

Background

ESKD is a chronic health condition for which communication between health care teams and patients is important to guide patient self-management activities. Yet, little is known about the quality of communication among patients with ESKD and their care team members. We examined the influence of patient's limited English proficiency (LEP) status on communication experiences at one dialysis center.

Methods

A survey was administered to adults receiving ESKD care at a dialysis unit within a public health care delivery system between July 2022 and February 2023, to ascertain kidney disease knowledge and perceptions of communication quality with the dialysis care team. Multivariable logistic and ordinal logistic regression models adjusted for age and sex were used to determine associations between LEP status and CKD knowledge.

Results

Among 93 eligible patients, 88.2% (n =82) completed the survey. Approximately 37.8% (n =31) had LEP, mean age was 58.8 years, 68.3% were men, mean dialysis vintage was 3.9 years, and 25% had a positive depression screen (LEP 30%; English-proficient 22%). A higher proportion of English-proficient patients screened positive for limited health literacy compared to those with LEP (74.5% versus 38.7%, P = 0.002). Overall, knowledge of assigned cause of ESKD (53.4%) and CKD/transplant knowledge (57.3%) was suboptimal. After adjustment, LEP status was not significantly associated with knowing the correct cause of kidney failure (odds ratio, 0.49; 95% confidence interval, 0.19 to 1.27) but was significantly associated with having a higher score on a CKD/transplant knowledge scale (odds ratio, 3.99; 95% confidence interval, 1.66 to 9.58). Patients with LEP reported poorer communication quality with dialysis providers and staff (less listening, fewer clear explanations, less time spent with patients) compared with English-proficient patients, although differences were not statistically significant.

Conclusions

Overall communication between patients with ESKD and members of the dialysis care team was suboptimal, regardless of English proficiency. Interventions to enhance communication for ESKD patients are needed.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Development and validation of the provider assessed quality of consultations with language interpretation scale (PQC-LI)

OBJECTIVE

With the growing immigrant communities in the western world, there is an urgent need to address language barriers to care, and health disparities as a whole. Studies on limited English proficiency patients (LEP) have focused on patient perspectives of office visits, however little is known about health care provider perspectives of medical visits using interpretive services. We aimed to develop a pragmatic brief questionnaire for assessing providers' views of the quality of communication in outpatient visits with patients with LEP. The questionnaire was validated in a cross-sectional study (n = 99) using principal component analyses (PCA) with oblimin rotation. Internal consistency was analyzed using Cronbach's alpha.

RESULTS

Based on theory and literature, a seven-item scale was developed that captures two relevant concepts: (1) Provider - patient interaction during the consultation and (2) perceived quality of translation. The questionnaire was used to assess 99 LEP consultations and demonstrated good feasibility in a clinical setting. PCA revealed the two theory-based components with good factor loadings and internal consistency of α = 0.77. These preliminary results indicate that the questionnaire provides medical professionals with a validated tool to evaluate LEP patient encounters. Further confirmatory validation of the Provider-assessed Quality of Consultations with Language Interpretation (PQC-LI) in larger samples is warranted.

Exploring the Connectivity Paradox: How the Sociophysical Environment of Telehealth Shapes Adolescent Patients' and Parents' Perceptions of the Patient-Clinician Relationship

Even before the widespread transition to telehealth as a result of COVID-19, there was a considerable amount of research exploring its value and impact. However, telehealth research with adolescent patients is somewhat limited, with most work focusing on access, feasibility, and acceptability but reporting far less frequently on relationship building and rapport. This study examines qualitative interviews with adolescent patients (n = 14) and parents (n = 20) from a larger convergent parallel mixed methods study to explore how they understand telehealth to have altered the sociophysical environment of primary care clinic encounters and whether they perceive these changes to influence adolescents' relationships with clinicians. We show that participants perceived the sociophysical environment of telehealth to be both less institutional (e.g. more relaxed and less rushed) and more instrumental (e.g. more focused on the chief complaint), which shaped interactions with clinicians in ways that were experienced as paradoxically less personal (e.g. lacking social connection) and more person-centered (e.g. more attentive to the individual patient). We discuss theoretical and practical implications of these findings and what they mean for defining person-centered communication for adolescent care.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Qualitative, semi-structured interviews.

PARTICIPANTS

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

APPROACH

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

KEY RESULTS

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

CONCLUSIONS

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

Patient-centered care outcomes for patients in the emergency department with a non-English language preference: A scoping review

OBJECTIVE

This review highlights what is known about patient-centered care outcomes (PCCOs) for emergency department (ED) patients with non-English language preferences (NELP).

METHODS

Four databases were searched and included article were written in English, presented primary evidence, published in a peer-reviewed journal, and reported PCCOs from the perspective of ED patients with NELP. PCCOs were defined using the Institute of Medicine definition, outcomes that evaluate respect and responsiveness to patient preferences, needs and values. Two reviewers assessed all articles, extracted data, and resolved discrepancies. PCCOs were grouped in categories (needs, preferences, and values) based on the definition's domains.

RESULTS

Of the 6524 potentially eligible studies, 20 met inclusion criteria. Of these, 16 focused on needs; 4 on preferences and 8 on values. Within patient need, five studies found a large unmet need for language services. Within patient value, three found that language discordance negatively influenced perceptions of care.

CONCLUSIONS

Most studies in this review found that not speaking English negatively influenced perceptions of care and highlighted a large unmet need for language services in the ED.

PRACTICE IMPLICATIONS

More work needs to be done to characterize PCCOs in ED patients with NELP and develop interventions to improve care.

Patient dissatisfaction associated with physician-patient linguistic discordance in California clinics: an analytical cross-sectional study

BACKGROUND

Patient satisfaction is considered as a product of two psychological processes, a cognitive one, including expectations and perceptions, and an emotional one resulting from the congruence between expectation and subjective perception of the user. The objective was to identify the factors associated with the level of perceived satisfaction in patients treated in 36 nonprofit health clinics that offer comprehensive health care services in four counties in the state of California, United States.

METHODS

Cross-sectional analytical study in 14 clinics in four California counties. It consisted of the application of a 30-item questionnaire to determine the degree of patient satisfaction with the clinic. The factorial composition of the quality of care and clinic quality components was analyzed and two factors with an Eigen value greater than 1 were obtained.

RESULTS

A total of 846 responses were registered. Factor analysis identified two underlying dimensions: Physician Attitude and Empathy. It was found that the discordance in language between the physician and the patient generates a difference in the perception of satisfaction. Patients who prefer to speak English have better satisfaction than those who speak Spanish. Spanish speakers who do not have interpreter have lower satisfaction than those who do (p < 0,01).

CONCLUSIONS

The most important sociodemographic cofactor was language. Satisfaction decreased in Spanish-speaking patients who were not proficient in the use of English since they expressed fewer comments and doubts.

Barriers in Healthcare for Latinx Patients with Limited English Proficiency-a Narrative Review

Latinx (includes Hispanics and is the non-gendered term for Latino/Latina which is a person of Latin American origin or descent) constitutes the largest racial and ethnic minority group in the United States (US). Many members of this group report limited English proficiency, experience discrimination, feel distrust in the healthcare setting, and face poorer health outcomes than non-Latinx Whites. As healthcare systems assess internal structures of care, understanding the experiences of Latinx patients may inform strategies to improve care. This narrative review describes studies that assessed the experiences of Latinx patients with limited English proficiency (LEP) in the inpatient and outpatient settings in the US. We searched PubMed for studies published between January 1, 1990, and March 2021. We reviewed all citations and available abstracts (n = 429). We classified study titles (n = 156) as warranting detailed consideration of the original article. Limited English proficiency is a well-documented challenge reported by Latinx patients seeking care in the outpatient setting, resulting in mistrust of healthcare organizations and clinicians. The effects of LEP overlap substantially with challenges related to patients' immigration status, cultural traditions, and socioeconomic needs. Use of professional interpretation rather than ad hoc interpretation improves trust and satisfaction. There is no consensus about the most effective mode of delivering professional interpretation (in person, telephonic, video conferencing), although rapid simultaneous telephone translation is a promising modality. Increasing awareness of the barriers to effective communication, improving skills in communicating through translators, and increasing the amount of time spent with patients may improve communication and trust more than structural changes like mode of translation or bedside rounding. Cultural fluency training, standardized language training for providers, and incentive pay for fluency are also deserving of further consideration.

Racial and Ethnic Differences in Communication Quality During Family-Centered Rounds

OBJECTIVES

To evaluate racial and ethnic differences in communication quality during family centered rounds.

METHODS

We conducted an observational study of family-centered rounds on hospital day 1. All enrolled caregivers completed a survey following rounds and a subset consented to audio record their encounter with the medical team. We applied a priori defined codes to transcriptions of the audio-recorded encounters to assess objective communication quality, including medical team behaviors, caregiver participatory behaviors, and global communication scores. The surveys were designed to measure subjective communication quality. Incident Rate Ratios (IRR) were calculated with regression models to compare the relative mean number of behaviors per encounter time minute by race and ethnicity.

RESULTS

Overall, 202 of 341 eligible caregivers completed the survey, and 59 had accompanying audio- recorded rounds. We found racial and ethnic differences in participatory behaviors: English-speaking Latinx (IRR 0.5; 95% confidence interval [CI] 0.3-0.8) Black (IRR 0.6; 95% CI 0.4-0.8), and Spanish-speaking Latinx caregivers (IRR 0.3; 95% CI 0.2-0.5) participated less than white caregivers. Coder-rated global ratings of medical team respect and partnership were lower for Black and Spanish-speaking Latinx caregivers than white caregivers (respect 3.1 and 2.9 vs 3.6, P values .03 and .04, respectively: partnership 2.4 and 2.3 vs 3.1, P values .03 and .04 respectively). In surveys, Spanish-speaking caregivers reported lower subjective communication quality in several domains.

CONCLUSIONS

In this study, Black and Latinx caregivers were treated with less partnership and respect than white caregivers.

Communicating National Disability Insurance Scheme - Exploring Interpreters' Perspective

This article reports of a study on 19 Australian community interpreters and their experience in facilitating mediated communication in the National Disability Insurance Scheme (NDIS), which was introduced in Australia in 2016. These interpreters were among those who attended a training workshop comprising of a pedagogical segment explaining this new scheme in detail, and a hands-on segment to translate a selection of NDIS terms into their target language to highlight possible linguistic and cultural challenges they may encounter. The training aimed to enable the interpreters to facilitate NDIS communication with clients from linguistically and culturally diverse backgrounds in ways that make sense to their culture and experience. The purpose of the current study is to understand the extent the participant interpreters applied their learning in NDIS communication, and their perspective about specific challenges in this new contextual area, where certain concepts and terms may be hard to translate, and the understanding of disability may be culturally bound. The aim of the study is to deepen the understanding of multicultural communication in disability services, and to inform similar future professional development during major changes to systems in the disability sector, and more broadly in health and welfare.

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.

Communication about distress and well-being: Epistemic and ethical considerations

Communication about well-being and distress involves multiple stakeholders, including experts by experience (EBE), researchers, clinical practitioners, interpreters, and translators. Communication can involve a variety of discourses and languages and each of the stakeholders may employ diverging epistemologies to understand and explain experiences. These epistemologies may link to different sources of authority and be articulated using particular linguistic resources. Epistemic injustice can occur when stakeholders, intentionally or unintentionally, fail to recognise the validity of other stakeholders' ways of conceptualising and verbalising their experience of well-being and distress. Language lies at the heart of the risk of epistemic injustice involved in the process of expressing well-being and distress as seen in: 1) the interface between divergent discourses on well-being and distress (e.g., biomedical vs. spiritual); and 2) communications involving multiple linguistic resources, which can be subdivided into multi-language communications involving a) translation of assessment measures, and b) interpreted interactions. Some of the challenges of multi-language communication can be addressed by translators or interpreters who strive for conceptual equivalence. We argue, however, that all stakeholders have an important role as "epistemic brokers" in the languaging of possible epistemological differences. Effective epistemic brokering requires that all stakeholders are reflexively and critically aware of the risks of epistemic injustice inherent in multi-language communication. The article concludes with a set of prompts to help raise stakeholder awareness and reflexivity when engaging in communication about well-being and distress.

Limited English proficiency in the labor and delivery unit

PURPOSE OF REVIEW

Limited English proficiency (LEP) impacts patient access to safe and comprehensive care during the antepartum, intrapartum, and postpartum periods. In this review, we explore disparities in care delivery and outcomes that LEP women experience, and discuss the importance of providing language concordant care and using interpretation services appropriately.

RECENT FINDINGS

The number of individuals with LEP is steadily increasing in the United States. Pregnant women with LEP suffer disparities in obstetric care and are at risk for postpartum depression, breastfeeding difficulties, and substandard newborn care after neonatal ICU discharge because of insufficient education. Addressing these issues requires the implementation of language concordant care and education, along with the utilization of medically trained interpreters. Although further evidence is needed, the authors support these interventions to improve patient satisfaction, decrease medical errors, and curtail misdiagnoses.

SUMMARY

The pregnant woman with limited English proficiency is at risk of receiving suboptimal care and experiencing negative outcomes during the antepartum, intrapartum, and postpartum periods. The use of medically trained interpreters and the provision of language concordant care, through workforce diversification and the creation of forms and educational materials in diverse languages, can improve patient safety, outcomes, and quality of care.

Addressing health disparities in hispanic communities through an innovative team-based medical spanish program at the medical school level - a single-institution study

BACKGROUND

There are insufficient Spanish-speaking physicians to effectively serve a large and rapidly growing Spanish-speaking patient population.

METHODS

A team-based hybrid medical Spanish program was designed and implemented at a single medical school in Southern California. This pilot program consisted of a weekly in-person portion where students reviewed Spanish vocabulary and grammar and practiced clinical encounters in teams through active role play. Students supplemented in-class learning with online coursework. Program success was measured through physician-evaluated clinical encounters with Spanish-speaking standardized patients, a 100-question multiple-choice exam, and pre- and post-program surveys.

RESULTS

97% of students in the program (n = 32) received a passing grade at program completion. Student surveys demonstrated enthusiasm and engagement in weekly sessions (95% overall attendance, 97% reported feeling either excited or ready to learn prior to class). In a post-program survey, 100% of students felt better suited and increased desire to treat Hispanic patients. Additionally, all students indicated an interest in the continued use of Spanish in both their schooling and future practice. In a follow-up survey after three months of clinical experience in their 3^rd year of medical school, 100% of students reported that medical Spanish is "very beneficial" in patient care and that students with medical Spanish proficiency have advantages over non-speaking students when it comes to patient care opportunities. 100% felt that time spent learning medical Spanish during pre-clinical years was time well spent and that the medical Spanish program enhanced their care of Spanish-speaking students.

CONCLUSIONS

The results of the pilot program show a significant increase in the ability of students to engage in clinical interaction in Spanish. The results of our study demonstrate a significant increase in the knowledge, clinical skills, and self-reported confidence of students to treat Hispanic patients. Furthermore, all students not only felt better equipped and more confident to treat Hispanic patients, but they also had an increased desire to do so moving forward in their careers. We conclude that an effective medical Spanish program can be executed simultaneously with a pre-clinical medical school curriculum.

Considerations for the Medical Management of the Circus Performance Artist and Acrobat

Medical management of the circus performer encompasses a wide variety of multicultural, transdisciplinary and multifaceted decision-making considerations. There is a paucity of research evidence investigating both the unique diversity of skill sets and cultural considerations in addition to injury patterns of performers within the circus environment. Since a previously established framework for supporting the health and well-being of the circus performer across various aspects of medical management does not exist in the literature, most recommendations in this regard must come from practical experience working with this highly specialized performance athlete population. The purpose of this clinical commentary is to provide the reader with a greater understanding of the unique challenges associated with the medical management of performance artists and acrobats as well as recommendations for developing an integrated approach for mitigating injury risk within a highly specialized, diverse athlete population.

LEVEL OF EVIDENCE

5.

The active role of interpreters in medical discourse - An observational study in emergency medicine

OBJECTIVE

To study communicative tasks executed and related strategies used by patients, health professionals, and medical interpreters.

METHODS

English proficient and limited English proficient emergency department patients were observed. The content of patient-hospital staff communication was documented via pen and paper. Key themes and differences across interpreter types were established through qualitative analysis. Themes and differences across interpreter type were vetted and updated through member checking interviews.

RESULTS

6 English proficient and 9 limited English proficient patients were observed. Key themes in communicative tasks included: establishing, maintaining, updating, and repairing understanding and rapport. All tasks were observed with English proficient and limited English proficient patients. The difference with limited English proficient patients was that medical interpreters played an active role in completing communicative tasks. Telephone-based interpreters faced challenges in facilitating communicative tasks based on thematic comparisons with in-person interpreters, including issues hearing and lost information due to the lack of visual cues.

CONCLUSIONS

Professional interpreters play an important role in communication between language discordant patients and health professionals that goes beyond verbatim translation.

PRACTICAL IMPLICATIONS

Training for interpreters and health professionals, and the design of tools for facilitating language discordant communication, should consider the role of interpreters beyond verbatim translation.

[Challenges of medical care in urban areas - a conceptual framework for primary care in the city]

BACKGROUND

Germany already has a high degree of urbanisation, and the share of urban population is expected to increase further. Thus, it is important to explore urban primary care from a scientific point of view.

METHOD

In this article, the author suggests a framework for urban primary care.

RESULTS AND CONCLUSION

Three core characteristics of urban areas are a high population density, a high population heterogeneity (including socioeconomic heterogeneity) and a fragmentation of health care and social care. These characteristics influence the health of urban dwelling population. Thus, these characteristics form the future challenges for urban primary care.

Application of the Spanish-Language Consultation and Relational Empathy (CARE) Measure to Assess Patient-Centered Care Among Latino Populations

INTRODUCTION

Reliable and valid measures are needed to assess the patient-centeredness of clinical care among Latino populations.

METHODS

We translated the Consultation and Relational Empathy (CARE) measure from English to Spanish and assessed its psychometric properties using data from 349 Latino parents/guardians visiting a pediatric clinic. Using confirmatory factor analysis, we examined the psychometric properties of the Spanish CARE measure.

RESULTS

Internal reliability of the Spanish CARE measure was high (Omega coefficient = 0.95). Similar to the English-language CARE measure, factor analysis of the Spanish CARE measure yielded a single domain of patient-centeredness with high item loadings (factor loadings range from 0.79 to 0.96).

CONCLUSION

This preliminary analysis supports the reliability and validity of the Spanish version of the CARE measure among Latinos in pediatric care settings. With further testing, the Spanish CARE measure may be a useful tool for tracking and improving the health care delivered to Latino populations.

Hand Surgery Transfers to Level 1 Center: Variables Affecting Transfer Method and Diagnostic Accuracy

We hypothesize that some costly patient transfers to a level 1 trauma center for hand specialist management may be unnecessary. This analysis evaluates transfer cost effectiveness and whether time of consult, transfer distance, diagnosis at time of transfer, and provider level influence diagnostic accuracy and transport method.

Methods

Two hundred and sixty-five patients transferred to a suburban level 1 trauma center for hand surgeon evaluation between 2014 and 2019 were evaluated for patient and injury characteristics, time of consult, transfer distance, provider level, transport method, treatment cost, and diagnostic accuracy.

Results

The average patient age was 36.2 years, and 80.3% were men. 21% of transfers had inaccurate pre-transfer diagnoses, and certain pre-transfer diagnoses correlated with an increased likelihood of inaccuracy, including flexor tenosynovitis and vascular injury. Patients with a language barrier had a greater likelihood of being transferred with an inaccurate diagnosis (P < 0.05). Compared with ground transport, air ambulance was associated with a higher cost of treatment ($225,679 versus $133,887, P < 0.00001). Of all transfers, 14 (5%) were discharged from the emergency department (ED) without a procedure, 9 (3%) were admitted for observation, 73 (27%) had an ED procedure before discharge, and 166 (62%) received operative management.

Conclusions

Over 30% of transfers to a level 1 trauma center likely could have been managed at the transferring facility at a decreased cost. Certain diagnoses are associated with increased risk for diagnostic error and unnecessarily urgent transport. Providers can use this information to consider transfer patterns and to educate transferring providers.

After encounters: revealing patients’ unseen work through their pathways to care

Purpose

Research has long focused on the notion of access and the trajectory towards a healthcare encounter but has neglected what happens to patients after these initial encounters. This paper focuses attention on what happens after an initial healthcare encounter leading to a more nuanced understanding of how patients from a diverse range of backgrounds make sense of medical advice, how they mix this knowledge with other forms of information and how they make decisions about what to do next.

Design/methodology/approach

Drawing on 160 in-depth interviews across four European countries the paper problematizes the notion of access; expands the definition of “decision partners”; and reframes the medical encounter as a journey, where one encounter leads to and informs the next.

Findings

This approach reveals the significant unseen, unrecognised and unacknowledged work that patients undertake to solve their health concerns.

Originality/value

De-centring the professional from the healthcare encounter allows us to understand why patients take particular pathways to care and how resources might be more appropriately leveraged to support both patients and professionals along this journey.

The impact of hospital language on the rate of in-hospital harm. A retrospective cohort study of home care recipients in Ontario, Canada

Background

Patients who live in minority language situations are generally more likely to experience poor health outcomes, including harmful events. The delivery of healthcare services in a language-concordant environment has been shown to mitigate the risk of poor health outcomes related to chronic disease management in primary care. However, data assessing the impact of language-concordance on the risk of in-hospital harm are lacking. We conducted a population-based study to determine whether admission to a language-discordant hospital is a risk factor for in-hospital harm.

Methods

We used linked administrative health records to establish a retrospective cohort of home care recipients (from 2007 to 2015) who were admitted to a hospital in Eastern or North-Eastern Ontario, Canada. Patient language (obtained from home care assessments) was coded as English (Anglophone group), French (Francophone group), or other (Allophone group); hospital language (English or bilingual) was obtained using language designation status according to the French Language Services Act. We identified in-hospital harmful events using the Hospital Harm Indicator developed by the Canadian Institute for Health Information.

Results

The proportion of hospitalizations with at least 1 harmful event was greater for Allophones (7.63%) than for Anglophones (6.29%, p <  0.001) and Francophones (6.15%, p <  0.001). Overall, Allophones admitted to hospitals required by law to provide services in both French and English (bilingual hospitals) had the highest rate of harm (9.16%), while Francophones admitted to these same hospitals had the lowest rate of harm (5.93%). In the unadjusted analysis, Francophones were less likely to experience harm in bilingual hospitals than in hospitals that were not required by law to provide services in French (English-speaking hospitals) (RR = 0.88, p = 0.048); the opposite was true for Anglophones and Allophones, who were more likely to experience harm in bilingual hospitals (RR = 1.17, p <  0.001 and RR = 1.41, p <  0.001, respectively). The risk of harm was not significant in the adjusted analysis.

Conclusions

Home care recipients residing in Eastern and North-Eastern Ontario were more likely to experience harm in language-discordant hospitals, but the risk of harm did not persist after adjusting for confounding variables.

Missed Opportunities to Build Rapport: A Pragmalinguistic Analysis of Interpreted Medical Conversations with Spanish-Speaking Patients

Interpreted medical discourse presents significant challenges for communication because portions of the original message are often reduced, omitted, or revised, particularly by untrained interpreters. Linguistic devices that contribute to rapport and politeness may be perceived as unimportant or unnecessary and therefore are omitted. Thus, when messages are conveyed without interpretation of politeness and rapport attempts, pragmatic issues and misunderstandings occur. This investigation examined 43 transcriptions of interpreted medical consultations at a family medicine clinic. We quantified rapport-building attempts that frequently occurred, yet were not interpreted. We then examined specific and general effects of non-interpretation and noted potential consequences for physician-patient communication. Building on both linguistic and communication frameworks, results align with previous research suggesting that rapport-related variables including verbal immediacy are not secondary to "more important" information communicated by doctors; instead, patients' impressions of rapport may be even more important than the health-related information itself. The application of linguistic pragmatics in this analysis offers additional insights into the relationship between verbal communication and rapport.

Interpreters in healthcare: Nursing perspectives

PURPOSE

This study explored nursing experiences using interpreters in primary healthcare settings.

METHODS

Eight nurses in southern Sweden were subjected to semistructured interviews. The responses were divided into three categories using content analysis: interpreter influence, challenges, and strategies.

RESULTS

Despite using an interpreter to minimize language barriers, nurses do not achieve the same level of person-centered care as those who speak the same language as their patients, but translation services remain a useful communication tool for patient care.

CONCLUSION

Communication through an interpreter is an inevitability for healthcare professionals, and formal education is recommended to improve nurses' utilization of these services.

Through health workers' eyes: a qualitative study of health service provision for migrants at Schengen border

Background

Croatia and Slovenia were the transit countries on the Balkan route for migrants and refugees from Middle East countries in 2015 and 2016. They had to optimize health care delivery in the special circumstances in refugee camps and transit centres. Little is known about health care provision in border camps where a large number of migrants stay for only couple of hours. Previous studies emphasize that language barriers and cultural differences play a central part in the relationship between health workers and migrants inside the transit zone. The aim of the study was to identify specific characteristics of health care provision experienced by primary healthcare providers in order to prepare solutions on how to organise health care in refugee settings.

Methods

Twelve thematic interviews were conducted in the middle of the most intense migration movements to the North-West Europe between November and December 2015 with health workers from Croatia and Slovenia. Interview transcripts were read, coded, reviewed, and labelled. We used qualitative content analysis.

Results

Four themes about the health service provision for refugees at Schengen border were identified. The circumstance when mutual understanding is poor and the consultation not successful, cultural differences represent a central barrier. Participants highlighted that the importance of respecting human dignity is crucial for the provision of basic medical care for migrants in transit.

Conclusion

Successful overcoming language barriers, respecting cultural differences, humanity, susceptibility to social deprivation and traumatic experiences are the key factors important for organisation of health care in transit centers and camps. This article gives some useful tips for healthcare workers and policy makers who are participating in health services provision for migrants and other refugees. Health workers should be prepared to work in special working conditions with a lack of resources. Their work would require timely planning and reflection on the organization of more transit camps.

Trial registration

Ethical Committee of the Republic of Slovenia approved the study as a project number 112/02/16.

Agents of empathy: How medical interpreters bridge sociocultural gaps in genomic sequencing disclosures with Spanish-speaking families

OBJECTIVES

To describe how linguistic tools used by interpreters during return of genomic sequencing results may have impacted communication with Spanish-speaking families, and to discuss the implications for the role of medical interpreters.

METHODS

Using discourse analysis, we identified and categorized the various ways hospital-based interpreters adapted clinicians' language in 37 audio-recorded sessions in which Spanish-speaking parents participating in a clinical trial received their child's genomic sequencing results from English-speaking clinicians.

RESULTS

We found that interpreters adapted clinicians' statements using five empathic linguistic tools: contextualization, encouragement, checking comprehension, endearment, and softening. Interpreters used an average of four linguistic tools per session, with contextualization and encouragement being the most frequently used.

CONCLUSIONS

Interpreters used empathic linguistic tools to alter clinicians' statements when communicating genomic information to Spanish-speaking families. Our findings demonstrate the critical role of interpreters as cultural mediators and facilitators of understanding for Spanish-speaking families.

PRACTICE IMPLICATIONS

This study expands upon the definition of clinical empathy in interpreter-mediated sessions. Our findings suggest that revisions of standards of medical interpretation practice may be warranted regarding interpreters' ability to adapt clinicians' language in a culturally sensitive manner during interpretation.

Patient-provider communication quality for persons with disabilities: A cross-sectional analysis of the Health Information National Trends Survey

BACKGROUND

It is unclear how perceived patient-provider communication quality (PPPCQ) varies according to disability status. Lack of adequate patient-provider communication may prevent providers from considering healthcare issues that are relevant and important to persons with disabilities (PWD), potentially contributing to poorer health outcomes.

OBJECTIVE/HYPOTHESIS

To examine PPPCQ by disability status using current U.S. Department of Health and Human Services standards for surveillance of functional disabilities.

METHODS

This cross-sectional study used nationally-representative data from the 2012-2013 Health Information National Trends Survey (HINTS). Participants were categorized as having any disability (hearing, vision, mobility, cognitive, self-care, and/or independent living limitations). PPPCQ was assessed using seven HINTS questions about communication with healthcare professionals. Linear regression was used to estimate mean differences in composite PPPCQ scores, and logistic regression was used to estimate odds ratios (OR) for a provider "always or usually" performing PPPCQ.

RESULTS

The study population comprised 5301 participants, representing 180,442,731 U.S. adults. Overall, 22.1% (weighted) reported any disability. Adjusted mean PPPCQ scores were significantly lower for PWD (72.8, 95% CI: 68.2-77.4) than persons without disability (78.3, 95% CI: 76.5-80.2), p = 0.021. More specifically, PWD were significantly less likely to be given attention needed to address feelings and emotions (OR = 0.6, 95% CI: 0.4, 0.9, p = 0.017), to have next steps understood (OR = 0.4, 95% CI: 0.2, 0.8, p = 0.019), and to receive a clear explanation (OR = 0.3, 95% CI: 0.1, 0.8, p = 0.018).

CONCLUSIONS

PWD are less likely to report key elements of effective patient-provider communication. Implementing patient-centered care may improve patient-provider communication for this vulnerable population.

Constructing a Culturally Informed Spanish Decision-Aid to Counsel Latino Parents Facing Imminent Extreme Premature Delivery

Objective How Latino parents perceive and understand antenatal counseling for extreme prematurity, < 26 weeks of gestational age (GA), is not clear. We aim to characterize Latino parental perceptions of antenatal counseling in order to construct and validate a Spanish decision-aid (SDA) to improve parental knowledge of prematurity after antenatal consults. Methods This is a three-phased, prospective, multicenter study. First, interviews of 22 Latino parents with a history of birth < 26 weeks GA were conducted. Thematic analysis identified themes valued during antenatal counseling for decisions regarding neonatal resuscitation. Next, we incorporated these themes into the SDA. Finally, improvement in knowledge of prematurity in two Spanish-speaking groups, 'experienced' parents with a history of extremely premature birth and 'naïve' adult Latino volunteers, was measured using a multiple choice test before and after simulated counseling with the SDA. Result Twenty-two interviews generated seven unique themes. An SDA was constructed that preserved six themes paralleled by those found in a previously studied English population, and addressed a novel theme of "intercultural linguistic barriers" unique to our population. Knowledge scores rose in "naive" volunteers, 41 ± 12% to 71 ± 15% (P < 0.001), after simulated counseling with the SDA. 'Experienced' parents had a ceiling effect in knowledge scores, 62 ± 9% to 65 ± 11% (P = 0.22). The SDA was well received by participants. Conclusions for Practice Interviews of Latino parents with a history of premature birth generated similar themes to English-speaking parents, with intercultural linguistic barriers as a novel theme. An SDA for Latino parents facing extremely premature birth may improve comprehension of antenatal counseling.

Neonatal Intensive Care Unit discharge preparedness among families with limited english proficiency

OBJECTIVE

We compared the Neonatal Intensive Care Unit discharge preparedness of families with and without Limited English Proficiency (LEP).

STUDY DESIGN

We performed a retrospective analysis of discharged families. Each family's discharge preparation was self-assessed on the day of discharge, and the discharging nurse assessed the family's overall emotional and technical discharge preparedness all on 9-point Likert scales. Families were considered not prepared for discharge if they rated themselves or the nurse rated their preparedness as <7 on the Likert scale.

RESULTS

Among 1307 discharged families, 90 had LEP. The odds of being prepared for discharge were the same for both groups (aOR = 0.62, 95% CI: 0.27-1.41; p = 0.258). In multivariable analyses, families with LEP were less likely to be prepared with technical baby care skills (aOR = 0.32, 95% CI: 0.13-0.81).

CONCLUSION

Families with LEP are at higher risk and may require special attention when preparing for NICU discharge.

Principles for Patient and Family Partnership in Care: An American College of Physicians Position Paper

In this position paper, the American College of Physicians (ACP) examines the rationale for patient and family partnership in care and reviews outcomes associated with this concept, including greater adherence to care plans, improved satisfaction, and lower costs. The paper also explores and acknowledges challenges associated with implementing patient- and family-centered models of care. On the basis of a comprehensive literature review and a multistakeholder vetting process, the ACP's Patient Partnership in Healthcare Committee developed a set of principles that form the foundation for authentic patient and family partnership in care. The principles position patients in their rightful place at the center of care while acknowledging the importance of partnership between the care team and patient in improving health care and reducing harm. The principles state that patients and families should be treated with dignity and respect, be active partners in all aspects of their care, contribute to the development and improvement of health care systems, and be partners in the education of health care professionals. This paper also recommends ways to implement these principles in daily practice.

Differences in Code Status and End-of-Life Decision Making in Patients With Limited English Proficiency in the Intensive Care Unit

OBJECTIVE

To determine whether code status, advance directives, and decisions to limit life support were different for patients with limited English proficiency (LEP) in the intensive care unit (ICU) as compared with patients whose primary language was English.

PATIENTS AND METHODS

We conducted a retrospective cohort study in adult patients admitted to 7 ICUs in a single tertiary academic medical center from May 31, 2011, through June 1, 2014.

RESULTS

Of the 27,523 patients admitted to the ICU, 779 (2.8%) had LEP. When adjusted for severity of illness, sex, education level, and insurance status, patients with LEP were less likely to change their code status from full code to do not resuscitate during ICU admission (odds ratio [OR], 0.62; 95% CI, 0.46-0.82; P<.001) and took 3.8 days (95% CI, 1.9-5.6 days; P<.001) longer to change to do not resuscitate. Patients with LEP who died in the ICU were less likely to receive a comfort measures order set (OR, 0.38; 95% CI, 0.16-0.91; P=.03) and took 19.1 days (95% CI, 13.2-25.1 days; P<.001) longer to transition to comfort measures only. Patients with LEP were less likely to have an advance directive (OR, 0.23; 95% CI, 0.18-0.29; P<.001), more likely to receive mechanical ventilation (OR, 1.26; 95% CI, 1.07-1.48; P=.005), and more likely to have restraints used (OR, 1.36; 95% CI, 1.11-1.65; P=.003). The hospital length of stay was 2.7 days longer for patients with LEP. Additional adjustment for religion, race, and age yielded similar results.

CONCLUSION

There are important differences in end-of-life care and decision making for patients with LEP.

The influence of patient-clinician ethnocultural and language concordance on continuity and quality of care: a cross-sectional analysis

BACKGROUND

Concordance refers to shared characteristics between a clinician and patient, such as ethnicity or language. The purpose of this study was to examine whether patient-clinician concordance is associated with patient-reported continuity of care (relational, informational and management) and patient-reported impacts of care (quality and empowerment).

METHODS

This is a secondary analysis of cross-sectional patient surveys that were administered across British Columbia, Manitoba and Quebec using random digit dialling. Participants were adults who spoke English, French, Mandarin, Cantonese or Punjabi and who had visited a primary care clinician in the previous 12 months (n = 3156). Patients self-identified as being of European, Chinese, South Asian and Indigenous descent. Outcome measures included patients' perceptions of continuity, quality and empowerment. Adjusted logistic regression models and odds ratio were generated.

RESULTS

More than 64% of non-Indigenous respondents reported ethnocultural concordance. Ethnocultural concordance was associated with higher odds of relational and management continuity. This same pattern held when there was both ethnocultural and language concordance. No association was found between language concordance and any outcome measure. Chinese participants reported lower quality (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.12-0.48), as did South Asian participants (OR 0.17, 95% CI 0.09-0.31) than did participants of European descent.

INTERPRETATION

Higher relational and management continuity is more likely with the presence of patient-clinician ethnocultural and language concordance. Lower continuity and quality reported by Chinese and South Asian particpants could indicate important health care disparities.

Adherence to Newly Prescribed Diabetes Medications Among Insured Latino and White Patients With Diabetes

Importance

Medication adherence is essential to diabetes care. Patient-physician language barriers may affect medication adherence among Latino individuals.

Objective

To determine the association of patient race/ethnicity, preferred language, and physician language concordance with patient adherence to newly prescribed diabetes medications.

Design, Setting, and Participants

This observational study was conducted from January 1, 2006, to December 31, 2012, at a large integrated health care delivery system with professional interpreter services. Insured patients with type 2 diabetes, including English-speaking white, English-speaking Latino, or limited English proficiency (LEP) Latino patients with newly prescribed diabetes medication.

Exposures

Patient race/ethnicity, preferred language, and physician self-reported Spanish-language fluency.

Main Outcomes and Measures

Primary nonadherence (never dispensed), early-stage nonpersistence (dispensed only once), late-stage nonpersistence (received ≥2 dispensings, but discontinued within 24 months), and inadequate overall medication adherence (>20% time without sufficient medication supply during 24 months after initial prescription).

Results

Participants included 21 878 white patients, 5755 English-speaking Latino patients, and 3205 LEP Latino patients with a total of 46 131 prescriptions for new diabetes medications. Among LEP Latino patients, 50.2% (n = 1610) had a primary care physician reporting high Spanish fluency. For oral medications, early adherence varied substantially: 1032 LEP Latino patients (32.2%), 1565 English-speaking Latino patients (27.2%), and 4004 white patients (18.3%) were either primary nonadherent or early nonpersistent. Inadequate overall adherence was observed in 1929 LEP Latino patients (60.2%), 2975 English-speaking Latino patients (51.7%), and 8204 white patients (37.5%). For insulin, early-stage nonpersistence was 42.8% among LEP Latino patients (n = 1372), 34.4% among English-speaking Latino patients (n = 1980), and 28.5% among white patients (n = 6235). After adjustment for patient and physician characteristics, LEP Latino patients were more likely to be nonadherent to oral medications and insulin than English-speaking Latino patients (relative risks from 1.11 [95% CI, 1.06-1.15] to 1.17 [95% CI, 1.02-1.34]; P < .05) or white patients (relative risks from 1.36 [95% CI, 1.31-1.41] to 1.49 [95% CI, 1.32-1.69]; P < .05). English-speaking Latino patients were more likely to be nonadherent compared with white patients (relative risks from 1.23 [95% CI, 1.19-1.27] to 1.30 [95% CI, 1.23-1.39]; P < .05). Patient-physician language concordance was not associated with rates of nonadherence among LEP Latinos (relative risks from 0.92 [95% CI, 0.71-1.19] to 1.04 [95% CI, 0.97-1.1]; P > .28).

Conclusions and Relevance

Nonadherence to newly prescribed diabetes medications is substantially greater among Latino than white patients, even among English-speaking Latino patients. Limited English proficiency Latino patients are more likely to be nonadherent than English-speaking Latino patients independent of the Spanish-language fluency of their physicians. Interventions beyond access to interpreters or patient-physician language concordance will be required to improve medication adherence among Latino patients with diabetes.

Patient Satisfaction in an Outpatient Hand Surgery Office: A Comparison of English- and Spanish-Speaking Patients

BACKGROUND

As health care in the United States transitions from a fee-for-service to an outcomes-based environment, patient satisfaction is increasingly incentivized and publicly reported. Despite the continued growth of the Latino population and concomitant rise in the demand for health care, relatively little is known regarding patient satisfaction in Spanish speakers. We sought to compare patient satisfaction with hand surgery office visits between Spanish- and English-speaking patients.

METHODS

Directly after the office visit, 150 patients (75 English speakers and 75 Spanish speakers) completed a sociodemographic survey, an 11-point ordinal rating of pain intensity, and a survey of satisfaction with the encounter using items derived from the CG-CAHPS (Clinician and Group-Consumer Assessment of Healthcare Providers and Systems) survey. Multivariable regression modeling was used to identify factors associated with patient dissatisfaction.

RESULTS

Overall, 79% of Spanish-speaking patients were satisfied with the physician as compared with 91% of English speakers (P = .041). Compared with English-speaking patients, Spanish speakers were less likely to be satisfied with provider listening carefully (91% vs 100%, P = .007) and spending enough time with them (56% vs 93%, P < .001), as well as with waiting times (81% vs 96%, P = .005). There was no difference with regard to provider showing respect, clarity of communication, and explanation of what was done. Younger age and Spanish language were independent predictors of patient dissatisfaction.

CONCLUSIONS

Spanish-speaking patients are less satisfied with the care provided in a hand surgery office. In light of the growing diversity of the US population and the fact that patient satisfaction is increasingly tied to reimbursement, additional research might identify potential areas of improvement from both the surgeon (eg, communication strategies, cultural competence) and patient (eg health literacy, expectations) perspectives.

Family Engagement in Pediatric Sickle Cell Disease Visits

Adults with sickle cell disease (SCD) report problems in relationship building and information exchange during clinic visits. To explore the origin of these communication challenges, we compare communication in pediatric SCD, diabetes, and asthma visits. We collected visit videos and parent surveys from 78 children ages 9-16 years with SCD, asthma, or diabetes. Coders assessed child, parent, and physician utterances reflecting relationship building, information giving, and information gathering. Associations of engagement with type of chronic disease visit were performed with negative binomial regression. Compared to SCD visits, children in diabetes visits spoke 53% more relationship-building utterances (p < .05) and physicians in asthma visits spoke 48% fewer relationship building utterances to the child (p < .01). In diabetes visits, physicians gave almost twice as much information to children and gave 48% less information to parents (both p < .01) compared to SCD visits. Compared to SCD visits, physicians spoke fewer information-gathering utterances to parents in diabetes and asthma visits (85% and 72% respectively, both p < .001). SCD visits reflect less engagement of the children and greater physician effort to gather information from parents. These differences highlight opportunities to enhance engagement as a mechanism for ultimately improving SCD care.

The Challenges of Electronic Health Records and Diabetes Electronic Prescribing: Implications for Safety Net Care for Diverse Populations

Widespread electronic health record (EHR) implementation creates new challenges in the diabetes care of complex and diverse populations, including safe medication prescribing for patients with limited health literacy and limited English proficiency. This review highlights how the EHR electronic prescribing transformation has affected diabetes care for vulnerable patients and offers recommendations for improving patient safety through EHR electronic prescribing design, implementation, policy, and research. Specifically, we present evidence for (1) the adoption of RxNorm; (2) standardized naming and picklist options for high alert medications such as insulin; (3) the widespread implementation of universal medication schedule and language-concordant labels, with the expansion of electronic prescription 140-character limit; (4) enhanced bidirectional communication with pharmacy partners; and (5) informatics and implementation research in safety net healthcare systems to examine how EHR tools and practices affect diverse vulnerable populations.

The Impact of Professional Language Interpreting in Midwifery Care: A Review of the Evidence

BACKGROUND: Patients’ limited proficiency in the language of health care providers is known to be associated with health care disparities. Reluctance to use professional interpreting is documented across a wide range of health care professionals. Most of the literature on the effect of interpreting practices has focused on non-midwifery contexts.

OBJECTIVE: To review the evidence regarding how using professional interpreters impacts the midwifery care of women with limited dominant language proficiency (LDLP).

METHODS: Eligible studies were identified using searches of MEDLINE, CINAHL, and Maternity and Infant Care, then analyzed and assessed for applicability to midwifery.

RESULTS: 40 eligible papers, and two systematic reviews containing 48 additional papers, were included. The use of professional interpreters was found to support all aspects of the midwife’s direct role, with some complex findings on woman-centered communication during interpreted encounters. The use of ad hoc interpreters, or no interpreting, undermines all aspects of midwifery care for women with LDLP.

IMPLICATIONS: Midwifery care should be enhanced by increasing midwives’ use of professional interpreters; future research should consider how best to achieve this or investigate the comparative efficacy of more complex interventions, such as interpreter-doulas.

Training Effective Interpreters for Diabetes Care and Education

PURPOSE

This article describes a pilot project to improve knowledge, attitudes, and skills of ad hoc interpreters working with Native American diabetes patients with limited English proficiency.

METHODS

Case-based studies reflecting clinical situations were developed. Key concepts and terms from the cases were translated into the Navajo language and carefully back translated using the newly standardized Navajo diabetes terminology. Twenty-two health care workers from 2 Indian Health Service facilities were recruited for a pilot study to compare the performance of interpreters trained in a formal workshop using the case studies with that of interpreters who independently reviewed a video made from the training.

RESULTS

Workshop participants noted significant improvements in their knowledge and comfort level in interpretation of diabetes concepts but not about unrelated topics; the independent study group perceived less improvement.

CONCLUSION

Formal training for interpreters working with diabetes patients should be considered by diabetes educators working in settings where medical interpreters are needed. Diabetes educators should encourage back translation of key diabetes concepts to understand exactly what is being said to patients. Those working with multiple interpreters should make sure there are opportunities for interpreters to discuss translations of key concepts with each other and the educators so that translations are accurate and consistent among interpreters. Independent study did not appear to be an effective way to improve the ability of interpreters to translate current diabetes concepts accurately.

Health Plan Disenrollment in a Choice-Based Medicaid Managed Care Program

Consumer decisions to switch health plans have implications for quality of care and risk selection. We examine factors related to time to disenrollment in a Medicaid managed care program where beneficiaries face a menu of plans and can change plans every month. Several findings have direct policy relevance. Families and individuals who make active choices upon entering the program are at substantially lower risk of disenrollment than those who are auto-assigned. Interactions between enrollee ethnicity and provider language proficiency suggest that enrollee satisfaction depends on the cultural competence of providers. Differential disenrollment by risk status results in adverse retention for certain types of plans.