Limited English Proficiency and Perioperative Patient-Centered Outcomes: A Systematic Review

Is Limited English Proficiency Associated With Differences in Care Processes and Treatment Outcomes in Patients Undergoing Orthopaedic Surgery? A Systematic Review

BACKGROUND

Approximately 25 million people in the United States have limited English proficiency. Current developments in orthopaedic surgery, such as the expansion of preoperative education classes or patient-reported outcome collection in response to bundled payment models, may exacerbate language-related barriers. Currently, there are mixed findings of the associations between limited English proficiency and care processes and outcomes, warranting a cross-study synthesis to identify patterns of associations.

QUESTIONS/PURPOSES

In this systematic review, we asked: Is limited English proficiency associated with (1) differences in clinical care processes, (2) differences in care processes related to patient engagement, and (3) poorer treatment outcomes in patients undergoing orthopaedic surgery in English-speaking countries?

METHODS

On June 9, 2023, a systematic search of four databases from inception through the search date (PubMed, Ovid Embase, Web of Science, and Scopus) was performed by a medical librarian. Potentially eligible articles were observational studies that examined the association between limited English proficiency and the prespecified categories of outcomes among pediatric and adult patients undergoing orthopaedic surgery or receiving care in an orthopaedic surgery setting. We identified 10,563 records, of which we screened 6966 titles and abstracts after removing duplicates. We reviewed 56 full-text articles and included 29 peer-reviewed studies (outcome categories: eight for clinical care processes, 10 for care processes related to patient engagement, and 15 for treatment outcomes), with a total of 362,746 patients or encounters. We extracted data elements including study characteristics, definition of language exposure, specific outcomes, and study results. The quality of each study was evaluated using adapted Newcastle-Ottawa scales for cohort or cross-sectional studies. Most studies had a low (48%) or moderate (45%) risk of bias, but two cross-sectional studies had a high risk of bias. To answer our questions, we synthesized associations and no-difference findings, further stratified by adjusted versus unadjusted estimates, for each category of outcomes. No meta-analysis was performed.

RESULTS

There were mixed findings regarding whether limited English proficiency is associated with differences in clinical care processes, with the strongest adjusted associations between non-English versus English as the preferred language and delayed ACL reconstruction surgery and receipt of neuraxial versus general anesthesia for other non-Spanish versus English primary language in patients undergoing THA or TKA. Limited English proficiency was also associated with increased hospitalization costs for THA or TKA but not opioid prescribing in pediatric patients undergoing surgery for fractures. For care processes related to patient engagement, limited English proficiency was consistently associated with decreased patient portal use and decreased completion of patient-reported outcome measures per adjusted estimates. The exposure was also associated with decreased virtual visit completion for other non-Spanish versus English language and decreased postoperative opioid refill requests after TKA but not differences in attendance-related outcomes. For treatment outcomes, limited English proficiency was consistently associated with increased hospital length of stay and nonhome discharge per adjusted estimates, but not hospital returns. There were mixed findings regarding associations with increased complications and worse postoperative patient-reported outcome measure scores.

CONCLUSION

Findings specifically suggest the need to remove language-based barriers for patients to engage in care, including for patient portal use and patient-reported outcome measure completion, and to identify mechanisms and solutions for increased postoperative healthcare use. However, interpretations are limited by the heterogeneity of study parameters, including the language exposure. Future research should include more-precise and transparent definitions of limited English proficiency and contextual details on available language-based resources to support quantitative syntheses.

LEVEL OF EVIDENCE

Level III, therapeutic study.

The impact of limited English proficiency on oncological outcomes in the United States: A systematic review

BACKGROUND

The increasing number of immigrants in the United States (U.S.) has resulted in more patients with limited English proficiency (LEP). LEP contributes to patient-provider language discordance, which may impact oncologic health outcomes.

OBJECTIVES

To assess the effects of LEP compared to English proficiency (EP) for oncological outcomes in adult cancer patients in the United States.

SEARCH METHODS

We searched MEDLINE (Ovid), the Cochrane Library (Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials), PsycINFO, CINAHL and Scopus from data inception to 26 January 2023. We also searched the reference lists and cited lists of included studies. Studies were limited to the United States and the English language.

SELECTION CRITERIA

We included retrospective and cross-sectional studies that analyzed one or more clinical outcomes (survival, readmission, length of stay, complications and discharge disposition) in LEP and EP cancer patients. Studies were eligible if they assessed cancer patients in the United States who were 18 years and older.

DATA COLLECTION AND ANALYSIS

Using a piloted, standardized data collection form, two non-blinded, independent reviewers extracted data in duplicate from studies meeting our inclusion criteria. Reviewers resolved discrepancies through discussion. We then performed a qualitative assessment of the findings.

MAIN RESULTS

We retrieved 2425 records from the database searches. We screened 1496 records by title and abstract and reviewed the full text of eight records. We retrieved 347 records from additional search methods and reviewed the full text of six records. We included 14 papers in total for analysis. The studies included 55,141 total patients and assessed outcomes in brain, oesophageal, head and neck, pancreatic and skin cancer. Our qualitative assessment demonstrated limited information on whether LEP impacted survival, complications and discharge disposition. We found no significant association between LEP and readmission or length of stay.

CONCLUSIONS

Studies assessing the impact of LEP and EP on the health outcomes of cancer patients are sparse and inconsistent in the measurements of outcomes and data reporting. The inconclusiveness of our study indicates that further standardized research is needed to assess the impact of LEP on the outcomes of cancer patients in the United States.

Challenges in Assessment and Management of Postoperative Agitation and Delirium in a Stroke Patient with Limited English Proficiency: Case Report

While Title VI of the Civil Rights Act of 1964 mandates use of interpreters for patients with limited English proficiency, significant disparities persist in intensive postsurgical care. We present the case of a 60-year-old Vietnamese-speaking man with a Type A aortic dissection requiring postoperative mechanical ventilation and stroke care. Despite use of a remote video interpreter, our language-discordant nursing and physician providers faced challenges in managing agitation and delirium and assessing neurological function. This case highlights the need for adequate interpretation equipment, linguistic diversity among providers, and interventions to promote and enable consistent certified and professional medical interpreter use.

The Impact of Using Electronic Consents on Documentation of Language-Concordant Surgical Consent for Patients with Limited English Proficiency

BACKGROUND

Although access to a professional medical interpreter is federally mandated, surgeons report underutilization during informed consent. Improvement requires understanding the extent of the lapses. Adoption of electronic consent (eConsent) has been associated with improvements in documentation and identification of practice improvement opportunities. The authors evaluated the impact of the transition from paper to eConsent on language-concordant surgical consent delivery for patients with limited English proficiency (LEP).

METHODS

The study period (February 8, 2023, to June 14, 2023) corresponds to the period immediately following the institutional adoption of eConsents. Inclusion criteria included age > 18 years, documented preferred language other than English, and self-signed eConsent form. The authors assessed documentation of language-concordant interpreter-mediated verbal consent discussion and delivery of the written surgical consent form in a language-concordant template. Performance was compared to a preimplementation baseline derived from monthly random audits of paper consents between January and December 2022.

RESULTS

A total of 1,016 eConsent encounters for patients with LEP were included, with patients speaking 49 different languages, most commonly Spanish (46.5%), Chinese (22.1%), and Russian (6.8%). After the implementation of eConsent, overall documentation of language-concordant interpreter-mediated consents increased from 56.9% to 83.9% (p < 0.001), although there was variation between surgical services and between languages, suggesting that there is still likely room for improvement. Most patients (94.1%) whose preferred language had an associated translated written consent template (Spanish, Chinese, Russian, Arabic), received a language-concordant written consent.

CONCLUSION

The transition to eConsent was associated with improved documentation of language-concordant informed consent in surgery, both in terms of providing written materials in the patient's preferred language and in the documentation of interpreter use, and allowed for the identification of areas to target for practice improvement with interpreter use.

Use of Professional Interpreters for Patients With Limited English Proficiency Undergoing Surgery

This cohort study examines measures of hospital interpreter usage for surgical patients with limited English proficiency (LEP) undergoing common general operations.

Communication between healthcare providers and communicatively-vulnerable patients with associated health outcomes: A scoping review of knowledge syntheses

OBJECTIVE

Summarize literature on provider-patient communication linked to health outcomes in communicatively-vulnerable patient populations.

METHODS

Scoping review of reviews: systematically searched six databases.

INCLUSION CRITERIA

systematic searches and syntheses of literature; one or more providers and communicatively-vulnerable patients; synchronous in-person communication; intermediate or health outcome linked to communication.

RESULTS

The search yielded 14,615 citations; 47 reviews - with wide range of providers, communication vulnerabilities, communication practices, and health outcomes - met inclusion criteria. Methodology included qualitative, quantitative, and mixed approaches. Quality ranged from very low to high. Six categories of communication practices linked to health outcomes were identified: 1) motivation-based; 2) accommodation of language, culture, gender, sexual identity, and other concordance with the patient; 3) cultural adaptations of interventions; 4) use of interpreters; 5) other provider-patient communication practices; 6) patient communication practices.

CONCLUSION

Communication practices were studied in a wide range of providers, with common themes regarding best practices. A unique finding is the role of the patient's communication practices. The specificity of communication practices studied is heterogeneous, with many reviews providing insufficient details.

PRACTICE IMPLICATIONS

Motivation-based practices and culturally- and linguistically-appropriate care have impacts on patient outcomes across a range of settings with different professions and communicatively-vulnerable groups.

Advancing language concordant care: a multimodal medical interpretation intervention

BACKGROUND

Ensuring language concordant care through medical interpretation services (MIS) allows for accurate information sharing and positive healthcare experiences. The COVID-19 pandemic led to a regional halt of in-person interpreters, leaving only digital MIS options, such as phone and video. Due to longstanding institutional practices, and lack of accessibility and awareness of these options, digital MIS remained underused. A Multimodal Medical Interpretation Intervention (MMII) was developed and piloted to increase digital MIS usage by 25% over an 18-month intervention period for patients with limited English proficiency.

METHODS

Applying quality improvement methodology, an intervention comprised digital MIS technology and education was trialled for 18 months. To assess intervention impact, the number of digital MIS minutes was measured monthly and compared before and after implementation. A questionnaire was developed and administered to determine healthcare providers' awareness, technology accessibility and perception of MIS integration in the clinical workflow.

RESULTS

Digital MIS was used consistently from the beginning of the COVID-19 pandemic (March 2020) and over the subsequent 18 months. The total number of minutes of MIS use per month increased by 44% following implementation of our intervention. Healthcare providers indicated that digital MIS was vital in facilitating transparent communication with patients, and the MMII ensured awareness of and accessibility to the various MIS modalities.

CONCLUSION

Implementation of the MMII allowed for an increase in digital MIS use in a hospital setting. Providing digital MIS access, education and training is a means to advance patient-centred and equitable care by improving accuracy of clinical assessments and communication.

A multi-language qualitative study of limited English proficiency patient experiences in the United States

Objective

The purpose of this study was to understand the limited English proficiency patient experience with health care services in an urban setting in the United States.

Methods

Through a narrative analysis approach, 71 individuals who spoke either Spanish, Russian, Cantonese, Mandarin, or Korean shared their experiences through semi-structured interviews between 2016 and 2018. Analyses used monolingual and multilingual open coding approaches to generate themes.

Results

Six themes illustrated patient experiences and identified sources of structural inequities perpetuating language barriers at the point of care. An important thread throughout all interviews was the sense that the language barrier with clinicians posed a threat to their safety when receiving healthcare, citing an acute awareness of additional risk for harm they might experience. Participants also consistently identified factors they felt would improve their sense of security that were specific to clinician interactions. Differences in experiences were specific to culture and heritage.

Conclusions

The findings highlight the ongoing challenges spoken language barriers pose across multiple points of care in the United States' health care system.

Innovation

The multi-language nature of this study and its methodological insights are innovative as most studies have focused on clinicians or patient experiences in a single language.

Preferred language and disease severity predict evaluation for liver transplantation among patients admitted with alcohol-associated hepatitis

BACKGROUND

Liver transplantation (LT) for alcohol-associated hepatitis (AH) is a relatively new practice and limited work exists surrounding the role social determinants of health may play in evaluation. This includes language that defines how patients interact with the healthcare system. We explored characteristics of patients with AH evaluated for LT within an integrated health system.

METHODS

Using a system-wide registry, we identified admissions for AH from 1 January 2016 to 31 July 2021. A multivariable logistic regression model was developed to evaluate independent predictors of LT evaluation.

RESULTS

Among 1723 patients with AH, 95 patients (5.5%) underwent evaluation for LT. Evaluated patients were more likely have English as their preferred language (95.8% vs 87.9%, P = 0.020), and had higher INR (2.0 vs 1.4, P < 0.001) and bilirubin (6.2 vs 2.9, P < 0.001). AH patients who underwent evaluation had a lower burden of mood and stress disorders (10.5% vs 19.2%, P < 0.05). Patients with English preferred language had a greater than three times adjusted odds of LT evaluation compared with all others when adjusting for clinical disease severity, insurance status, sex, and psychiatric comorbid conditions (OR, 3.20; 95% CI, 1.14-9.02).

CONCLUSION

Patients with AH evaluated for LT were more likely to have English as their preferred language, more psychiatric comorbidities, and more severe liver disease. Despite adjustment for psychiatric comorbidities and disease severity, English preferred language remained the strongest predictor of evaluation. As programs expand LT for AH, it is vital to build equitable systems that account for the interaction between language and healthcare in transplantation.

Association of Language Barriers With Perioperative and Surgical Outcomes: A Systematic Review

Importance

English language proficiency has been reported to correlate with disparities in health outcomes. Therefore, it is important to identify and describe the association of language barriers with perioperative care and surgical outcomes to inform efforts aimed at reducing health care disparities.

Objective

To examine whether limited English proficiency compared with English proficiency in adult patients is associated with differences in perioperative care and surgical outcomes.

Evidence Review

A systematic review was conducted in MEDLINE, Embase, Web of Science, Sociological Abstracts, and CINAHL of all English-language publications from database inception to December 7, 2022. Searches included Medical Subject Headings terms related to language barriers, perioperative or surgical care, and perioperative outcomes. Studies that investigated adults in perioperative settings and involved quantitative data comparing cohorts with limited English proficiency and English proficiency were included. The quality of studies was evaluated using the Newcastle-Ottawa Scale. Because of heterogeneity in analysis and reported outcomes, data were not pooled for quantitative analysis. Results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guideline.

Findings

Of 2230 unique records identified, 29 were eligible for inclusion (281 266 total patients; mean [SD] age, 57.2 [10.0] years; 121 772 [43.3%] male and 159 240 [56.6%] female). Included studies were observational cohort studies, except for a single cross-sectional study. Median cohort size was 1763 (IQR, 266-7402), with a median limited English proficiency cohort size of 179 (IQR, 51-671). Six studies explored access to surgery, 4 assessed delays in surgical care, 14 assessed surgical admission length of stay, 4 assessed discharge disposition, 10 assessed mortality, 5 assessed postoperative complications, 9 assessed unplanned readmissions, 2 assessed pain management, and 3 assessed functional outcomes. Surgical patients with limited English proficiency were more likely to experience reduced access in 4 of 6 studies, delays in obtaining care in 3 of 4 studies, longer surgical admission length of stay in 6 of 14 studies, and more likely discharge to a skilled facility than patients with English proficiency in 3 of 4 studies. Some additional differences in associations were found between patients with limited English proficiency who spoke Spanish vs other languages. Mortality, postoperative complications, and unplanned readmissions had fewer significant associations with English proficiency status.

Conclusions and Relevance

In this systematic review, most of the included studies found associations between English proficiency and multiple perioperative process-of-care outcomes, but fewer associations were seen between English proficiency and clinical outcomes. Because of limitations of the existing research, including study heterogeneity and residual confounding, mediators of the observed associations remain unclear. Standardized reporting and higher-quality studies are needed to understand the impact of language barriers on perioperative health disparities and identify opportunities to reduce related perioperative health care disparities.