The Influence of Language Discordance Between Patient and Physician on Time-to-Thrombolysis in Acute Ischemic Stroke

The influence of primary language on postoperative stroke outcomes

BACKGROUND

Language barriers have the potential to influence acute stroke outcomes. Thus, we examined postoperative stroke outcomes among non-English primary language speakers.

METHODS

Utilizing the Healthcare Cost and Utilization Project State Inpatient Database (2016-2019), we conducted a retrospective cohort study of adults diagnosed with a postoperative stroke in Michigan, Maryland, and New Jersey. Patients were classified by primary language spoken: English (EPL) or non-English (n-EPL). The primary outcome was hospital length-of-stay. Secondary outcomes included stroke intervention, feeding tube, tracheostomy, mortality, cost, disposition, and readmission. Propensity-score matching and post-match regression were used to quantify outcomes.

RESULTS

Among 3078 postoperative stroke patients, 6.2 ​% were n-EPL. There were no differences in length-of-stay or secondary outcomes, except for higher odds of feeding tube placement (OR 1.95, 95 ​% CI 1.10-3.47, p ​= ​0.0227) in n-EPL.

CONCLUSIONS

Postoperative stroke outcomes were comparable by primary language spoken. However, higher odds of feeding tube placement in n-EPL may suggest differences in patient-provider communication.

The Relationship Between Limited English Proficiency and Outcomes in Stroke Prevention, Management, and Rehabilitation: A Systematic Review

Introduction

Individuals with limited English proficiency (LEP) face structural challenges to communication in English-speaking healthcare environments. We performed a systematic review to characterize the relationship between LEP and outcomes in stroke prevention, management, and recovery.

Methods

A systematic review was conducted using the PubMed, Embase, Scopus, and Web of Science databases. Titles and abstracts from articles identified were read and selected for full text review. Studies meeting inclusion criteria were reviewed in full for study design, aim, and outcomes.

Results

Of 891 unique articles, 20 were included. Eleven articles did not provide information about interpreter availability or usage, limiting the ability to draw conclusions about the effect of LEP on measured outcomes in these studies. Overall, studies demonstrated that English proficiency is associated with better outcomes in preventive aspects of stroke care such as stroke symptom awareness, anticoagulation maintenance, and knowledge of warfarin indication. Some acute stroke care metrics were independent of English proficiency in seven studies while other evidence showed associations between interpreter requirement and quality of inpatient care received. LEP and English-proficient groups show similar mortality despite greater lengths of stay and greater proportions of care in dedicated stroke units for LEP patients. Post-stroke quality of life can be worse for those with LEP, and language barriers can negatively impact patient and provider experiences of rehabilitation.

Conclusions

Stroke patients with LEP face barriers to equitable care at multiple stages. While some studies demonstrate worse outcomes for LEP patients, equitable care was shown in multiple studies frequently in the setting of a high degree of interpreter availability. Patients with LEP will benefit from tailored education regarding stroke symptom recognition and medication regimens, and from provision of translated written educational material. Inequities in inpatient care and rehabilitation exist despite similar mortality rates in four studies. Future studies should report interpreter availability and usage within LEP groups and whether patient interactions were language-concordant or discordant in order to allow for more generalizable and reliable conclusions.

Disparities in Care and Outcome of Stroke Patients from Culturally and Linguistically Diverse Communities in Metropolitan Australia

Background: Acute stroke is a time-critical emergency where diagnosis and acute management are highly dependent upon the accuracy of the patient’s history. We hypothesised that the language barrier is associated with delayed onset time to thrombolysis and poor clinical outcomes. This study aims to evaluate the effect of language barriers on time to thrombolysis and clinical outcomes in acute ischemic stroke. Concerning the method, this is a retrospective study of all patients admitted to a metropolitan stroke unit (Melbourne, Victoria, Australia) with an acute ischemic stroke treated with tissue plasminogen activator between 1/2013 and 9/2017. Baseline characteristics, thrombolysis time intervals, length of stay, discharge destination, and in-hospital mortality were compared among patients with and without a language barrier using multivariate analysis after adjustment for age, sex, stroke severity, premorbid modified Rankin Scale (mRS), and Charlson Comorbidity Index (CCI). Language barriers were defined as a primary language other than English. A total of 374 patients were included. Our findings show that 76 patients (20.3%) had a language barrier. Mean age was five years older for patients with language barriers (76.7 vs. 71.8 years, p = 0.004). Less non-English speaking patients had premorbid mRS score of zero (p = 0.002), and more had premorbid mRS score of one or two (p = 0.04). There was no statistically significant difference between the two groups in terms of stroke severity on presentation (p = 0.06). The onset to needle time was significantly longer in patients with a language barrier (188 min vs. 173 min, p = 0.04). Onset to arrival and door to imaging times were reassuringly similar between the two groups. However, imaging to needle time was 9 min delayed in non-English speaking patients with a marginal p value (65 vs. 56 min, p = 0.06). Patients with language barriers stayed longer in the stroke unit (six vs. four days, p = 0.02) and had higher discharge rates than residential aged care facilities in those admitted from home (9.2% vs. 2.3%, p = 0.02). In-hospital mortality was not different between the two groups (p = 0.8). In conclusion, language barriers were associated with almost 14 min delay in thrombolysis. The delay was primarily attributable to imaging to needle time. Language barriers were also associated with poorer clinical outcomes.

Physician-Patient Language Discordance and Poor Health Outcomes: A Systematic Scoping Review

Objective: This systematic review assessed whether physician-patient language concordance, compared with discordance, is associated with better health outcomes. Methods: A systematic literature search was conducted, without language restrictions, using PubMed, EMBASE, Web of Science, and PsycINFO, from inception to July 2020. We included studies that evaluated the effects of physician-patient language concordance on health outcomes. Articles were screened, selected, and data-extracted in duplicate. Review protocol was prospectively registered (PROSPERO, CRD42020157229). Results: There were 541 citations identified through databases and eight citations through reverse search and Google Scholar. A total of 15 articles (84,750 participants) were included reporting outcomes within five domains: diabetes care (four studies), inpatient care (five studies), cancer screening (three studies), healthcare counseling (two studies), and mental health care (one study). Ten studies were of good quality, four were fair, and one was poor, according to the modified Newcastle-Ottawa Scale. Eight studies (53%) showed a significant negative association between language discordance and at least one clinical outcome. Five studies (33%) found no association. Conclusion: Over half the evidence collated showed that physician-patient language concordance was associated with better health clinical outcomes.

Language disparity is not a significant barrier for time-sensitive care of acute ischemic stroke

BACKGROUND

Language barriers were reported to affect timely access to health care and outcome. The aim of this study was to investigate the effect of language disparity on quality benchmarks of acute ischemic stroke therapy.

METHODS

Consecutive patients with acute ischemic stroke at the University of California Irvine Medical Center from 2013 to 2016 were studied. Patients were categorized into 3 groups according to their preferred language: English, Spanish, and other languages. Quality benchmarks and outcomes of the 3 language groups were analyzed.

RESULTS

Of the 928 admissions, 69.7% patients recorded English as preferred language, as compared to 17.3% Spanish and 13.0% other languages. There was no significant difference in the rate of receiving intravenous thrombolysis (24.3, 22.1 and 21.0%), last-known-well to door time, door-to-imaging time, door-to-needle time, and hospital length of stay among the 3 language groups. In univariate analysis, the other languages group had lower chance of favorable outcomes than the English-speaking group (26.3% vs 40.4, p < 0.05) while the Spanish-speaking group had lower mortality rate than English-speaking group (3.1% vs 7.7%, p = 0.05). After adjusting for age and initial NIHSS scores, multivariate regression models showed no significant difference in favorable outcomes and mortality between different language groups.

CONCLUSION

We demonstrate no significant difference in quality benchmarks and outcome of acute ischemic stroke among 3 different language groups. Our results suggest that limited English proficiency is not a significant barrier for time-sensitive stroke care at Comprehensive Stroke Center.

Scoping review: Definitions and outcomes of patient-provider language concordance in healthcare

OBJECTIVE

To conduct a scoping literature review to understand the conceptualization and nature of the research on patient-provider language concordance (LC) in health care.

METHODS

We searched PubMed, EMBASE, CINAHL, PsycINFO, and Scopus to identify peer-reviewed articles between January 1961 and August 2018. We extracted study characteristics, content, definitions, and findings.

RESULTS

Fifty studies were included. Forty studies were quantitative, seven were qualitative, and three were mixed methods. Overall, the studies revealed inconsistent definitions and measures of patient-provider LC. Outcomes studied in connection to LC included: (1) interpersonal relationships, (2) access to health information, (3) access to care, (4) satisfaction and health-care experience, and (5) patient-related health outcomes. While four studies found that LC care had a negative or no impact on health outcomes, 46 studies reported positive outcomes associated with LC care.

CONCLUSIONS

The study findings highlight the need for more research on LC care and a consistent definition of LC using multiple measures of LC to capture the complex and multidimensional nature of language in social interaction.

PRACTICAL IMPLICATIONS

The study findings highlight the importance of how ideologies of language shape the perceptions of language and LC, thereby influence resource allocation and priorities.

Impact of Patient Language on Emergency Medical Service Use and Prenotification for Acute Ischemic Stroke

Background and Purpose

Use of emergency medical services (EMS) is associated with decreased door-to-needle time in acute ischemic stroke (AIS). Whether patient language affects EMS utilization and prenotification in AIS has been understudied. We sought to characterize EMS use and prenotification by patient language among intravenous tissue plasminogen activator (IV-tPA) tissue plasminogen (IV-tPA) treated patients at a single center with a large Spanish-speaking patient population.

Methods

We performed a retrospective analysis of all patients who received IV-tPA in our emergency department between July 2011 and June 2016. Baseline characteristics, EMS use, and prenotification were compared between English- and Spanish-speaking patients. Logistic regression was used to measure the association between patient language and EMS use.

Results

Of 391 patients who received IV-tPA, 208 (53%) primarily spoke English and 174 (45%) primarily spoke Spanish. Demographic and clinical factors including National Institutes of Health Stroke Scale (NIHSS) did not differ between language groups. Emergency medical services use was higher among Spanish-speaking patients (82% vs 70%; P < .01). Prenotification did not differ by language (61% vs 63%; P = .8). In a multivariable model adjusted for age, sex, and NIHSS, Spanish speakers remained more likely to use EMS (odds ratio: 1.8, 95% confidence interval: 1.1-3.0).

Conclusion

Emergency medical services usage was higher in Spanish speakers compared to English speakers among AIS patients treated with IV-tPA; however, prenotification rates did not differ. Future studies should evaluate differences in EMS utilization according to primary language and ethnicity.

Language barriers between physicians and patients are not associated with thrombolysis of stroke mimics

BACKGROUND

Acute stroke is a time-sensitive condition in which rapid diagnosis must be made in order for thrombolytic treatment to be administered. A certain proportion of patients who receive thrombolysis will be found on further evaluation to have a diagnosis other than stroke, so-called "stroke mimics." Little is known about the role of language discordance in the emergency department diagnosis of acute ischemic stroke.

METHODS

This is a retrospective analysis of all acute ischemic stroke patients who received IV tissue plasminogen activator (tPA) in our emergency department between July 2011 and December 2015. Baseline characteristics, patient language, and final diagnosis were compared between encounters in which the treating neurologist and patient spoke the same language (concordant cases) and encounters in which they did not (discordant cases).

RESULTS

A total of 350 patients received IV tPA during the study period. English was the primary language for 52.6%, Spanish for 44.9%, and other languages for 2.6%; 60.3% of cases were classified as language concordant and 39.7% as discordant. We found no significant difference in the proportion of stroke mimics in the language concordant compared to discordant groups (16.6% vs 9.4%, p = 0.06). Similarly, the proportion of stroke mimics did not differ between English- and Spanish-speaking patients (15.8% vs 11.5%, p = 0.27).

CONCLUSIONS

Language discordance was not associated with acute stroke misdiagnosis among patients treated with IV tPA. Prospective evaluation of communication during acute stroke encounters is needed to gain clarity on the role of language discordance in acute stroke misdiagnosis.