Emergency department and inpatient health care utilization among patients who require interpreter services

Racial difference in receiving computed tomography for head injury patients in emergency departments

STUDY OBJECTIVE

Prior studies have suggested potential racial differences in receiving imaging tests in emergency departments (EDs), but the results remain inconclusive. In addition, most prior studies may only have limited racial groups for minority patients. This study aimed to investigate racial differences in head computed tomography (CT) administration rates in EDs among patients with head injuries.

METHODS

Patients with head injuries who visited EDs were examined. The primary outcome was patients receiving head CT during ED visits, and the primary exposure was patient race/ethnicity, including Asian, Hispanic, Non-Hispanic Black (Black), and Non-Hispanic White (White). Multivariable logistic regression analyses were performed using the National Hospital Ambulatory Medical Care Survey database, adjusting for patients and hospital characteristics.

RESULTS

Among 6130 patients, 51.9% received a head CT scan. Asian head injury patients were more likely to receive head CT than White patients (59.1% versus 54.0%, difference 5.1%, p < 0.001). This difference persisted in adjusted results (odds ratio, 1.52; 95% CI, 1.06-2.16, p = 0.022). In contrast, Black and Hispanic patients have no significant difference in receiving head CT than White patients after the adjustment.

CONCLUSIONS

Asian head injury patients were more likely to receive head CT than White patients. This difference may be attributed to the limited English proficiency among Asian individuals and the fact that there is a wide variety of different languages spoken by Asian patients. Future studies should examine rates of receiving other diagnostic imaging modalities among different racial groups and possible interventions to address this difference.

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.

Racial, ethnic and language disparities in healthcare utilization in pediatric patients following tonsillectomy

IMPORTANCE

Tonsillectomy is one of the most common surgical procedures performed in the United States. However, there is little known about the intersectionality of race, ethnicity, and language and how these factors influence post-tonsillectomy outcomes such as ED utilization and hospital readmission rates.

OBJECTIVE

To examine disparities in emergency department (ED) utilization and hospital readmissions for post-tonsillectomy complications based on insurance status, patient race, ethnicity and language spoken.

DESIGN

This was retrospective cohort over four years.

SETTING

Tertiary Care Children's Hospital.

PARTICIPANTS

All children (n = 10,215) who underwent tonsillectomy or adenotonsillectomy at a tertiary children's hospital from January 2015 to December 2018 were identified and included. There were no exclusion criteria.

EXPOSURE

The exposure of interest was tonsillectomy.

MAIN OUTCOMES AND MEASURES

Outcomes and variables of interest were defined prior to data collection. The primary outcome of this study was emergency department (ED) utilization defined as any ED or urgent care visit within 21 days of the tonsillectomy for surgery-related concerns. The secondary outcome of this study was readmissions following tonsillectomy.

RESULTS

A total of 10215 pediatric patients (median age, 6 years; 5096 [50 %] male) who underwent tonsillectomy were included in the analysis. 13 % of patients presented to the ED with surgery-related complaints. Among English proficient patients, multi-racial patients were the only group with an elevated odds of ED utilization (OR:1.5, 95 % CI: 1.2, 1.9). Non-English language preference (NELP) patients of Black, Hispanic, Asian, and American Indian/Alaskan Native race/ethnicity also had elevated odds of ED use post-tonsillectomy compared to non-Hispanic White English proficient patients. Six percent of all patients had an unplanned hospital readmission. Asian patients with non-English language preference had 2.1 times the odds of readmission (95 % CI: 1.2, 3.6); and were disproportionately admitted for post-tonsillectomy hemorrhage.

CONCLUSIONS

and Relevance: Language disparities in ED use and readmission persist after adjusting for risk factors. Non-English language preference populations have a higher rate of ED utilization, especially for minor complications. Disparities may result from differential health literacy or predispositions to complications. Future directions include additional research on mechanisms and targeted interventions to increase education and access to language-appropriate resources.

Open to interpretation: An integrated primary care behavioral health training approach for treating linguistically diverse patients

INTRODUCTION

Integrated primary care settings serve an increasingly high volume of linguistically diverse patients. In English language-dominant countries, limited English proficiency (LEP) is associated with disparities in access and quality of behavioral health (BH) care. Interpretive services (IS) aim to address these disparities by assisting in the delivery of clinical care between patients and providers who speak different languages. Yet, there is a need for greater emphasis on the utilization of IS in clinical training for BH professionals (e.g., psychology, social work, counseling, and family therapy).

METHOD

In this conceptual article, we describe a BH practicum rotation for predoctoral psychology trainees in a free, student-run integrated primary care clinic that largely serves uninsured adults with LEP. First, we discuss our training model which includes a 90-min didactic lecture on IS for BH and supervised applied clinical experiences (e.g., psychotherapy, warm handoffs, and consultation). Then, we present vignettes prepared by trainees about the challenges and benefits associated with delivering BH care with IS at the predoctoral level of training.

RESULTS

From the practicum experience, clinical psychology trainees reported improved knowledge and competencies in utilizing IS as well as generalizable skills for delivering BH care with a focus on multicultural practice.

DISCUSSION

We recommend that other integrated primary care BH training sites consider emphasizing training in IS. This article concludes with recommendations for implementation and dissemination of our training model on other sites. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Differences in Telemedicine, Emergency Department, and Hospital Utilization Among Nonelderly Adults with Limited English Proficiency Post-COVID-19 Pandemic: a Cross-Sectional Analysis

BACKGROUND

The unprecedented use of telemedicine during the COVID-19 pandemic provided an opportunity to examine its uptake among individuals with limited English proficiency (LEP).

OBJECTIVE

To assess telemedicine use among nonelderly adults with LEP and the association between use of telehealth and emergency department (ED) and hospital visits.

DESIGN

Cross-sectional study using the National Health Interview Survey (July 2020-December 2021) PARTICIPANTS: Adults (18-64 years), with LEP (N=1488) or English proficiency (EP) (N=25,873) MAIN MEASURES: Telemedicine, ED visits, and hospital visits in the past 12 months. We used multivariate logistic regression to assess (1) the association of English proficiency on having telemedicine visits; and (2) the association of English proficiency and telemedicine visits on having ED and hospital visits.

KEY RESULTS

Between July 2020 and December 2021, 22% of adults with LEP had a telemedicine visit compared to 35% of adults with EP. After controlling for predisposing, enabling, and need factors, adults with LEP had 20% lower odds of having a telemedicine visit than adults with EP (p=0.02). While English proficiency was not associated with ED or hospital visits during this time, adults with telemedicine visits had significantly greater odds of having any ED (aOR: 1.80, p<0.001) and hospital visits (aOR: 2.03, p<0.001) in the past 12 months.

CONCLUSIONS

While telemedicine use increased overall during the COVID-19 pandemic, its use remained much less likely among adults with LEP. Interventions targeting structural barriers are needed to address disparities in access to telemedicine. More research is needed to understand the relationship between English proficiency, telemedicine visits, and downstream ED and hospital visits.

Factors associated with frequent emergency department visits among health centre patients receiving primary care

RATIONALE, AIMS AND OBJECTIVES

We sought to examine specific care-seeking behaviours and experiences, access indicators, and patient care management approaches associated with frequency of emergency department (ED) visits among patients of Health Resources and Services Administration-funded health centres that provide comprehensive primary care to low-income and uninsured patients.

METHOD

We used cross-sectional data of a most recent nationally representative sample of health centre adult patients aged 18-64 (n = 4577) conducted between October 2014 and April 2015. These data were merged with the 2014 Uniform Data System to incorporate health centre characteristics. We measured care-seeking behaviours by whether the patient called the health centre afterhours, for an urgent appointment, or talked to a provider about a concern. Access to care indicators included health centre continuity of care and receipt of transportation or translation services. We included receipt of care coordination and specialist referral as care management indicators. We used a multilevel multinomial logistic regression model to identify the association of independent variables with number of ED visits (4 or more visits, 2-3 visits, 1 visit, vs. 0 visits), controlling for predisposing, enabling, and need characteristics.

RESULTS

Calling the health centre after-hours (OR = 2.41) or for urgent care (OR = 2.53), and being referred to specialists (OR = 2.36) were associated with higher odds of four or more ED visits versus none. Three or more years of continuity with the health centre (OR = 0.32) was also associated with lower odds of four or more ED visits versus none.

CONCLUSIONS

Findings underscore opportunities to reduce higher frequency of ED visits in health centres, which are primary care providers to many low-income populations. Our findings highlight the potential importance of improving patient retention, better access to providers afterhours or for urgent visits, and access to specialist as areas of care in need of improvement.

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.

Management of low back pain in Australian emergency departments for culturally and linguistically diverse populations from 2016 to 2021

BACKGROUND

Disparate care in the ED for minority populations with low back pain is a long-standing issue reported in the USA. Our objective was to compare care delivery for low back pain in Australian EDs between culturally and linguistically diverse (CALD) and non-CALD patients.

METHODS

This is a retrospective review of medical records of the ED of three public hospitals in Sydney, New South Wales, Australia from January 2016 to October 2021. We included adult patients diagnosed with non-serious low back pain at ED discharge. CALD status was defined by country of birth, preferred language and use of interpreter service. The main outcome measures were ambulance transport, lumbar imaging, opioid administration and hospital admission.

RESULTS

Of the 14 642 included presentations, 7656 patients (52.7%) were born overseas, 3695 (25.2%) preferred communicating in a non-English language and 1224 (8.4%) required an interpreter. Patients born overseas were less likely to arrive by ambulance (adjusted OR (aOR) 0.68, 95% CI 0.63 to 0.73) than Australian-born patients. Patients who preferred a non-English language were also less likely to arrive by ambulance (aOR 0.82, 95% CI 0.75 to 0.90), yet more likely to be imaged (aOR 1.12, 95% CI 1.01 to 1.23) or be admitted to hospital (aOR 1.16, 95% CI 1.04 to 1.29) than Native-English-speaking patients. Patients who required an interpreter were more likely to receive imaging (aOR 1.43, 95% CI 1.25 to 1.64) or be admitted (aOR 1.49, 95% CI 1.29 to 1.73) compared with those who communicated independently. CALD patients were generally less likely to receive weak opioids than non-CALD patients (aOR range 0.76-0.87), yet no difference was found in the use of any opioid or strong opioids.

CONCLUSION

Patients with low back pain from a CALD background, especially those lacking English proficiency, are significantly more likely to be imaged and admitted in Australian EDs. Future interventions improving the quality of ED care for low back pain should give special consideration to CALD patients.

Access to Care Among Adults with Limited English Proficiency

BACKGROUND

There are approximately 25.6 million individuals with limited English proficiency (LEP) in the USA, and this number is increasing.

OBJECTIVE

Investigate associations between LEP and access to care in adults.

DESIGN

Cross-sectional nationally representative survey.

PARTICIPANTS

Adults with (n = 18,908) and without (n = 98,060) LEP aged ≥ 18 years identified from the 2014-2018 Medical Expenditure Panel Survey MAIN MEASURES: Associations between LEP and access to healthcare and preventive services were evaluated with multivariable logistic regression models, stratified by age group (18-64 and ≥ 65 years). The official government definition of LEP (answers "not at all/not well/well" to the question "How well do you speak English?") was used. Access to care included having a usual source of care (and if so, distance from usual source of care, difficulty contacting usual source of care, and provision of extended hours), visiting a medical provider in the past 12 months, having to forego or delay care, and having trouble paying for medical bills. Preventive services included blood pressure and cholesterol check, flu vaccination, and cancer screening.

KEY RESULTS

Adults aged 18-64 years with LEP were significantly more likely to lack a usual source of care (adjusted odds ratios [aOR] = 2.48; 95% confidence interval [CI] = 2.27-2.70), not have visited a medical provider (aOR = 2.02; CI = 1.89-2.16), and to be overdue for receipt of preventive services, including blood pressure check (aOR = 2.00; CI = 1.79-2.23), cholesterol check (aOR = 1.22; CI = 1.03-1.44), and colorectal cancer screening (aOR = 1.58; CI = 1.37-1.83) than adults without LEP. Results were similar among adults aged ≥ 65 years.

CONCLUSIONS

Adults with LEP had consistently worse access to care than adults without LEP. System-level interventions, such as expanding access to health insurance coverage, providing language services, improving provider training in cultural competence, and increasing diversity in the medical workforce may minimize barriers and improve equity in access to care.

A Narrative Review of Medical Interpretation Services and their Effect on the Quality of Health Care

Half of the foreign-born population in the United States speaks English "less than very well." The extant literature suggests that low-English-proficient (LEP) patients experience poorer healthcare outcomes than do language-concordant patients. It remains unclear which methods of interpreter services are best for communicating effectively and achieving positive health outcomes for LEP patients. This review examines interpretation methods to compare their effectiveness and frequency of use and identifies the remaining gaps in our knowledge. The evidence suggests that any type of professional language service is superior to untrained interpreting and vastly better than not using an interpreter at all. Even with this knowledge, use of interpreter services is unacceptably low and gaps remain. Further research is needed to isolate and examine different methods of interpretation and measure objective health outcomes. In addition, education is needed for interpreters and healthcare providers to ensure the most effective communicative strategies for LEP patients.

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.

Breaking through barriers: the need for effective research to promote language-concordant communication as a facilitator of equitable emergency care

Individuals with limited English proficiency (LEP) are at high risk for adverse outcomes in the US health care system. This is particularly true for patients with LEP seeking care in the emergency department (ED). Although professional language interpretation improves the quality of care for these patients, it remains underused. The dynamic, discontinuous nature of an ED visit poses distinct challenges and opportunities for providing equitable, high-quality care for patients with LEP. Evidence-based best practices for identifying patients with LEP and using professional interpretation are well described but inadequately implemented. There are few examples in the literature of rigorous interventions to improve quality of care and outcomes for patients with LEP. There is an urgent need for high-quality research to improve communication with patients with LEP along the continuum of emergency care in order to achieve equity in outcomes.

Pediatric Emergency Department Discharge Instructions for Spanish-Speaking Families: Are We Getting It Right?

OBJECTIVES

Patients who speak Spanish are less likely to comply with discharge instructions, adhere to appointments, and take medications than English-speaking patients. However, adherence is improved when discharge instructions are provided in Spanish. This study was designed to assess the frequency of providing written discharge instructions in Spanish to patients who speak Spanish and request interpretation services, and to determine factors associated with receiving written discharge instructions in the preferred language in a pediatric emergency department (ED).

METHODS

This was a retrospective cross-sectional study of all discharges of Spanish-speaking patients who requested an interpreter in 1 year from a large urban pediatric ED and an associated community ED. Multivariable logistic regression was used to identify patient and visit level characteristics associated with receiving written discharge instructions in Spanish.

RESULTS

Sixty-one percent of 11,545 patient encounters where a Spanish interpreter was requested received written discharge instructions in Spanish. Patients aged 1 to 3 years (adjusted odds ratio [aOR], 2.87; 95% CI, 2.18-3.77) and aged 4 to 12 years (aOR, 2.06; 95% CI, 1.6-2.65), those seen without a trainee (aOR, 1.37; 95% CI, 1.25-1.5), and those with low acuity triage levels (aOR, 1.6; 95% CI, 1.29-1.97) were more likely to receive discharge instruction in Spanish. Female patients were less likely to receive Spanish discharge instructions (aOR, 0.9; 95% CI, 0.83-0.97).

CONCLUSIONS

Discharged pediatric ED patients often do not receive written instructions in the preferred language. Patient and provider factors are associated with receiving written instructions in Spanish. Quality improvement efforts are needed to ensure appropriate language discharge education.

Health Equity and Disparities in ROP Care: A Need for Systematic Evaluation

Retinopathy of prematurity (ROP) is a vasoproliferative retinal disorder that can have devastating visual sequelae if not managed appropriately. From an ophthalmology standpoint, ROP care is complex, since it spans multiple care settings and providers, including those in the neonatal intensive care unit (NICU), step down nurseries, and the outpatient clinic setting. This requires coordination and communication between providers, ancillary staff, and most importantly, effective communication with the patient's family members and caregivers. Often, factors related to the social determinants of health play a significant role in effective communication and care coordination with the family, and it is important for ophthalmologists to recognize these risk factors. The aim of this article is to (1) review the literature related to disparities in preterm birth outcomes and infants at risk for ROP; (2) identify barriers to ROP care and appropriate follow up, and (3) describe patient-oriented solutions and future directions for improving ROP care through a health equity lens.

The Impact of Language on Emergency Department Visits, Hospitalizations, and Length of Stay Among Home Care Recipients

BACKGROUND

Research considering the impact of language on health care utilization is limited. We conducted a population-based study to: (1) investigate the association between residents' preferred language and hospital-based health care utilization; and (2) determine whether this association is modified by dementia, a condition which can exacerbate communication barriers.

METHODS

We used administrative databases to establish a retrospective cohort study of home care recipients (2015-2017) in Ontario, Canada, where the predominant language is English. Residents' preferred language (obtained from in-person home care assessments) was coded as English (Anglophones), French (Francophones), or other (Allophones). Diagnoses of dementia were ascertained with a previously validated algorithm. We identified all emergency department (ED) visits and hospitalizations within 1 year.

RESULTS

Compared with Anglophones, Allophones had lower annual rates of ED visits (1.3 vs. 1.8; P<0.01) and hospitalizations (0.6 vs. 0.7; P<0.01), while Francophones had longer hospital stays (9.1 vs. 7.6 d per admission; P<0.01). After adjusting for potential confounders, Francophones and Allophones were less likely to visit the ED or be hospitalized than Anglophones. We found evidence of synergism between language and dementia; the average length of stay for Francophones with dementia was 25% (95% confidence interval: 1.10-1.39) longer when compared with Anglophones without dementia.

CONCLUSIONS

Residents whose preferred language was not English were less frequent users of hospital-based health care services, a finding that is likely attributable to cultural factors. Francophones with dementia experienced the longest stays in hospital. This may be related to the geographic distribution of Francophones (predominantly in rural areas) or to suboptimal patient-provider communication.

Prior Frequent Emergency Department Use as a Predictor of Emergency Department Visits After a New Cancer Diagnosis

PURPOSE

To determine whether emergency department (ED) visit history prior to cancer diagnosis is associated with ED visit volume after cancer diagnosis.

METHODS

This was a retrospective cohort study of adults (≥ 18 years) with an incident cancer diagnosis (excluding nonmelanoma skin cancers or leukemia) at an academic medical center between 2008 and 2018 and a safety-net hospital between 2012 and 2016. Our primary outcome was the number of ED visits in the first 6 months after cancer diagnosis, modeled using a multivariable negative binomial regression accounting for ED visit history in the 6-12 months preceding cancer diagnosis, electronic health record proxy social determinants of health, and clinical cancer-related characteristics.

RESULTS

Among 35,090 patients with cancer (49% female and 50% non-White), 57% had ≥ 1 ED visit in the 6 months immediately following cancer diagnosis and 20% had ≥ 1 ED visit in the 6-12 months prior to cancer diagnosis. The strongest predictor of postdiagnosis ED visits was frequent (≥ 4) prediagnosis ED visits (adjusted incidence rate ratio [aIRR]: 3.68; 95% CI, 3.36 to 4.02). Other covariates associated with greater postdiagnosis ED use included having 1-3 prediagnosis ED visits (aIRR: 1.32; 95% CI, 1.28 to 1.36), Hispanic (aIRR: 1.12; 95% CI, 1.07 to 1.17) and Black (aIRR: 1.21; 95% CI, 1.17 to 1.25) race, homelessness (aIRR: 1.95; 95% CI, 1.73 to 2.20), advanced-stage cancer (aIRR: 1.30; 95% CI, 1.26 to 1.35), and treatment regimens including chemotherapy (aIRR: 1.44; 95% CI, 1.40 to 1.48).

CONCLUSION

The strongest independent predictor for ED use after a new cancer diagnosis was frequent ED visits before cancer diagnosis. Efforts to reduce potentially avoidable ED visits among patients with cancer should consider educational initiatives that target heavy prior ED users and offer them alternative ways to seek urgent medical care.

Severity of Inpatient Hospitalizations Among Undocumented Immigrants and Medi-Cal Patients in a Los Angeles, California, Hospital: 2019

Objectives. To compare the severity of inpatient hospitalizations between undocumented immigrants and Medi-Cal patients in a large safety-net hospital in Los Angeles, California. Methods. We conducted a retrospective analysis of all 2019 inpatient stays at a Los Angeles hospital (n = 22 480), including patients of all races/ethnicities. We examined 3 measures by using insurance status to approximate immigration status: illness severity, length of hospital stay, and repeat hospitalizations. We calculated group differences between undocumented and Medi-Cal patients by using inverse probability weighted regression adjustment separately for patients aged 18 to 64 years and those aged 65 years and older. Results. Younger undocumented patients had less severe illness and shorter lengths of stay than their Medi-Cal counterparts. Older undocumented immigrants also had less severe illness, but had similar lengths of stay and were more likely to have repeated hospitalizations. Conclusions. While existing work suggests that undocumented immigrants could have more severe health care needs on account of their poorer access to medical care, we did not see clear health disadvantages among hospitalized undocumented immigrants, especially younger patients. There were fewer differences between undocumented and Medi-Cal patients who were older. (Am J Public Health. 2021;111(11):2019-2026. https://doi.org/10.2105/AJPH.2021.306485).

Pulled away: the experience of bilingual nurses as ad hoc interpreters in the emergency department

This study aimed to understand the experiences of bilingual nurses asked to interpret in the Emergency Department (ED), and the subsequent impact on safety climate. Australian ED clinicians assess and treat high numbers of linguistically diverse patients, many with limited English proficiency. New South Wales Health policy mandates the use of accredited interpreters when collecting personal and health information, and when obtaining consent for medical procedures. Semi-structured interviews with 12 nurses (representing 12 languages) from two metropolitan EDs were audio-recorded and analysed using qualitative content analysis, guided by Glendon & Stanton's model of organisational climate and culture. Analysis revealed widespread underlying assumptions that engaging interpreters is difficult, time-consuming and costly. Bilingual ED nurses with variable language fluency were used across organisations as the first choice due to clinical urgency, task urgency, and hospital workflow pressures. While the use of nurse interpreters facilitated timely assessment for the benefit of patients, it equally led to increased nurse workload, missed or misinterpreted information and subsequent perceived clinical risk. These practices were supported and facilitated by unit level managerial and multidisciplinary team practices, physician pressure and the nurses' own values and beliefs. While some, (but not all) participants were aware of the interpreter policy, they were torn between their acknowledgement of risky translation practices and their desire to support their colleagues to provide timely, culturally-competent assessment and care. Findings suggests a 'top-down' approach to translation policy has failed to influence the local safety culture and practices and does not address a climate created by clinical urgency and workflow. Formal training and accreditation of bilingual nurses, and/or embedded interpreters for common language groups may reduce risks for non-English speaking patients.

Communication in Health Care: Impact of Language and Accent on Health Care Safety, Quality, and Patient Experience

Permanent or temporary migration results in communication issues related to language barriers. The migrant's mother tongue is often different from that of the host country. Even when the same language is spoken, communication barriers arise because of differences in accent. These communication barriers have a significant negative impact on migrants accessing health care and their ability to understand instructions and seek follow-up care. A multidisciplinary team often has professionals from various countries. These migrant health care professionals find it difficult to communicate with patients of the host country and with their colleagues. Communication barriers, therefore, result in miscommunication or no communication between health care professionals and between health care professionals and patients. This increases the risk of medical errors and impacts quality of care and patient safety. This review looks at the impact of communication barriers in health care and endeavors to find effective solutions.

Limited English Proficient Patient Visits and Emergency Department Admission Rates for Ambulatory Care Sensitive Conditions in California: a Retrospective Cohort Study

BACKGROUND

Little is known about the risk of admission for emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) by limited English proficient (LEP) patients.

OBJECTIVE

Estimate admission rates from ED for ACSCs comparing LEP and English proficient (EP) patients and examine how these rates vary at hospitals with a high versus low proportion of LEP patients.

DESIGN

Retrospective cohort study of California's 2017 inpatient and ED administrative data PARTICIPANTS: Community-dwelling individuals ≥ 18 years without a primary diagnosis of pregnancy or childbirth. LEP patients had a principal language other than English.

MAIN MEASURES

We used a series of linear probability models with incremental sets of covariates, including patient demographics, primary diagnosis, and Elixhauser comorbidities, to examine admission rate for visits of LEP versus EP patients. We then added an interaction covariate for high versus low LEP-serving hospital. We estimated models with and without hospital-level random effects.

KEY RESULTS

These analyses included 9,641,689 ED visits; 14.7% were for LEP patients. . Observed rate of admission for all ACSC ED visits was higher for LEP than for EP patients (26.2% vs. 25.2; p value < .001). Adjusted rate of admission was not statistically significant (27.3% [95% CI 25.4-29.3%] vs. 26.2% [95% CI 24.3-28.1%]). For COPD, the difference was significant (36.8% [95% CI 35.0-38.6%] vs. 33.3% [95% CI 31.7-34.9%]). Difference in adjusted admission rate for LEP versus EP visits did not differ in high versus low LEP-serving hospitals.

CONCLUSIONS

In adjusted analyses, LEP was not a risk factor for admission for most ACSCs. This finding was observed in both high and low LEP-serving hospitals.

Racial and ethnic disparities in emergency department restraint use: A multicenter retrospective analysis

BACKGROUND

Research regarding disparities in physical restraint use in the emergency department (ED) is limited. We evaluated the role of race, ethnicity, and preferred language on the application of physical restraint among ED patients held under a Massachusetts section 12(a) order for mandatory psychiatric evaluation.

METHODS

We identified all ED patient encounters with a section 12(a) order across a large integrated 11-hospital health system from January 2018 through December 2019. Information on age, race, ethnicity, preferred language, insurance, mental illness, substance use, history of homelessness, and in-network primary care provider was obtained from the electronic health record. We evaluated for differences in physical restraint use between subgroups via a mixed-effect logistic regression with random-intercept model.

RESULTS

We identified 32,054 encounters involving a section 12(a) order. Physical restraints were used in 2,458 (7.7%) encounters. Factors associated with physical restraint included male sex (adjusted odds ratio [aOR] = 1.44, 95% confidence interval [CI] = 1.28 to 1.63), Black/African American race (aOR = 1.22, 95% CI = 1.01 to 1.48), Hispanic ethnicity (aOR = 1.45, 95% CI = 1.22 to 1.73), Medicaid insurance (aOR = 1.21, 95% CI = 1.05 to 1.39), and a diagnosis of bipolar disorder or psychotic disorder (aOR = 1.51, 95% CI = 1.31 to 1.74). Across all age groups, patients who were 25 to 34 years of age were at highest risk of restraint (aOR = 2.01, 95% CI = 1.69 to 2.39). Patients with a primary care provider within our network (aOR = 0.81, 95% CI = 0.72 to 0.92) were at lower risk of restraint. No associations were found between restraint use and language, history of alcohol or substance use, or homelessness.

CONCLUSION

Black/African American and Hispanic patients under an involuntary mandatory emergency psychiatric evaluation hold order experience higher rates of physical restraint in the ED. Factors contributing to racial disparities in the use of physical restraint, including the potential role of structural racism and other forms of bias, merits further investigation.

Closing the Gap: Participatory Formative Evaluation to Reduce Cancer Screening Disparities among Patients with Limited English Proficiency

Patients with limited English proficiency (LEP) have disproportionately lower rates of cancer screening than English-proficient patients. Given the multifactorial nature of screening disparities, strategies to improve screening rates must address barriers within and outside of the clinic setting. The objectives of this study were to understand local barriers from multiple stakeholder perspectives, to identify potential multilevel intervention approaches, and to mobilize community-engaged intervention decision making and planning. This participatory formative evaluation approach employed needs assessment and user engagement in order to enhance intervention usefulness and relevance. The study took place in several stages and involved clinic and community partners in a small metropolitan area of the Midwest USA. Interviews were conducted with LEP patients (n = 9) who had not completed three recommended screenings (breast, cervical, and colorectal), primary care providers (n = 5), medical interpreter (n = 5), and community members (n = 3). These highlighted multilevel barriers including limited patient understanding of preventive health, time and cost constraints, and variable roles of language interpreters. The literature was also reviewed to identify interventions used with similar populations. Findings from this review suggest that interventions are largely focused on single population groups or address single screening barriers. Finally, a community-academic summit (n = 48 participants) was held to review results and develop recommendations for community and clinic interventions. Findings from this study indicate that it is possible to engage a diverse group of stakeholders in strategies that are responsive to health care providers and patients, including LEP patients from heterogeneous backgrounds.

Emergency Medical Services Communication Barriers and the Deaf American Sign Language User

Objective: We sought to identify current Emergency Medical Services (EMS) practitioner comfort levels and communication strategies when caring for the Deaf American Sign Language (ASL) user. Additionally, we created and evaluated the effect of an educational intervention and visual communication tool on EMS practitioner comfort levels and communication. Methods: This was a descriptive study assessing communication barriers at baseline and after the implementation of a novel educational intervention with cross-sectional surveys conducted at three time points (pre-, immediate-post, and three months post-intervention). Descriptive statistics characterized the study sample and we quantified responses from the baseline survey and both post-intervention surveys. Results: There were 148 EMS practitioners who responded to the baseline survey. The majority of participants (74%; 109/148) previously responded to a 9-1-1 call for a Deaf patient and 24% (35/148) reported previous training regarding the Deaf community. The majority felt that important details were lost during communication (83%; 90/109), reported that the Deaf patient appeared frustrated during an encounter (72%; 78/109), and felt that communication limited patient care (67%; 73/109). When interacting with a Deaf person, the most common communication strategies included written text (90%; 98/109), friend/family member (90%; 98/109), lip reading (55%; 60/109), and spoken English (50%; 55/109). Immediately after the training, most participants reported that the educational training expanded their knowledge of Deaf culture (93%; 126/135), communication strategies to use (93%; 125/135), and common pitfalls to avoid (96%; 129/135) when caring for Deaf patients. At 3 months, all participants (100%, 79/79) reported that the educational module was helpful. Some participants (19%, 15/79) also reported using the communication tool with other non-English speaking patients. Conclusions: The majority of EMS practitioners reported difficulty communicating with Deaf ASL users and acknowledged a sense of patient frustration. Nearly all participants felt the educational training was beneficial and clinically relevant; three months later, all participants found it to still be helpful. Additionally, the communication tool may be applicable to other populations that use English as a second language.

The Role of Health Disparities and Socioeconomic Status in Emergent Gastrointestinal Procedures

Objectives: There is limited data describing the role of health disparity factors and socioeconomic status (SES) on emergent versus nonemergent gastrointestinal (GI) procedures within pediatrics. We aimed to characterize risk factors and determine the role of SES on emergent versus nonemergent GI care. We hypothesized that patients with lower SES incur higher risk of having emergent procedures performed.

Methods: Retrospective chart review was performed between 2012 and 2016, with 2556 patient records reviewed. Demographic data and SES categories were determined. The majority of emergent procedures were performed on an inpatient basis. Health disparity factors analyzed included age, gender, insurance type, race, language, and SES using census tracts. Logistic regression analyses and paired t-tests were utilized.

Results: Two hundred eighty-six (11.2%) patients had emergent GI procedures performed. Logistic regression (odds ratio [OR], confidence interval (95% CI)] showed patients from 6–11 to 12–17 years of age were less likely to seek emergent care than the youngest group [0.47, 0.33–0.66 and 0.61, 0.45–0.84]. Patients with Medicaid insurance [1.68, 1.27–2.26], African American or “other” race [2.07, 1.48–2.90 and 2.43, 1.77–3.36, respectively], as well as “other” language [2.1, 1.14–3.99] more often sought emergent care. Using geocoded data, we found that as SES increases by 1, emergent risk for procedures decreased by 2.9% (OR 0.97, p=0.045).

Conclusions: Children with lower SES, at extremes of age (<5, >18 years), non-English or Spanish speaking and with Medicaid insurance are at higher risk of undergoing emergent GI procedures. This study gives us an opportunity to plan targeted interventions to improve access and quality of care.

Too Little Information: Accessibility of Information About Language Services on Hospital Websites

Hospital websites are an important resource to patients with limited English proficiency (LEP) seeking information about a facility's language assistance services. We sought to identify the types of such services described on hospital websites in a diverse state and compare them by hospital characteristics. Washington State acute care hospital websites were systematically reviewed in February 2018 for translated content and information about language assistance services. Hospital characteristics included annual admissions and revenue, bed size and the proportion of populations with LEP in the hospital's county. Of 93 hospitals, 10.8% provided translated websites. Interpreter services were mentioned on 81.7% of websites; access required navigation through 1-4 English webpages. Larger bed-size, higher revenue, and more admissions were positively associated with providing language services information (p < 0.01), whereas county-level population with LEP was not (p = 0.17). Many hospital websites are not translated or lack easily accessible information about language assistance services and consequently may not be a useful resource to patients with LEP.

Disparities in Preterm Infant Emergency Room Utilization and Rehospitalization by Maternal Immigrant Status

OBJECTIVE

To evaluate the effects of immigrant mother status and risk factors on the rates of emergency room (ER) visits and rehospitalizations of preterm infants within 90 days after discharge.

STUDY DESIGN

This was a retrospective cohort study of 732 mothers of 866 preterm infants (<37 weeks of gestational age) cared for in a neonatal intensive care unit (NICU) for >5 days. Medical and demographic data and number of ER visits and rehospitalizations were collected. The primary outcomes were the numbers of ER visits and rehospitalizations. Analysis included bivariate comparisons of immigrant and native mother-infant dyads. Regression models were run to estimate the effects of immigrant mother status and risk factors.

RESULTS

Compared with native mothers, immigrant mothers (176 of 732; 24%) were more likely to be older, to be gravida >1, to be nonwhite, to have a non-English primary language, to have less than a high school education, and to have Medicaid insurance but less likely to have child protective services, substance abuse, and a mental health disorder. Infants of immigrant mothers (203 of 866; 23%) had higher rates of ER visits and more days of hospitalization compared with infants of native mothers. Among immigrant mothers only, >5 years living in the US, non-English primary language, and bronchopulmonary dysplasia (BPD) were predictive of ER visits, whereas Medicaid and BPD were predictive of rehospitalization. For the total cohort, after an interaction between Medicaid and immigrant status was added to the model, immigrant status became nonsignificant and immigrant mothers with Medicaid emerged as a strong predictor of hospitalization and a borderline predictor for ER visits.

CONCLUSIONS

Among immigrant mothers, non-English primary language, >5 years living in the US, and BPD increased the odds of an ER visit. For the total cohort, however, the interaction of immigrant mother with Medicaid as a marker of poverty provided a significant modifying effect on increased rehospitalization and ER use.

Disparities in Health Insurance Coverage and Access to Care by English Language Proficiency in the USA, 2006-2016

BACKGROUND

In the USA, people with limited English proficiency (LEP) disproportionately experience gaps in health insurance coverage and access to care. The Patient Protection and Affordable Care Act (ACA) of 2010 included reforms that could improve these outcomes.

OBJECTIVE

To describe changes in insurance coverage and access to health care by English language proficiency over 2006-2016.

DESIGN

We used regression models to estimate changes in coverage and access after 2010 for adults with high vs. limited English proficiency, adjusting for socio-economic status, demographic characteristics, and health care needs. We used difference-in-differences models to assess adjusted changes in disparities by English proficiency after 2010. Supplemental analyses used nearest-neighbor propensity score matching to balance the characteristics of respondents.

PARTICIPANTS

Respondents aged 18-64 in the Medical Expenditure Panel Survey over 2006-2016, with high (n = 174,214) or limited (n = 16,484) English language proficiency.

MAIN MEASURES

Insurance coverage was a binary variable indicating any health insurance coverage during the past 12 months. Access to care was measured using binary variables indicating whether the respondent had a usual source of care and received necessary medical, dental, and preventive care.

KEY RESULTS

Gains in health insurance coverage after 2010 were significant for adults with high English proficiency (1.7 percentage points, p < 0.001) and adults with limited English proficiency (4.6 percentage points, p = 0.007); gains did not significantly vary by English proficiency. Adults with LEP showed larger improvements than adults with high English proficiency in having a usual source of care (5 percentage points, p = 0.007) and receiving needed medical care and dental care (1.4 percentage points, p = 0.013, and 2.8 percentage points, p = 0.009, respectively). Findings remained similar when matching was used to balance the measured characteristics of respondents with high vs. limited English proficiency.

CONCLUSIONS

Disparities in health care access by English proficiency narrowed after 2010, the year of passage of the ACA.

Association of Primary Language and Hospitalization for Ambulatory Care Sensitive Conditions

BACKGROUND

Limited English proficiency is associated with decreased access to ambulatory care, however, it is unclear if this disparity leads to increased use of emergency departments (EDs) for low severity ambulatory care sensitive conditions (ACSCs).

OBJECTIVE

We sought to determine the association between the patient's preferred language and hospital utilization for ACSCs.

RESEARCH DESIGN

We conducted a retrospective cohort study of all ED visits in New Jersey in 2013 and 2014. The primary outcome was hospital admission for acute ACSCs, chronic ACSCs, and fractures (a nonambulatory care sensitive control condition). Secondary outcomes included intensive care unit (ICU) utilization and length of stay. Mixed-effect regression models estimated the association between preferred language (English vs. non-English) and study outcomes, controlling for demographics, comorbidities, and hospital characteristics.

RESULTS

We examined 201,351 ED visits for acute ACSCs, 251,193 visits for chronic ACSCs, and 148,428 visits for fractures, of which 13.5%, 11.1%, and 9.9%, respectively, were by non-English speakers. In adjusted analyses, non-English speakers were less likely to be admitted for acute ACSCs [-3.1%; 95% confidence interval (CI), -3.6% to -2.5%] and chronic ACSCs (-2.3%; 95% CI, -2.8% to -1.7%) but not fractures (0.4%; 95% CI, -0.2% to 1.0%). Among hospitalized patients, non-English speakers were less likely to receive ICU services but had no difference in length of stay.

CONCLUSIONS

These findings suggest non-English-speaking patients may seek ED care for lower acuity ACSCs than English-speaking patients. Efforts to decrease preventable ED and increase access to ambulatory care use should consider the needs of non-English-speaking patients.

The Use of a Mobile Application to Increase Access to Interpreters for Cancer Patients With Limited English Proficiency: A Pilot Study

BACKGROUND

Language barriers can influence the quality of health care and health outcomes of limited English proficient patients with cancer. The use of medical interpretation services can be a valuable asset for improving communications in emergency care settings.

OBJECTIVE

To evaluate whether a mobile translation application increased call frequency to interpreter services among providers in an Urgent Care Center at a comprehensive cancer center and to assess provider satisfaction of the mobile application.

RESEARCH DESIGN

Prospective pre-post nonrandomized intervention of a mobile translation application with access to an over the phone interpreter (OPI) service at the push of a button and poststudy satisfaction survey.

SUBJECTS

Sixty-five clinicians working at the Urgent Care Center in a cancer center in New York City.

MEASURES

Mean call frequency to OPI services, tested by the nonparametric Wilcoxon Mann Whitney test, and self-reported provider satisfaction descriptives.

RESULTS

The mobile application contributed to increasing the frequency of phone calls to OPI services during the intervention period (mean=12.8; P=0.001) as compared with the preintervention period (mean=4.3), and showed continued use during the postintervention period (mean=5.7). Most clinicians were satisfied with the use of the mobile application and access to the OPI services.

CONCLUSIONS

The results suggest that mobile application tools contribute to increasing the use and ease of access to language services. This has the potential to improve the quality of communication between medical providers and limited English proficient patients in the delivery of cancer care in urgent care settings.

Travel, Time, and Cost Savings Associated with a University Medical Center's Video Medical Interpreting Program

Background: Patients with limited English proficiency experience disparities in health care access, quality, costs, and outcomes. Providing qualified medical interpreting services (MIS) in the health care setting can reduce these disparities. Unfortunately, health organizations face logistical and financial difficulties in meeting the need for qualified medical interpreters. Introduction: This descriptive review evaluated travel, time, and cost savings associated with video interpreting services compared to traditional in-person services. Materials and Methods: We conducted a retrospective review of all inpatient and outpatient medical interpreting encounters at a large academic hospital delivered through video and in person between 2006 and 2017. Outcome measures included interpreter travel distance, time, and cost for in-person encounters and savings associated with avoided travel for services provided through video. Results: We reviewed 281,701 interpreting encounters, including 249,357 in person and 32,344 by video. Video encounters occurred both for on-site and off-site visits. For on-site encounters, the use of video resulted in an average round trip walking distance saved of 0.75 miles (SD = 0.33) and an average round trip walking time saved of 14.75 min (SD = 6.30) per encounter. For off-site encounters, the use of video resulted in an average round trip driving distance saved of 8.63 miles (SD = 9.13), an average round trip driving time saved of 23.78 min (SD = 9.50), and an average round trip driving cost savings of $4.66 per encounter. Conclusions: This single institution review of the travel, time, and cost savings associated with providing MIS through video demonstrates the opportunity for more efficient use of time and resources.

Community Health Workers as an Extension of Care Coordination in Primary Care: A Community-Based Cosupervisory Model

Community health workers (CHWs) bring their unique capacity as liaisons for patients, communities, and health care systems to health care teams. We describe the collaborative development of a community-based CHW program to address the social determinants of health that affect patients. This cosupervisory, generalist CHW model provides an innovative template for cocreation of patient-centered infrastructure and resourcing within an evolving and replicable holistic care continuum across patient ages, diagnoses, health care payers, and communities to promote health equity. The program has been effective in decreasing health care utilization and cost.

Disparities in Health Care Utilization Between Asian Immigrant Women and Non-Hispanic White Women in the United States

Background: Asians accounted for 30% of all U.S. immigrants in 2014, of which 53% were women. Foreign-born Asian immigrant (FBAI) women experience difficulties in obtaining timely and needed health care due to multifaceted barriers. This study examined factors influencing health service utilization among FBAI women compared with native-born (non-Hispanic) White American (NBWA) women. Materials and Methods: A secondary data analysis was conducted using the 2014-2015 California Health Interview Survey. Guided by a modified version of Andersen's behavioral model of health service utilization, FBAI women aged 18 to 64 (n = 1,021) were compared with NBWA women of the same ages (n = 7,086). Outcome variables included having at least one doctor's visit in the past year and having an emergency room (ER) visit in the past year. Analyses included descriptive statistics, t-tests, chi-square tests, and multivariate logistic regressions. Results: FBAI women were significantly less likely to have at least one doctor's visit in the past year and were less likely to have a usual source of care than NBWA women. Significant predictors of having at least one doctor's visit for FBAI women were having high school education, having a usual source of care, having medical insurance, and having a chronic disease. The only significant predictor of having an ER visit for FBAI women was having a chronic disease. Conclusions: Health care providers must be aware of lower levels of health service utilization among FBAI women than NBWA women regardless of whether or not the FBAI women have chronic conditions. It is important to educate these women on the importance of regular health care visits.

Emergency Department Care for Patients with Limited English Proficiency: a Retrospective Cohort Study

BACKGROUND

Limited English proficiency (LEP) patients may be particularly vulnerable in the high acuity and fast-paced setting of the emergency department (ED).

OBJECTIVE

To compare the care processes of LEP patients in the ED.

DESIGN

Retrospective cohort study.

SETTING

ED in a large tertiary care academic medical center.

PATIENTS

Adult LEP and English Proficient (EP) patients during their index presentation to the ED from September 1, 2013, to August 31, 2015. LEP patients were identified as those who selected a preferred language other than English when registering for care.

MAIN MEASURES

Rates of diagnostic studies, admission, and return visits for those originally discharged from the ED.

KEY RESULTS

We studied 57,435 visits of which 5241 (9.1%) were for patients with LEP. In adjusted analyses, LEP patients were more likely to receive an X-ray/ultrasound (OR 1.11, CI 1.03-1.19) and be admitted to the hospital (OR 1.09, CI 1.01-1.19). There was no difference in 72-h return visits (OR 0.98, CI 0.73-1.33). LEP patients presenting with complaints related to the cardiovascular system were more likely to receive a stress test (OR 1.51, CI 1.22-1.86), and those with gastrointestinal diagnoses were more likely to have an X-ray/ultrasound (OR 1.31, CI 1.02-1.68). In stratified analyses, Spanish speakers were less likely to be admitted (OR 0.8, CI 0.70-0.91), but those preferring "other" languages, which were all languages with < 500 patients, had a statistically significant higher adjusted rate of admission (OR 1.35, CI 1.17-1.57).

CONCLUSIONS

ED patients with LEP experienced both increased rates of diagnostic testing and of hospital admission. Research is needed to examine why these differences occurred and if they represent inefficiencies in care.

Language interpretation conditions and boundaries in multilingual and multicultural emergency healthcare

BACKGROUND

With an increasing migrant population globally the need to organize interpreting service arises in emergency healthcare to deliver equitable high-quality care. The aims of this study were to describe interpretation practices in multilingual emergency health service institutions and to explore the impact of the organizational and institutional context and possible consequences of different approaches to interpretation. No previous studies on these issues in multilingual emergency care have been found.

METHODS

A qualitative descriptive study was used. Forty-six healthcare professionals were purposively recruited from different organizational levels in ambulance service and psychiatric and somatic emergency care units. Data were collected between December 2014 and April 2015 through focus-group and individual interviews, and analyzed by qualitative content analysis.

RESULTS

Organization of interpreters was based on patients' health status, context of emergency care, and access to interpreter service. Differences existed between workplaces regarding the use of interpreters: in somatic emergency care bilingual healthcare staff and family members were used to a limited extent; in psychiatric emergency care the norm was to use professional interpreters on the spot; and in ambulance service persons available at the time, e.g. family and friends were used. Similarities were found in: procuring a professional interpreter, mainly based on informal workplace routines, sometimes on formal guidelines and national laws, but knowledge of existing laws was limited; the ideal was a linguistically competent interpreter with a professional attitude, and organizational aspects such as appropriate time, technical and social environment; and wishes for development of better procedures for prompt access to professional interpreters at the workplace, regardless of organizational context, and education of interpreters and users.

CONCLUSION

Use of interpreters was determined by health professionals, based on the patients' health status, striving to deliver as fast and individualized care as possible based on humanistic values. Defects in organizational routines need to be rectified and transcultural awareness is needed to achieve the aim of person-centered and equal healthcare. Clear formal guidelines for the use of interpreters in emergency healthcare need to be developed and it is important to fulfill health professionals' wishes for future development of prompt access to interpreters and education of interpreters and users.

Healthcare interpreter utilisation: analysis of health administrative data

Background

Few people with limited English proficiency are provided with the services of a healthcare interpreter when admitted to hospital. This retrospective study utilised health administrative data to explore which patients with limited English proficiency were provided with a healthcare interpreter during their hospital admission.

Method

A retrospective analysis of health administrative data for adult overnight-stay patients admitted to a public hospital in a region of significant cultural and linguistic diversity in Sydney, Australia in 2014–2015. Descriptive analyses were used to explore demographic and diagnostic data. Chi-square and analysis of variance were used to test for association between variables.

Results

The site hospital provided for 19,627 overnight-stay episodes of care over the one year period. Emergency admissions made up 70.5% (n = 13,845) of all hospital admissions and obstetric patients 11.7% (n = 2291). For 15.7% (n = 3074) of episodes of care a healthcare interpreter was identified at hospital admission as being required. In 3.7% (n = 727) of episodes of care a healthcare interpreter was provided. Patients who received an interpreter were more likely to be female, of a younger age and admitted to hospital for childbirth.

Conclusions

A minority of patients with limited English proficiency received a healthcare interpreter during their episode of care. The majority of interpreter services were provided to obstetric patients.

Collaborative Care for Depression among Patients with Limited English Proficiency: a Systematic Review

BACKGROUND

Patients with limited English proficiency (LEP) have high rates of depression, yet face challenges accessing effective care in outpatient settings. We undertook a systematic review to investigate the effectiveness of the collaborative care model for depression for LEP patients in primary care.

METHODS

We queried online PubMed, PsycINFO, CINAHL and EMBASE databases (January 1, 2000, to June 10, 2017) for quantitative studies comparing collaborative care to usual care to treat depression in adults with LEP in primary care. We evaluated the impact of collaborative care on depressive symptoms or on depression treatment. Two reviewers independently extracted key data from the studies and assessed risk of bias using the Cochrane bias and quality assessment tool (RCTs) and the Newcastle-Ottawa Quality Assessment Scale (non-RCTs).

RESULTS

Of 86 titles identified, 15 were included (representing 9 studies: 5 RCTs, 3 cohort studies, and 1 case-control study). Studies included 4859 participants; 2679 (55%) reported LEP. The majority spoke Spanish (93%). The wide variability in study design and outcome definitions precluded performing a meta-analysis. Follow-up ranged from 3 months to 2 years. Three of four high-quality RCTs reported that 13-25% more patients had improved depressive symptoms when treated with culturally tailored collaborative care compared to usual care; the last had high treatment in the control arm and found equal improvement. Two non-RCT studies suggest that Spanish-speaking patients may benefit as much as, if not more than, English-speaking patients treated with collaborative care. The remaining studies reported increased receipt of preferred depression treatment (therapy vs. antidepressants) in the intervention groups. Eight of nine studies used bilingual providers to deliver the intervention.

DISCUSSION

While limited by the number and variability of studies, the available research suggests that collaborative care for depression delivered by bilingual providers may be more effective than usual care among patients with LEP. Implementation studies of collaborative care, particularly among Asian and non-Spanish-speakers, are needed.

Working With Clients With Limited English Proficiency: Mapping Language Access in Occupational Therapy

Nearly one in ten US residents have difficulty speaking and understanding English and are deemed to have limited English proficiency (LEP). Despite federal mandates for provision of interpreters and other language access services, individuals with LEP experience notable health disparities. Occupational therapists must be prepared to equitably serve this population, however there is a dearth of research evidence and practical recommendations about our profession's readiness to serve this growing population. This paper maps the current healthcare policy environment and existing language access research relevant to occupational therapy. Implications for the future of occupational therapy research, education and practice are discussed.

Quality of Life Is Poorer for Patients With Stroke Who Require an Interpreter: An Observational Australian Registry Study

BACKGROUND AND PURPOSE

In multicultural Australia, some patients with stroke cannot fully understand, or speak, English. Language barriers may reduce quality of care and consequent outcomes after stroke, yet little has been reported empirically.

METHODS

An observational study of patients with stroke or transient ischemic attack (2010-2015) captured from 45 hospitals participating in the Australian Stroke Clinical Registry. The use of interpreters in hospitals, which is routinely documented, was used as a proxy for severe language barriers. Health-Related Quality of Life was assessed using the EuroQoL-5 dimension-3 level measured 90 to 180 days after stroke. Logistic regression was undertaken to assess the association between domains of EuroQoL-5 dimension and interpreter status.

RESULTS

Among 34 562 registrants, 1461 (4.2%) required an interpreter. Compared with patients without interpreters, patients requiring an interpreter were more often women (53% versus 46%; P<0.001), aged ≥75 years (68% versus 51%; P<0.001), and had greater access to stroke unit care (85% versus 78%; P<0.001). After accounting for patient characteristics and stroke severity, patients requiring interpreters had comparable discharge outcomes (eg, mortality, discharged to rehabilitation) to patients not needing interpreters. However, these patients reported poorer Health-Related Quality of Life (visual analogue scale coefficient, -9; 95% CI, -12.38, -5.62), including more problems with self-care (odds ratio: 2.22; 95% CI, 1.82, 2.72), pain (odds ratio: 1.84; 95% CI, 1.52, 2.34), anxiety or depression (odds ratio: 1.60; 95% CI, 1.33, 1.93), and usual activities (odds ratio: 1.62; 95% CI, 1.32, 2.00).

CONCLUSIONS

Patients requiring interpreters reported poorer Health Related Quality of Life after stroke/transient ischemic attack despite greater access to stroke units. These findings should be interpreted with caution because we are unable to account for prestroke Health Related Quality of Life. Further research is needed.

Professional Interpreter Use and Discharge Communication in the Pediatric Emergency Department

OBJECTIVE

Families with limited English proficiency (LEP) experience communication barriers and are at risk for adverse events after discharge from the pediatric emergency department (ED). We sought to describe the characteristics of ED discharge communication for LEP families and to assess whether the use of a professional interpreter was associated with provider communication quality during ED discharge.

METHODS

Transcripts of video-recorded ED visits for Spanish-speaking LEP families were obtained from a larger study comparing professional interpretation modalities in a freestanding children's hospital. Caregiver-provider communication interactions that included discharge education were analyzed for content and for the techniques that providers used to assess caregiver comprehension. Regression analysis was used to assess for an association between professional interpreter use and discharge education content or assessment of caregiver comprehension.

RESULTS

We analyzed 101 discharge communication interactions from 47 LEP patient visits; 31% of communications did not use professional interpretation. Although most patients (70%) received complete discharge education content, only 65% received instructions on medication dosing, and only 55% were given return precautions. Thirteen percent of the patient visits included an open-ended question to assess caregiver comprehension, and none included teach-back. Professional interpreter use was associated with greater odds of complete discharge education content (odds ratio [OR], 7.1; 95% confidence interval [CI], 1.4-37.0) and high-quality provider assessment of caregiver comprehension (OR, 6.1; 95% CI, 2.3-15.9).

CONCLUSIONS

Professional interpreter use is associated with superior provider discharge communication behaviors. This study identifies clear areas for improving discharge communication, which may improve safety and outcomes for LEP children discharged from the ED.

Implications of language barrier on the diagnostic yield of computed tomography in pulmonary embolism

OBJECTIVES

To determine if a physician-patient language barrier impacts the diagnostic accuracy of pulmonary embolism (PE) evaluation.

METHODS

A retrospective chart review, conducted between June 2015 and December 2016, of a consecutive sample of diagnostic computed tomography pulmonary angiogram (CTPA) studies performed on adult patients. Positive and negative CTPA scans were further categorized by patient language and the positive diagnostic yield was determined for each language group. A post collection sub-analysis was performed to determine the yield when interpreter services were identified as necessary.

RESULTS

The yield for English speaking patients was 10.24% (92/898, 95% CI 8.39% to 12.36%), similar to the yield in Spanish speaking patients of 9.40% (25/266, 95% CI 6.31% to 13.37%, P=0.69). This contrasted with the yield in patients who identified as bilingual, which was significantly lower at 1.41% (1/71, 95% CI 0.07% to 6.75%) compared to both English-(P<0.02) and Spanish-only speakers (P<0.03). The yield for non-English speaking patients who requested an interpreter was 7.37% (14/190, 95% CI 4.26% to 11.77%) versus 3.23% (2/62, 95% CI 0.54% to 10.25%, P=0.25) in those who did not.

CONCLUSIONS

The diagnostic yield in English- and Spanish-only speaking patients was similar, however, the yield in those that self-identified as bilingual was significantly lower. In patient groups in which a language barrier existed and an interpreter was not utilized, there was a trend toward a lower diagnostic yield. This suggests an increased propensity to order diagnostic imaging when potential communication barriers exist.

Telephone triage utilization among patients with limited English proficiency

BACKGROUND

Communication between patients with limited English proficiency (LEP) and telephone triage services has not been previously explored. The purpose of this study was to determine the utilization characteristics of a primary care triage call center by patients with LEP.

METHODS

This was a retrospective cohort study of the utilization of a computer-aided, nurse-led telephone triage system by English proficiency status of patients empaneled to a large primary care practice network in the Midwest United States. Interpreter Services (IS) need was used as a proxy for LEP.

RESULTS

Call volumes between the 587 adult patients with LEP and an age-frequency matched cohort of English-Proficient (EP) patients were similar. Calls from patients with LEP were longer and more often made by a surrogate. Patients with LEP received recommendations for higher acuity care more frequently (49.4% versus 39.0%; P < 0.0004), and disagreed with recommendations more frequently (30.1% versus 20.9%; P = 0.0004). These associations remained after adjustment for comorbidities. Patients with LEP were also less likely to follow recommendations (60.9% versus 69.4%; P = 0.0029), even after adjusting for confounders (adjusted odds ratio [AOR] = 0.65; 95% confidence interval [CI], 0.49, 0.85; P < 0.001).

CONCLUSION

Patients with LEP who utilized a computer-aided, nurse-led telephone triage system were more likely to receive recommendations for higher acuity care compared to EP patients. They were also less likely to agree with, or follow, recommendations given. Additional research is needed to better understand how telephone triage can better serve patients with LEP.

Factors associated with imaging overuse in the emergency department: A systematic review

BACKGROUND

Emergency departments (ED) are sites of prevalent imaging overuse; however, determinants that drive imaging in this setting are not well-characterized. We systematically reviewed the literature to summarize the determinants of imaging overuse in the ED.

METHODS

We searched MEDLINE® and Embase® from January 1998 to March 2017. Studies were included if they were written in English, contained original data, pertained to a U.S. population, and identified a determinant associated with overuse of imaging in the ED.

RESULTS

Twenty relevant studies were included. Fourteen evaluated computerized tomography (CT) scanning in patents presenting to a regional ED who were then transferred to a level 1 trauma center; incomplete transfer of data and poor image quality were the most frequently described reasons for repeat scanning. Unnecessary pre-transfer scanning or repeated scanning after transfer, in multiple studies, was highest among older patients, those with higher Injury Severity Scores (ISS) and those being transferred further. Six studies explored determinants of overused imaging in the ED in varied conditions, with overuse greater in older patients and those having more comorbid diseases. Defensive imaging reportedly influenced physician behavior. Less integration of services across the health system also predisposed to overuse of imaging.

CONCLUSIONS

The literature is heterogeneous with surprisingly few studies of determinants of imaging in minor head injury or of spine imaging. Older patient age and higher ISS were the most consistently associated with ED imaging overuse. This review highlights the need for precise definitions of overuse of imaging in the ED.

Age, Sex, Health Insurance, and Race Associated With Increased Rate of Emergent Pediatric Gastrointestinal Procedures

OBJECTIVES

Few studies have examined the role health disparities play in pediatric gastrointestinal (GI) procedures. We hypothesized that health disparity factors affect whether patients undergo an emergent versus nonemergent GI procedure. The aims were to characterize the existing pediatric population undergoing GI procedures at our institution and assess specific risk factors associated with emergent versus nonemergent care.

METHODS

We retrospectively reviewed the medical records of 2110 patients undergoing GI procedures from January 2012 to December 2014. Emergent procedures were performed on an urgent inpatient basis. All other procedures were considered nonemergent. Health disparity factors analyzed included age, sex, insurance type, race, and language. Logistic regression analysis identified the odds of undergoing emergent procedures for each factor.

RESULTS

Most study patients were boys (58.2%), primarily insured by Medicaid (63.8%), white (44.0%), and spoke English (91.7%). Ten percent of all patients had an emergent procedure. Logistic regression analysis showed significant odds ratios (P value) for ages 18 years older (2.16, 0.003), females (0.62, 0.001), commercial insurance users (0.49, <0.0001), African Americans (1.94, <0.0001), and other race (1.72, 0.039).

CONCLUSIONS

Health disparities in age, sex, insurance, and race appear to exist in this pediatric population undergoing GI procedures. Patients older than 18 years, African Americans, and other races were significantly more likely to have an emergent procedure. Girls and commercial insurance users were significantly less likely to have an emergent procedure. More research is necessary to understand why these relations exist and how to establish appropriate interventions.

Shared Decision Making With Vulnerable Populations in the Emergency Department

The emergency department (ED) occupies a unique position within the healthcare system, serving as a safety net for vulnerable patients, regardless of their race, ethnicity, religion, country of origin, sexual orientation, socioeconomic status, or medical diagnosis. Shared decision making (SDM) presents special challenges when used with vulnerable population groups. The differing circumstances, needs, and perspectives of vulnerable groups invoke issues of provider bias, disrespect, judgmental attitudes, and lack of cultural competence, as well as patient mistrust and the consequences of their social and economic disenfranchisement. A research agenda that includes community-engaged approaches, mixed-methods studies, and cost-effectiveness analyses is proposed to address the following questions: 1) What are the best processes/formats for SDM among racial, ethnic, cultural, religious, linguistic, social, or otherwise vulnerable groups who experience disadvantage in the healthcare system? 2) What organizational or systemic changes are needed to support SDM in the ED whenever appropriate? 3) What competencies are needed to enable emergency providers to consider patients' situation/context in an unbiased way? 4) How do we teach these competencies to students and residents? 5) How do we cultivate these competencies in practicing emergency physicians, nurses, and other clinical providers who lack them? The authors also identify the importance of using accurate, group-specific data to inform risk estimates for SDM decision aids for vulnerable populations and the need for increased ED-based care coordination and transitional care management capabilities to create additional care options that align with the needs and preferences of vulnerable populations.

Frequent Emergency Department Utilizers Among Children with Cancer

BACKGROUND

Pediatric frequent emergency department (ED) utilizers contribute a significant proportion of ED visits, but no studies specifically address children with cancer.

METHODS

A retrospective study of Pediatric Health Information System analyzing ED visits for children with cancer, including ED visits within 365 days from the first inpatient encounter with a discharge diagnosis code for malignancy. We defined frequent ED utilizers as those with four or more visits in the year (top 10th percentile). Patient characteristics and ED services (medications, laboratory, or imaging) for discharged children were assessed. Factors associated with being a frequent ED utilizer were examined with multivariable regression.

RESULTS

Frequent utilizers accounted for 58% of ED visits. Frequent utilizers differed from infrequent utilizers in terms of type of cancer; 39.3% of frequent utilizers had acute lymphoblastic leukemia (ALL) and 16.0% had central nervous system (CNS) tumors compared with infrequent utilizers (21.9% had ALL and 24.8% CNS tumors, P-value < 0.001). Frequent utilization was associated with age 5-9 years (odds ratio [OR] = 1.4, 95% confidence interval [CI] 1.2-1.6) or 1-4 years (OR = 2.1, 95% CI 1.8-2.4) or <1 year (OR = 2.2, 95% CI 1.9-2.6) compared to 15-19 years and Hispanic ethnicity (OR 1.3, 95% CI 1.1-1.5) compared to white, non-Hispanics, and urban residence (OR = 1.5, 95% CI 1.3-1.7). Few children with cancer received no medication, laboratory, or imaging during their ED visit (frequent 11.0% vs. infrequent 12.5%, P = 0.01).

CONCLUSIONS

The ED is integral to the care provided to children with cancer. The subset of frequent utilizers should be the focus of future research and quality improvement efforts.