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

[Cross-cultural adaptation to Spanish of the Signs of Depression Scale (SODS) to the early assessment of mood in patients admitted to a Stroke Unit]

INTRODUCTION

Stroke hospitalization negatively affects mood. Clinical guidelines recommend early evaluation of mood disorders. However, there is no consensus on the most appropriate scale in Spanish language.

AIM

The objective of the study is the cross-cultural adaptation of the Signs of Depression Scale (SODS) in patients admitted to the stroke unit of the Hospital del Mar.

MATERIALS AND METHODS

The work scheme for transcultural adaptation into Spanish was: a) direct translation; b) reconciliation and synthesis of translations; c) reverse translation into English; d) consensus of the back-translated version with original author; e) cognitive interrogation; f) revision and consensus version in Spanish; g) reading test, spelling, and grammar check; h) final version. Analysis and descriptive summary of the adaptation process was performed.

RESULTS

There were no differences between direct translation versions. The back-translation version was accepted by the author of the original questionnaire. A convenience sample of patients with/without aphasia (n = 22) was included for cognitive interview from which no major problems were identified in the implementation of the questionnaire. Inclusive language was used in the final version.

CONCLUSION

The transcultural adaptation of the scale allows in a simple and early way the evaluation mood in patients admitted to the stroke unit. The Spanish version is equivalent to the original instrument. This adaptation can be incorporated into care in the Stroke Unit and is extrapolated to other Spanish-speaking centres.

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.

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.

Patient-Provider Language Concordance and Health Outcomes: A Systematic Review, Evidence Map, and Research Agenda

Although patient-provider language concordance has the potential to reduce health disparities for people with limited English proficiency, no previous work has synthesized this literature. Our systematic review sought to describe the characteristics of studies examining relationships between language concordance and health outcomes, summarize the nature of observed associations, and propose an evidence map and research agenda. A comprehensive search of published articles identified 38 quantitative studies for inclusion. Most studies were cross-sectional, conducted in primary care, concentrated in Western states, and focused on Spanish speakers and physician providers. Results were split between supporting a positive association versus no association of language concordance with patient behaviors, provider behaviors, interpersonal processes of care, and clinical outcomes. Several methodological limitations were identified. Based on these results, we developed an evidence map, identified knowledge gaps, and proposed a research agenda. There is a particular need for quasi-experimental longitudinal studies with well-characterized samples.

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.

Stroke Chameleons and Stroke Mimics in the Emergency Department

PURPOSE OF REVIEW

We discuss the frequency of stroke misdiagnosis in the emergency department (ED), identify common diagnostic pitfalls, describe strategies to reduce diagnostic error, and detail ongoing research.

RECENT FINDINGS

The National Academy of Medicine has re-defined and highlighted the importance of diagnostic errors for patient safety. Recent rates of stroke under-diagnosis (false-negative cases, "stroke chameleons") range from 2-26% and 30-43% for stroke over-diagnosis (false-positive cases, "stroke mimics"). Failure to diagnosis stroke can preclude time-sensitive treatments and has been associated with poor outcomes. Strategies have been developed to improve detection of posterior circulation stroke syndromes, but ongoing work is needed to reduce under-diagnosis in other atypical stroke presentations. The published rates of harm associated with stroke over-diagnosis, particularly thrombolysis of stroke mimics, remain low. Additional strategies to improve the accuracy of stroke diagnosis should focus on rapid clinical reasoning in the time-sensitive setting of acute ischemic stroke and identifying imperfections in the healthcare system which may contribute to diagnostic error.