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

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

BACKGROUND AND OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION AND SYNTHESIS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

DISCUSSION

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

PROSPERO REGISTRATION NUMBER

CRD42022302871.

Intersectionality and Inclusive Serious Illness Communication in the Intensive Care Unit

Serious illness communication can be especially distressing for patients who are critically ill and their loved ones who experience forms of discrimination based on identities such as their race, gender, sexual orientation, and other intersecting identities. In this article, we discuss the concept of intersectionality and its association with serious illness communication, decision-making, and care in the intensive care unit. Additionally, we present relevant concepts from clinical practice and contemporary nursing and health care literature to support critical care nurses in fostering more inclusive serious illness communication in the intensive care unit.

The effectiveness of out-of-hours palliative care telephone advice lines: A rapid systematic review

BACKGROUND

People with palliative care needs and their carers often rely on out-of-hours services to remain at home. Policymakers have recommended implementing telephone advice lines to ensure 24/7 access to support. However, the impact of these services on patient and carer outcomes, as well as the health care system, remains poorly understood.

AIM

To evaluate the clinical- and cost-effectiveness of out-of-hours palliative care telephone advice lines, and to identify service characteristics associated with effectiveness.

DESIGN

Rapid systematic review (PROSPERO ID: CRD42023400370) with narrative synthesis.

DATA SOURCES

Three databases (Medline, EMBASE and CINAHL) were searched in February 2023 for studies of any design reporting on telephone advice lines with at least partial out-of-hours availability. Study quality was assessed using the Mixed Methods Appraisal Tool, and quantitative and qualitative data were synthesised narratively.

RESULTS

Twenty-one studies, published 2000-2022, were included. Most studies were observational, none were experimental. While some evidence suggested that telephone advice lines offer guidance and reassurance, supporting care at home and potentially reducing avoidable emergency care use in the last months of life, variability in reporting and poor methodological quality across studies limit our understanding of patient/carer and health care system outcomes.

CONCLUSION

Despite their increasing use, evidence for the clinical- and cost-effectiveness of palliative care telephone advice lines remains limited, primarily due to the lack of robust comparative studies. There is a need for more rigorous evaluations incorporating experimental or quasi-experimental methods and longer follow-up, and standardised reporting of telephone advice line models and outcomes, to guide policy and practice.

Factors Associated with Costly Hospital Care among Patients with Dementia and Acute Respiratory Failure

Rationale: Understanding contributors to costly and potentially burdensome care for patients with dementia is of interest to healthcare systems and may facilitate efforts to promote goal-concordant care. Objective: To identify risk factors, in particular whether an early goals-of-care discussion (GOCD) took place, for high-cost hospitalization among patients with dementia and acute respiratory failure. Methods: We conducted an electronic health record-based retrospective cohort study of 298 adults with dementia hospitalized with respiratory failure (receiving ⩾48 h of mechanical ventilation) within an academic healthcare system. We collected demographic and clinical characteristics, including clinical markers of advanced dementia (weight loss, pressure ulcers, hypernatremia, mobility limitations) and intensive care unit (ICU) service (medical, surgical, neurologic). We ascertained whether a GOCD was documented within 48 hours of ICU admission. We used logistic regression to identify patient characteristics associated with high-cost hospitalization measured using the hospital system accounting database and defined as total cost in the top third of the sample (⩾$145,000). We examined a path model that included hospital length of stay as a final mediator between exposure variables and high-cost hospitalization. Results: Patients in the sample had a median age of 71 (IQR, 62-79) years. Approximately half (49%) were admitted to a medical ICU, 29% to a surgical ICU, and 22% to a neurologic ICU. More than half (59%) had a clinical indicator of advanced dementia. A minority (31%) had a GOCD documented within 48 hours of ICU admission; those who did had a 50% lower risk of a high-cost hospitalization (risk ratio, 0.50; 95% confidence interval, 0.2-0.8). Older age, limited English proficiency, and nursing home residence were associated with a lower likelihood of high-cost hospitalization, whereas greater comorbidity burden and admission to a surgical or neurologic ICU compared with a medical ICU were associated with a higher likelihood of high-cost hospitalization. Conclusions: Early GOCDs for patients with dementia and respiratory failure may promote high-value care by ensuring aggressive and costly life support interventions are aligned with patients' goals. Future work should focus on increasing early palliative care delivery for patients with dementia and respiratory failure, in particular in surgical and neurologic ICU settings.

Predisposing, Enabling, and Need Factors Driving Palliative Care Use in Head and Neck Cancer

OBJECTIVE

Characterizing factors associated with palliative care (PC) use in patients with stage III and VI head and neck cancer using Anderson's behavioral model of health service use.

STUDY DESIGN

A retrospective study of the 2004 to 2020 National Cancer Database.gg METHODS: We used multivariate logistic regression to assess the association of predisposing, enabling, and need factors with PC use. We also investigated the association of these factors with interventional PC type (chemotherapy, radiotherapy, surgery) and refusal of curative treatment in the last 6 months of life.

RESULTS

Five percent of patients received PC. "Predisposing factors" associated with less PC use include Hispanic ethnicity (adjusted odds ratio [aOR], 086; 95% confidence interval [CI], 0.76-0.97) and white and black race (vs white: aOR, 1.14; 95% CI, 1.07-1.22). "Enabling factors" associated with lower PC include private insurance (vs uninsured: aOR, 064; 95% CI, 0.53-0.77) and high-income (aOR, 078; 95% CI, 0.71-0.85). "Need factors" associated with higher PC use include stage IV (vs stage III cancer: aOR, 2.25; 95% CI, 2.11-2.40) and higher comorbidity index (vs Index 1: aOR, 1.58; 95% CI, 1.42-1.75). High-income (aOR, 0.78; 95% CI, 0.71-0.85) and private insurance (aOR, 0.6; 95% CI, 0.53, 0.77) were associated with higher interventional PC use and lower curative treatment refusal (insurance: aOR, 0.82; 95% CI, 0.55, 0.67; income aOR, 0.48; 95% CI, 0.44, 0.52).

CONCLUSION

Low PC uptake is attributed to patients' race/culture, financial capabilities, and disease severity. Culturally informed counseling, clear guidelines on PC indication, and increasing financial accessibility of PC may increase timely and appropriate use of this service.

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

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

SIGNIFICANCE OF RESULTS

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

The end-of-life needs of Aboriginal and immigrant communities: a challenge to conventional medical models

Introduction

Concerns have been raised internationally about the palliative care needs of migrants and First Nations people. This article presents insights from research investigating the end-of-life needs of Aboriginal and culturally and linguistically diverse people living in Western Sydney, Australia. This region has a large rapidly growing, and highly diverse population and on average low socioeconomic status. The research was guided by an advisory panel made up of representatives of supportive and palliative medicine, bereavement support, Aboriginal health, and multicultural health facilities. It aimed to generate findings to support the delivery of culturally sensitive services in the public health system.

Method

The multi-method design and the conduct of the research were informed by the literature on researching with marginalized groups which highlights the ethical considerations needed to avoid replicating past injustices. Qualitative data was generated from key informants and community focus groups.

Results

The analysis revealed seven themes and some suggested solutions which were relevant across several themes. The seven themes were: the Need for trusted relationships; Talking about death and dying; Knowledge of key services; Decision-making and obtaining consent from the patient; Appropriate physical spaces; Cultural practices around EOL; and Language barriers.

Discussion

Within each theme a variety of cultural beliefs and practices were revealed that conflicted with mainstream medical systems, indicating the need for changes in such systems. 'Compassionate Communities' was identified as a model to support the necessary changes.

Disparities in advance care planning rates persist among emergency general surgery patients: Current state and recommendations for improvement

BACKGROUND

Unanticipated changes in health status and worsening of chronic conditions often prompt the need to consider emergency general surgery (EGS). Although discussions about goals of care may promote goal-concordant care and reduce patient and caregiver depression and anxiety, these conversations, as well as standardized documentation, remain infrequent for EGS patients.

METHODS

We conducted a retrospective cohort study using electronic health record data from patients admitted to an EGS service at a tertiary academic center to determine the prevalence of clinically meaningful advance care planning (ACP) documentation (conversations and legal ACP forms) during the EGS hospitalization. Multivariable regression was performed to identify patient, clinician, and procedural factors associated with the lack of ACP.

RESULTS

Among 681 patients admitted to the EGS service in 2019, only 20.1% had ACP documentation in the electronic health record at any time point during their hospitalization (of those, 75.5% completed before and 24.5% completed during admission). Two thirds (65.8%) of the total cohort had surgery during their admission, but none of them had a documented ACP conversation with the surgical team preoperatively. Patients with ACP documentation tended to have Medicare insurance (adjusted odds ratio, 5.06; 95% confidence interval, 2.09-12.23; p < 0.001) and had greater burden of comorbid conditions (adjusted odds ratio, 4.19; 95% confidence interval, 2.55-6.88; p < 0.001).

CONCLUSION

Adults experiencing a significant, often abrupt change in health status leading to an EGS admission are infrequently engaged in ACP conducted by the surgical team. This is a critical missed opportunity to promote patient-centered care and to communicate patients' care preferences to the surgical and other inpatient medical teams.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.