Impact of language barriers on patient satisfaction in an emergency department

Disparate Use of Diagnostic Modalities for Patients With Limited English Proficiency and Neurologic Disorders

Background and Objectives

Limited English proficiency (LEP) impairs health access-including outpatient specialty care-and quality care, i.e., inappropriate use of diagnostic tests. At least in some cases, studies have suggested that clinicians may substitute testing for time-consuming clinical evaluation involving medical interpreters. This study (1) examines disparities in receipt of diagnostic testing among patients with LEP and neurologic illness, in both the ambulatory and emergency department (ED) settings, including (2) whether better patient-provider communication is associated with reduced testing disparities and (3) how testing disparities vary according to insurance.

Methods

We analyzed nationally representative data from the 2003-2018 Medical Expenditure Panel Survey and identified adults with neurologic illness using diagnostic codes. To assess the association between LEP status and diagnostic testing (CT/MRI, laboratory tests, and any diagnostic tests), we estimated logistic regression models that included year-fixed effects. We constructed separate models for ambulatory and ED settings, including models with a patient-provider communication measure to see how that influenced the LEP-diagnostic testing association. Finally, we conducted stratified analyses by sources of health insurance.

Results

LEP status was associated with greater receipt of laboratory tests (OR = 1.46, p < 0.05) but less CT/MRI in the ambulatory setting (0.86, p < 0.05), patterns that persisted in analyses stratified by insurance status. Factoring in patient-provider communication attenuated but did not eliminate these disparities, with attenuation most notable in rates of CT/MRI. We found fewer testing disparities for patients with LEP in the ED than in ambulatory settings.

Discussion

In this nationwide study of patients with neurologic illness, we observed both greater and less use of diagnostic tests for patients with LEP and neurologic illness. The greater use of laboratory tests may reflect the overuse of easily obtainable tests for patients with LEP. Conversely, the less use of CT/MRI may be due to time and transportation challenges in scheduling follow-up visits, alongside other barriers to patient follow-up. The population of patients with LEP is growing, making it critical to study not only disparities in their care but also nuances and determinants of these disparities beyond patient-provider communication and across clinical settings.

Is Primary Care Patient Experience Associated with Provider-Patient Language Concordance and Use of Interpreters for Spanish-preferring Patients: A Systematic Literature Review

BACKGROUND

Healthcare provided by a bilingual provider or with the assistance of an interpreter improves care quality; however, their associations with patient experience are unknown. We reviewed associations of patient experience with provider-patient language concordance (LC) and use of interpreters for Spanish-preferring patients.

METHOD

We reviewed articles from academic databases 2005-2023 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Joanna Briggs Institute Checklists to rate study quality. We reviewed 217 (of 2193) articles, yielding 17 for inclusion.

RESULTS

Of the 17 included articles, most articles focused on primary (n = 6 studies) or pediatric care (n = 5). All were cross-sectional, collecting data by self-administered surveys (n = 7) or interviews (n = 4). Most assessed the relationship between LC or interpreter use and patient experience by cross-sectional associations (n = 13). Two compared subgroups, and two provided descriptive insights into the conversational content (provider-interpreter-patient). None evaluated interventions, so evidence on effective strategies is lacking. LC for Spanish-preferring patients was a mix of null findings (n = 4) and associations with better patient experience (n = 3) (e.g., receiving diet/exercise counseling and better provider communication). Evidence on interpreter use indicated better (n = 2), worse (n = 2), and no association (n = 2) with patient experience. Associations between Spanish-language preference and patient experience were not significant (n = 5) or indicated worse experience (n = 4) (e.g., long waits, problems getting appointments, and not understanding nurses).

CONCLUSION

LC is associated with better patient experience. Using interpreters is associated with better patient experience but only with high-quality interpreters. Strategies are needed to eliminate disparities and enhance communication for all Spanish-preferring primary care patients, whether with a bilingual provider or an interpreter.

An assessment of evidence to inform best practice for the communication of acute venous thromboembolism diagnosis: a scoping review

Background

Physician communication with patients is a key aspect of excellent care. Scant evidence exists to inform best practice for physician communication in patients diagnosed with pulmonary embolism and deep vein thrombosis, collectively referred to as venous thromboembolism (VTE).

Objectives

The aim of this study was to summarize the existing literature on best practices for communication between healthcare providers and patients newly diagnosed with VTE.

Methods

We performed a scoping review to report existing literature on best practices for physician-patient communication and the diagnosis and management of acute VTE. Manuscripts on communication between healthcare professionals and patients presenting with acute VTE and acute vascular disease presentations that included atrial fibrillation and acute coronary syndrome were identified. Two authors independently reviewed studies for eligibility and a consensus determined article inclusion. The manuscripts were further categorized into 2 categories: best practices in communication and unmet needs in communication. Data aggregation was achieved by a modified thematic synthesis.

Results

Among 345 initial publications, 22 manuscripts met inclusion criteria, with 11 addressing VTE, 5 pulmonary embolism, 4 deep vein thrombosis, 1 atrial fibrillation, and 1 acute coronary syndrome. Eleven manuscripts addressed communication of VTE diagnosis, while 12 focused on communication of VTE treatment. Eleven manuscripts identified unmet communication needs, and 14 addressed best practices. Our review showed that good communication enhanced satisfaction, while suboptimal communication was associated with emotional, cognitive, behavioral, social, and health systems adverse effects.

Conclusion

Scant literature guides best practices for communicating VTE diagnosis and treatment. Further research is necessary to establish practices for improving communication with VTE patients.

Strategies to Improve Care in the Emergency Department for Culturally and Linguistically Diverse Adults: a Systematic Review

BACKGROUND

The emergency department (ED) is an important gateway into the health system for people from culturally and linguistically diverse (CALD) backgrounds; their experience in the ED is likely to impact the way they access care in the future. Our review aimed to describe interventions used to improve ED health care delivery for adults from a CALD background.

METHODS

An electronic search of four databases was conducted to identify empirical studies that reported interventions with a primary focus of improving ED care for CALD adults (aged ≥ 18 years), with measures relating to ED system performance, patient outcomes, patient experience, or staff experience. Studies published from inception to November 2022 were included. We excluded non-empirical studies, studies where an intervention was not provided in ED, papers where the full text was unavailable, or papers published in a language other than English. The intervention strategies were categorised thematically, and measures were tabulated.

RESULTS

Following the screening of 3654 abstracts, 89 articles underwent full text review; 16 articles met the inclusion criteria. Four clear strategies for targeting action tailored to the CALD population of interest were identified: improving self-management of health issues, improving communication between patients and providers, adhering to good clinical practice, and building health workforce capacity.

CONCLUSIONS

The four strategies identified provide a useful framework for targeted action tailored to the population and outcome of interest. These detailed examples show how intervention design must consider intersecting socio-economic barriers, so as not to perpetuate existing disparity.

REGISTRATION

PROSPERO registration number: CRD42022379584.

Spanish Translation and Validation of the LIMB-Q: A Patient-reported Outcome Measure for Lower Extremity Trauma

Background

Hispanic patients represent a notable portion of the adult trauma population in the United States, yet their participation in studies collecting patient-reported outcome measure data following lower extremity injuries is limited. This study aims to translate and linguistically validate the LIMB-Q in Spanish for use in this population.

Methods

We followed guidelines from the World Health Organization and the Professional Society for Health Economics and Outcomes Research to conduct this translation. Two independent translators conducted a blind forward translation of the LIMB-Q from English to Spanish, followed by a back translation to confirm the conceptual preservation of each LIMB-Q item. Five patients then participated in cognitive debriefing interviews to collect feedback on comprehension, interpretation, and language.

Results

Translators occasionally differed in the vocabulary they used in their forward translations. All conflicts were resolved by discussion and selection of the option with the greatest colloquial recognition and medical relevance. Back translation identified 25 differences, including items that did not fully convey semantics (n = 12), were missing parts (n = 9), or were listed out of order (n = 4). All items with inadequate semantics were revised to ensure full retention of their original meaning. Five patients participated in cognitive debriefing interviews, resulting in 5 revisions for diction and syntax.

Conclusions

The Spanish (US) translation of LIMB-Q is now available. This instrument may be used in both clinical and research settings to better understand the quality of life and satisfaction of Hispanic patients after traumatic lower extremity injury.

Interpreter Modalities and Unplanned Emergency Department Revisits in Limited English Proficiency Patients

INTRODUCTION

Emergency department encounters include an increasing number of patients with limited English proficiency, yet little is known about the impact of interpreter services on unplanned revisits to the emergency department. This study aims to assess interpreters' utilization and unplanned ED revisits, serving as an indicator of care quality.

METHODS

This was a single-center, retrospective chart review of ED visits at an urban academic center between January and April 2019. Inclusion criteria involved patients aged >18, discharged after evaluation, and with at least 1 ED revisit in the study period. Demographic data, interpreter modality, and revisit incidences within 72 hours and 30 days were analyzed using Chi-squared and Wilcoxon rank-sum tests.

RESULTS

Of 786 reviewed charts, 401 limited English proficiency patients and 294 controls matched by gender, race, and ethnicity were included. Among limited English proficiency patients, the majority identified as Hispanic (84.8% vs 36%, P<.01) and showed higher 72-hour unplanned revisit rates (2.8% vs 0.7%, P = .05). Interpreter documentation for limited English proficiency patients was only 49.6%, with in-person modality prevailing (45.8%). Trained interpreters were underutilized (13% in-person vs 7.7% video, P<.0001). Only 78% (P<.01) of patients with limited English proficiency received discharge instructions in their preferred language.

DISCUSSION

This study reveals a higher unplanned ED revisit rate among limited English proficiency patients, potentially linked to varying interpreter modality effectiveness and underutilization of trained interpreters. Emphasizing the critical role of trained interpreters, these findings offer an opportunity to enhance care quality for limited English proficiency patients in the emergency department.

Patient engagement in radiation oncology: a large retrospective study of survey response dynamics

Purpose

Patient satisfaction surveys are pivotal in evaluating healthcare quality and enhancing patient care. Understanding the factors influencing patient engagement with these surveys in radiation oncology can guide improvements in patient-centered care.

Methods

This retrospective study analyzed data from radiation oncology patients at a large multi-site single-institution center from May 2021 to January 2024. We assessed the influence of demographic, clinical, and socioeconomic factors on the likelihood of survey participation using univariate (UVA) and multivariable (MVA) logistic regression analyses. Factors included age, gender, race, socioeconomic status (SES) via Area Deprivation Index (ADI), language, marital status, smoking, employment, insurance type, mental health disorders (MHD), comorbidity index (CCI), and cancer type.

Results

In a comprehensive analysis of 11,859 patients, most were female (57.2%), over 65 years old (60.7%), and primarily insured by Medicare (45.9%). MVA showed that higher socioeconomic disadvantage significantly decreased survey participation (ADI third tertile vs. first tertile OR=0.708, p<0.001), with each unit increase in ADI reducing the odds of completion by 1% (p<0.001). Older adults, and patients with head and neck or genitourinary cancers were significantly more likely to participate, while those with higher comorbidities, MHD, or other minority status were less engaged (p<0.001). Telemedicine encounters also significantly increased participation compared to in-person visits (OR=1.149, p=0.006).

Conclusions

Multiple factors including age, race, SES, insurance type, cancer type, health conditions, and modality of healthcare delivery influence patient engagement with satisfaction surveys in radiation oncology. Strategies to enhance patient engagement must consider these diverse influences to ensure comprehensive and inclusive feedback mechanisms in healthcare settings. Tailored interventions to mitigate barriers specific to underrepresented groups are crucial for capturing a broad spectrum of patient experiences and improving the overall quality of patient care.

Current State and Proposal of Best Practices of Standardized Patients for Spanish-Language Objective Structured Clinical Encounters in US Medical Schools

INTRODUCTION

Medical Spanish programs commonly engage Spanish-speaking standardized patients (SPs) for communication skills assessment, yet no studies address SP recruitment, selection, or training.

METHODS

We sent questionnaires to medical Spanish faculty at 20 US medical schools to gauge their practices in recruiting and selecting Spanish-language SPs. We invited faculty to distribute a separate questionnaire to Spanish-language SPs to gather SP language abilities, training, and experience. We analyzed data using descriptive statistics and qualitative content analysis. When available, we reviewed SP video encounters to formally assess participating SPs' linguistic performance using the SP Oral Language Observation Matrix, a rating tool adapted from the Physician Oral Language Observation Matrix to assess oral medical Spanish proficiency.

RESULTS

Eighty percent of faculty (16/20) responded. Standardized patient recruitment sources included institutional English-language SPs, Hispanic student groups and professional organizations, communities, and language professionals. Faculty-reported strategies to determine language readiness included interviewing SP candidates in Spanish and asking them to self-rate language skills using a validated scale. Fifteen SPs (54%, 15/28) from 5 schools responded to the SP questionnaire, and one third (5/15) reported that their Spanish was not assessed before being selected as an SP. In addition, one third (5/15) did not receive any initial training before performing a medical Spanish case. Raters assessed 11 different SPs using the SP Oral Language Observation Matrix, and 6 were rated as linguistically "ready" for the SP role.

CONCLUSIONS

Current approaches to recruitment, training, and language assessment of SPs vary. We propose strategies to ensure that medical Spanish encounters authentically reflect Spanish-speaking patients.

Language interpretation and translation in emergency care: A scoping review protocol

INTRODUCTION

Patients with preferred languages other than English face barriers to communication and access to appropriate care in English-speaking emergency care systems, leading to poorer communication and quality of care, as well as increased rates of investigations and healthcare utilization. While professional interpretation can help bridge this gap, uptake is exceedingly poor, suggesting the need for enhanced implementation and more accessible modalities. Our study will map the existing literature on interpretation/translation in emergency care, with a focus on the breadth of modalities, barriers/facilitators to implementation, and effectiveness/implementation outcomes.

METHODS

We will conduct a scoping review based on the Joanna Briggs Institute methodology. We will search MEDLINE, Embase, PsycINFO, CINAHL, Scopus, iPortal, Native Health Database and Cochrane Library CENTRAL for articles from inception to May 2024 without any language or country restrictions. Primary research articles involving interpretation/translation between English and a non-English language during emergency healthcare encounters will be included. Screening and data extraction will be completed by two independent team members. Results will be descriptively summarized and barriers/facilitators to implementation will be mapped according to the Consolidated Framework for Implementation Research.

STAKEHOLDER ENGAGEMENT & KNOWLEDGE TRANSLATION

Results will be disseminated at academic conferences and published in a peer-reviewed journal. We will share our key findings via a graphical abstract and social media campaign. Our team includes our provincial health authority interpretation services lead who brings lived experience and will inform and validate our results and help identify future areas of needed research. They will also help us identify key messages and appropriate methods for dissemination to maximize knowledge translation to patients/families, local policy/clinical practice, as well as funding agencies.

Improving Quality of Care for Vacation-Related Emergency Department Visits: A Narrative Review of Patient Satisfaction and Contributing Factors

Emergency departments (EDs) encounter substantial challenges during peak vacation periods, including increased patient volumes, limited access to medical histories, language and cultural barriers, insurance complexities, and disruptions in continuity of care. These factors strain emergency department operations, resulting in prolonged wait times, diagnostic errors, and compromised care quality. This study reviews the literature to identify patient satisfaction indicators and common challenges and evaluate strategies to improve patient outcomes during vacation-related emergency department visits. Findings highlight critical issues in staffing and resource allocation, leading to delayed care. Limited interoperability of electronic health records (EHRs) often prevents access to essential patient information, increasing diagnostic errors and unnecessary repeat testing. Language and cultural barriers contribute to higher rates of misdiagnosis and lower patient satisfaction, while insurance and payment issues create delays, particularly for out-of-network or international patients. Effective strategies to address these challenges include the use of predictive analytics for better forecasting of patient volumes, specialized triage protocols, public health education campaigns, and telemedicine for remote management of non-critical conditions. These interventions help reduce wait times, optimize resource allocation, and improve patient satisfaction. By implementing adaptive approaches, such as flexible staffing models and enhanced electronic health record use, healthcare systems can significantly improve care delivery and patient outcomes during vacation seasons.

A Randomized Crossover Trial Evaluating the Impact of Cultural Dexterity Training on Surgical Residents' Knowledge, Cross-Cultural Care, Skills, and Beliefs: The Provider Awareness and Cultural Dexterity Training for Surgeons (PACTS) Trial

OBJECTIVES

This trial examines the impact of the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) curriculum on surgical residents' knowledge, cross-cultural care, skills, and beliefs.

BACKGROUND

Cross-cultural training of providers may reduce health care outcome disparities, but its effectiveness in surgical trainees is unknown.

METHODS

PACTS focuses on developing skills needed for building trust, working with patients with limited English proficiency, optimizing informed consent, and managing pain. The PACTS trial was a randomized crossover trial of 8 academic general surgery programs in the United States: The Early group ("Early") received PACTS between periods 1 and 2, while the Delayed group ("Delayed") received PACTS between periods 2 and 3. Residents were assessed preintervention and postintervention on Knowledge, Cross-Cultural Care, Self-Assessed Skills, and Beliefs. χ 2 and Fisher exact tests were conducted to evaluate within-intervention and between-intervention group differences.

RESULTS

Of 406 residents enrolled, 315 were exposed to the complete PACTS curriculum. Early residents' Cross-Cultural Care (79.6%-88.2%, P <0.0001), Self-Assessed Skills (74.5%--85.0%, P <0.0001), and Beliefs (89.6%-92.4%, P =0.0028) improved after PACTS; knowledge scores (71.3%-74.3%, P =0.0661) were unchanged. Delayed resident scores pre-PACTS to post-PACTS showed minimal improvements in all domains. When comparing the 2 groups in period 2, Early residents had modest improvement in all 4 assessment areas, with a statistically significant increase in Beliefs (92.4% vs 89.9%, P =0.0199).

CONCLUSIONS

The PACTS curriculum is a comprehensive tool that improved surgical residents' knowledge, preparedness, skills, and beliefs, which will help with caring for diverse patient populations.

Telehealth Experience Among Patients With Limited English Proficiency

This cross-sectional study assesses the implication of patients’ English language skills for telehealth use and visit experience.

Development and validation of the first Canadian Aboriginal syllabics visual acuity chart

OBJECTIVE

To design and validate the first visual acuity (VA) chart in the Canadian Aboriginal syllabics (CAS) alphabet.

DESIGN

Prospective, nonrandomized, within-subjects cross-sectional study.

PARTICIPANTS

Twenty Latin- and CAS-reading subjects were recruited from Ullivik, a residence in Montreal for Inuit patients.

METHODS

VA charts were made in Latin and in CAS using letters conserved across Inuktitut, Cree, and Ojibwe languages. Fonts were similar in style and size between charts. Each chart was made for a viewing distance of 3 m, with 11 lines of VAs from 20/200 to 20/10. Charts were created using LaTeX to ensure proper formatting and optotype sizing and displayed to scale on an iPad Pro. Each participant had his or her best-corrected VA for each eye measured using the Latin and CAS charts sequentially for a total of 40 eyes.

RESULTS

Median best-corrected VAs were 0.04 logMAR (range, -0.06-0.54) and 0.07 logMAR (range, 0-0.54) for the Latin and CAS charts, respectively. Median difference between CAS and Latin charts was 0 logMAR (range, -0.08-0.1). Mean ± SD difference between charts was 0.01 ± 0.03 logMAR. Pearson's r correlation between groups was 0.97. The two-tailed paired t test between groups was p = 0.26.

CONCLUSIONS

We demonstrate here the first VA chart in Canadian Aboriginal syllabics for Inuktitut-, Ojibwe-, and Cree-reading patients. The CAS VA chart has highly similar measurements to the standard Snellen chart. Testing VA for Indigenous patients in their native alphabet may provide patient-centred care and accurate VA measurements for Indigenous Canadians.

Preferred Communication Strategies for People with Communication Disabilities in Health Care Encounters: a Qualitative Study

BACKGROUND

People with communication disabilities (CDs), which includes disabilities in speech, language, voice and/or hearing, experience health and healthcare disparities. A barrier to accessing high-quality, equitable care is the lack of effective communication between patients and their providers.

OBJECTIVE

In designing a patient-prompted tool to facilitate communication, we analyzed qualitative feedback on communication strategies and the experience of people with CDs, caregivers, and providers in healthcare encounters. We aimed to describe communication strategies that patients with CDs find most useful and optimize a tool for patients to share their communication strategy preferences during clinical encounters. While patient-provider communication is paramount in every interaction, we aimed to highlight the intricacies of optimizing communication for this population.

DESIGN

We performed a qualitative study utilizing focus groups and interviews with patients with CDs, their caregivers, and healthcare providers.

PARTICIPANTS

A total of 46 individuals participated in focus groups or interviews; 26 participants self-reported a CD, nine were caregivers, and 11 were providers. Participants represented diverse types of CDs, including stuttering, aphasia, hearing loss, and people with autism or cerebral palsy who use assistive technology to communicate.

APPROACH

Analysis of qualitative interview and focus group data was guided by a qualitative content analysis approach.

KEY RESULTS

We identified three themes: (1) While communication strategies should be individualized, participants agreed upon a consolidated list of best strategies and accommodations. We used this consolidated list to finalize tool development. (2) Patients and providers preferred disclosure of the CD and desired communication strategies before the appointment. (3) Providers often do not use communication strategies and accommodations during clinical encounters.

CONCLUSIONS

For patients with CDs, it is critical to acknowledge and document the CD and individualize communication strategies during healthcare visits to facilitate communication. Studies are needed to evaluate whether improved communication strategy usage leads to improved health outcomes for this population.

The Effect of Language on the Decision to Image in the Evaluation of Atraumatic Headache

BACKGROUND

Patients with limited English proficiency seen in the emergency department (ED) experience lower quality of care and higher diagnostic resource utilization unless they are evaluated in their own language. Despite a low rate of serious pathology identified and the availability of guidelines to direct its use, computed tomography (CT) is commonly used to evaluate atraumatic headache in the ED.

OBJECTIVE

Our aim was to determine whether Spanish-speaking patients with atraumatic headache were more likely than their English-speaking counterparts to undergo head CT, and whether evaluation by a clinician who passed a Spanish proficiency test mitigated this difference.

METHODS

This retrospective observational study used electronic health record data of adult patients presenting with atraumatic headache to a level I trauma center during a 2-year period. Spanish-language testing of clinicians consisted of a brief, unvalidated, in-person, nonmedical verbal test administered by human resources staff.

RESULTS

A total of 3030 patients with atraumatic headache were identified; 1437 were English speaking and 1593 were Spanish speaking. Spanish-speaking patients were older (48.3 vs. 41.9 years), more likely to be women (68.8% vs. 60.5%), and more likely to undergo head CT (31.8% vs. 26.4%). Evaluation by a clinician who passed the Spanish proficiency test had no significant influence on the likelihood of head CT for Spanish-speaking patients after controlling for confounding variables (adjusted odds ratio 0.95; 95% CI 0.75-1.20).

CONCLUSIONS

Spanish-speaking patients are more likely to undergo head CT when evaluated for atraumatic headache than English-speaking patients. Evaluation by a clinician who passed a brief Spanish proficiency test did not mitigate this disparity.

Impact of Preferred Written Language in Patients Discharged With Bronchiolitis From a Children's Hospital

OBJECTIVES

This study aimed to identify differences in length of stay and readmission in patients admitted with bronchiolitis based on preferred written language. A secondary aim was to assess adherence to providing written discharge instructions in patients' preferred language.

METHODS

In this cross-sectional study, we included 384 patients aged 0 to 2 years discharged from 2 children's hospitals with bronchiolitis from May 1, 2021, through April 30, 2022; patients were excluded for history of prematurity, complex chronic condition, or ICU stay during the study period. A manual chart review was performed to determine preferred written language and language of written discharge instructions.

RESULTS

Patients preferring a written language other than English had a longer length of stay compared with English-preferring patients (37.9 vs 34.3 hours, P < .05), but there was no significant difference in unplanned 7-day readmissions. All patients who preferred English and Spanish received written discharge instructions in their preferred written language; no patients with other preferred languages did.

CONCLUSIONS

Patients who preferred a written language other than English had a longer length of stay than those preferring English but there was no difference in 7-day readmissions, though power for readmissions was limited. The study also identified significant disparities in the provision of written discharge instructions in languages other than English and Spanish.

Hear Our Voice: Pediatric Communication Barriers From the Perspectives of Refugee Mothers With Limited English Proficiency

BACKGROUND

Adverse health outcomes are more common for health consumers with limited English proficiency (LEP). This study examines the consumer experience of refugee mothers with LEP when communicating with paediatric health services.

METHOD

A community-based participatory qualitative study engaging participants from refugee-like backgrounds. Focus groups and in-depth individual interviews (using professional interpreters) were conducted in community settings and analysed using Grounded Theory principles.

RESULTS

Fifty ethnolinguistically diverse participants reported universal communication barriers; (i) "Negative health care experiences" (fear, helplessness, lack of safety, trust and dignity), (ii) "Ineffective health service communication and adverse outcomes", (iii) "Logistical access barriers" and (iv) self-sourced solutions". The "importance of professional interpreter utilisation" and subsequent "sense of empowerment" was unanimous.

CONCLUSIONS

This study highlights gaps in current health interactions which negatively impact care, inclusion, and culturally safe engagement. Recommendations include orgainzational reform enhancing language services, increased cultural competency, long term support, and research with LEP populations.

Technological Innovations to Improve Patient Engagement in Nephrology

Technological innovation has accelerated exponentially over the last 2 decades. From the rise of smartphones and social media in the early 2000s to the mainstream accessibility of artificial intelligence (AI) in 2023, digital advancements have transformed the way we live and work. These innovations have permeated health care, covering a spectrum of applications from virtual reality training platforms to AI-powered clinical decision support tools. In this review, we explore fascinating recent innovations that have and can facilitate patient engagement in nephrology. These include integrated care mobile applications, wearable health monitoring tools, virtual/augmented reality consultation and education platforms, AI-powered appointment booking systems, and patient information tools. We also discuss potential pitfalls in implementation and paradigms to adopt that may protect patients from unintended consequences of being cared for in a digitalized health care system.

Recommendations for Working with Culturally and Linguistically Diverse Families: A Report from the Field

Given the persistent shift in racial and ethnic demographics in the United States, board certified behavior analysts (BCBAs) will increasingly serve culturally and linguistically diverse families. There has been a recent increase in published resources to help behavior analysis practitioners navigate working with diverse populations. The purpose of this article is to add to these resources and demonstrate how these recommendations can be put into action. We outline five recommendations for working with culturally and linguistically diverse families in the context of a small company that has incorporated these practices in their own work focused on serving a large percentage of immigrant families.

A Case Study of the Impact of Language Concordance on Patient Care, Satisfaction, and Comfort with Sharing Sensitive Information During Medical Care

Linguistic barriers continue to be a source of difficulty and inappropriate treatment in our healthcare system. Several studies have shown the importance of language concordance, which leads to increased trust and higher patient satisfaction. The aim of this is study is to determine patients' satisfaction and comfort levels with sharing sensitive information in Spanish with either the health care provider or an interpreter, respectively, and to compare the results to find out if there is an option that patients prefer. There were two different groups of participants in the study. The experimental group was directly seen by Spanish-speaking student doctors while the control group was seen by English-speaking student doctors that had the aid of an interpreter. Several questions were asked to participants via survey in order to measure their comfort levels during the encounter. The results of this study demonstrate that having Spanish-speaking healthcare providers providing health care to Hispanic patients can raise patients' comfort levels and satisfaction in contrast to having the aid of an interpreter. Providing second language training to student doctors can potentially improve patient care and reduce health inequities facing LEP patients. Given the small sample size of our study, future projects should expand the study to include more participants.

Opportunities for standardization in emergency scenarios in the European Union

OBJECTIVE

Despite current standardization actions towards the unification between European Union (EU) countries, there is still much work to do. In this context, this paper aims to offer a comprehensive analysis of the limitations of the EU concerning emergency situations, specifically in cross-border, cross-hierarchical, and cross-sectorial emergencies, as well as the analysis of emergent opportunities for improvement. The final goal of this analysis is to serve as an initial step for pre-standardizing these opportunities.

MATERIALS AND METHODS

This work, performed in the context of the EU H2020 VALKYRIES project, first analyzed existing gaps from three dimensions: technological, procedural, collaboration, and training. Each gap was obtained from the literature, professional experience within VALKYRIES, or a consultation process on EU emergency agencies. This research subsequently obtained a list of opportunities from these limitations, aggregating those opportunities with similarities to ease their study. Then, this work prioritized the opportunities based on their feasibility and positive impact, performing an additional consultation process to EU emergencies for validation. Finally, this investigation provided a roadmap for pre-standardization for the five top-ranked opportunities per dimension.

RESULTS

This paper presents a set of 303 gaps and 255 opportunities across technological, procedural, collaboration, and training dimensions. After clustering the opportunities, this work provides a final set of 82 meta opportunities for improving emergency actions in the EU, prioritized based on their feasibility for adoption and positive impact. Finally, this work documents the roadmaps for three top-ranked opportunities for conciseness.

CONCLUSION

This publication highlights the limitations and opportunities in the EU concerning emergency agencies and, more specifically, those existing in cross-border and multi-casualty incidents. This work concludes that there is still room for improvement despite the current measures toward harmonization and standardization.

Reproductive inequity and inferior intrauterine insemination outcomes in patients with limited English proficiency: a retrospective cohort study

OBJECTIVE

To evaluate if language preference influences intrauterine insemination outcomes.

DESIGN

Retrospective cohort.

SETTING

The study was conducted at an urban medical center in New York from January 2016 to August 2021.

PATIENT(S)

All women older than 18 years undergoing their first IUI cycle with an infertility diagnosis were included.

INTERVENTION(S)

Intrauterine insemination after ovarian stimulation.

MAIN OUTCOME MEASURE(S)

Primary outcomes were intrauterine insemination success rate and duration of infertility before seeking infertility care. The primary outcomes used the Kaplan-Meier estimator to investigate the difference in duration of infertility before specialty consultation and logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) of clinical pregnancy among English speakers vs. those with limited English proficiency (LEP) undergoing initial IUI. Secondary outcomes included final IUI outcomes compared by language preference. Adjusted analyses controlled for race/ethnicity.

RESULTS

A total of 406 patients were included in this study, of which 86% preferred English, 7.6% preferred Spanish, and 5.2% preferred other. Patients with LEP have longer duration of infertility before seeking infertility care than English-proficient women (mean 4.53 ± 3.65 years vs. 2.01 ± 1.58 years). Although clinical pregnancy rate of initial IUI did not significantly vary (OR, 2.92; 95% CI, 0.68-12.47 unadjusted and OR, 2.88; 95% CI, 0.67-12.35 adjusted), the cumulative pregnancy rate was significantly higher in English-proficient patients than in LEP patients at the time of final IUI (22.32% vs. 15.38%). This is despite a similar number of total IUIs (2.40 English vs. 2.70 LEP). Additionally, LEP patients were significantly more likely to discontinue care after unsuccessful IUI, instead of proceeding to further fertility treatments such as in vitro fertilization.

CONCLUSIONS

Limited English proficiency is associated with longer duration of infertility before initiating care as well as poorer IUI outcomes, including lower cumulative pregnancy rate. Further research is needed to assess what clinical and socioeconomic factors are contributing to lower IUI success rates and lower continuation in infertility care in LEP patients.

Patient perceptions of the readability and helpfulness of bilingual clinical forms: a survey study

BACKGROUND

Patients with limited English proficiency (LEP) are rarely provided with translated clinical materials. Typically, healthcare clinics cite high costs of translation and lack of professional translators as barriers to this service. The purpose of the current study was to investigate the perceptions of LEP dental patients regarding the readability, understanding, and helpfulness of translated clinical forms produced by dental student doctor translators.

METHODS

We used a survey design and convenience sampling to recruit LEP patients from a dental school clinic. Participants completed a 9-question (8 Likert-type items and 1 open-ended item) paper survey about translated forms. The bilingual survey was a combination of English and 8 other languages (Arabic, Dari, Pashto, Russian, Spanish, Ukrainian, Urdu, or Vietnamese) and assessed the type of form received; self-reported literacy; design, readability, and helpfulness of the form; overall understanding of the form; understanding of medical and dental terms; helpfulness for patient-provider communication; and comfort level with dental care after receiving the form. Demographic characteristics of participants were collected from the clinic's electronic health record. Survey responses were analyzed descriptively, and Spearman's correlation was used to examine the relationship between outcomes.

RESULTS

Ninety-seven LEP patients (61.9% [60] female, 78.4% [70] Spanish speakers) completed 140 surveys for various translated forms in Dari, Pashto, Spanish, Urdu, or Vietnamese. Participants positively rated translated clinical forms: range, 50.4% (70) for design of the form to 80.0% (112) for comfort level with dental care after receiving the form. For the open-ended item, participants indicated the translations were good, and no improvements were needed. They also thought providing the form was evidence of good customer service. When examining relationships between outcomes, positive correlations were found between self-reported literacy and readability (Spearman r = .57, P < .001), overall understanding and understanding of medical and dental terms (Spearman r = .58, P < .001), and type of form and helpfulness for patient-provider communication (Spearman r = .26, P = .005).

CONCLUSIONS

Study results suggested the translated clinical forms were perceived as helpful and beneficial by LEP dental patients. Similar approaches should be considered to reduce language barriers in healthcare.

Evaluating Patient and Family Experience Among Spanish-Speaking and LatinX Patients: a Scoping Review of Existing Instruments

INTRODUCTION

LatinX populations are rapidly growing in the USA, but still report lower levels of patient centered care and satisfaction when compared to their non-LatinX white counterparts. This review encompasses literature which describes patient experience instruments that (1) evaluate LatinX experience, (2) have validated Spanish versions, or (3) measure language-concordant care experiences.

METHODS

A scoping review of literature in Ovid Medline, CINAHL, and PsycINFO was conducted. Articles were excluded if they were not applicable to the health care industry, did not include a patient experience instrument, or did not include LatinX or Spanish-speaking individuals within their study population. Data extraction was performed for concepts measured, study size, population, health care setting, and languages validated.

RESULTS

This review identified 224 manuscripts. Of these, 81 met full inclusion criteria and represented 60 unique instruments. These covered six categories: general patient experience (43%, n = 26/60), experiences of discrimination/mistrust (12%, n = 7/60), cultural factors (10%, n = 6/60), patient-provider relationship (10%, n = 6/60), and communication (8%, n = 5/60). The remaining instruments measured multiple categories (17%, n = 10/60). Just over one third of instruments (n = 24, 5 pediatric, 19 adult) were validated in Spanish and an additional 14 (23%) were validated in English alone. Finally, 4 (7%) instruments were identified which were developed for use in a language concordant setting.

CONCLUSION

Many instruments were identified which evaluate LatinX patient experience; however, none was both validated in Spanish and measured in all key categories of experience described above. Additionally, few instruments were developed for holistic evaluation of patient experience in pediatric or language concordant care settings.

Spanish-Speaking Caregivers' Perception of Emergency Physicians' Interpersonal and Communication Skills in a Pediatric Emergency Department

OBJECTIVES

Medical communication is more than just the delivery of information; language differences between physicians and patients/caregivers create a challenge to providing effective care in the pediatric emergency department (ED). Overcoming this barrier is vital to providing high-quality care. We evaluated Spanish- versus English-speaking caregivers' perception of their pediatric ED physicians' interpersonal and communication skills. We also compared perceptions of Spanish- versus English-speaking caregivers who self-identified as Hispanic.

METHODS

This study is a retrospective analysis of data from surveys administered in an urban, free-standing children's hospital ED. Surveys were administered in English and Spanish to pediatric patient caregivers. In person, video, and telephonic interpretations were available during patient encounters.

RESULTS

There were 2542 (82.4%) surveys completed in English and 543 (17.6%) in Spanish. There were significant differences in demographic data of English versus Spanish survey respondents, including level of education, insurance status, and rates of nonpublic insurance. Spanish survey respondents rated their physicians' interpersonal skills lower than English survey respondents. There were 1455 (47%) surveys completed by the respondents who self-identified as Hispanic. Within this group, 928 (63.8%) respondents completed the survey in English and 527 (36.2%) in Spanish. Among this Hispanic population, the Spanish survey respondents rated their physicians' interpersonal and communication skills lower than English survey respondents. After adjusting for education level and insurance type, these differences persisted.

CONCLUSIONS

Language barriers have a meaningful impact on physician ability to communicate effectively in the pediatric ED. Improving physicians' ability to overcome this barrier is essential toward enriching patient outcomes and experience in the ED.

Racial and Ethnic Disparities in Emergency Department Wait Times for Children: Analysis of a Nationally Representative Sample

OBJECTIVE

To evaluate the association of race and ethnicity with wait times for children in US emergency departments (ED).

METHODS

We performed a cross-sectional study of ED encounters of children (<18 years) from 2014 to 2019 using a multistage survey of nonfederal US ED encounters. Our primary variable of interest was composite race and ethnicity: non-Hispanic White (NHW), non-Hispanic Black, Hispanic, and all others. Our outcome was ED wait time in minutes. We evaluated the association between race and ethnicity and wait time in Weibull regression models that sequentially added variables of acuity, demographics, hospital factors, and region/urbanicity.

RESULTS

We included 163,768,956 survey-weighted encounters. In univariable analysis, Hispanic children had a lower hazard ratio (HR) of progressing to evaluation (HR 0.84, 95% confidence interval [CI] 0.76-0.93) relative to NHW children, indicating longer ED wait times. This association persisted in serial multivariable models incorporating acuity, demographics, and hospital factors. This association was not observed when incorporating variables of hospital region and urbanicity (HR 0.91, 95% CI 0.83-1.00). In subgroup analysis, Hispanic ethnicity was associated with longer wait times in pediatric EDs (HR 0.76, 95% CI 0.63-0.92), non-metropolitan EDs (HR 0.75, 95% CI 0.64-0.89), and the Midwest region (HR 0.77, 95% CI 0.69-0.87). No differences in wait times were observed for children of Black race or other races.

CONCLUSIONS

Hispanic children experienced longer ED wait times across serial multivariable models, with significant differences limited to pediatric, metropolitan, and Midwest EDs. These results highlight the presence of disparities in access to prompt emergency care for children.

Limited English Proficiency as a Barrier to Inclusion in Emergency Medicine-Based Clinical Stroke Research

AIMS

Individuals with Limited English Proficiency (LEP) represent a growing percentage of the U.S. population yet face inequities in health outcomes and barriers to routine care. Despite these disparities, LEP populations are often excluded from clinical research studies. The aim of this study was to assess for the inclusion of LEP populations in published acute care stroke research in the U.S.

METHODS

A systematic review was conducted of publications from three databases using acute care and stroke specific Medical Subject Heading key terms. The primary outcome was whether language was used as inclusion or exclusion criteria for study participation and the secondary outcome was whether the study explored outcomes by language.

RESULTS

A total of 167 studies were included. Twenty-two studies (13.2%) indicated the use of language as inclusion/exclusion criteria within the manuscript or dataset/registry and only 17 studies (10.2%) explicitly included LEP patients either in the study or dataset/registry. Only four papers (2%) include language as a primary variable.

CONCLUSIONS

As LEP populations are not routinely incorporated in acute care stroke research, it is critical that researchers engage in language-inclusive research practices to ensure all patients are equitably represented in research studies and ultimately evidence-based practices.

Impacts of the hearing aid intervention on healthcare utilization and costs among middle-aged and older adults: results from a randomized controlled trial in rural China

BACKGROUND

Hearing impairment has become a major global health issue. To reduce the burden of hearing impairment, we explored impacts of the hearing aid intervention on healthcare utilization and costs.

METHODS

In this randomized controlled trial, participants aged 45+ were allocated with a ratio of 1:1.5 (intervention: control). Neither the investigators nor the assessors were blinded to the allocation status. Those in the intervention group were fitted with hearing aids, and those in the control group received no care. We applied the difference-in-difference (DID) approach to examine the impacts on healthcare utilization and costs. Given that social network and age can be significant variables affecting effectiveness of the intervention, subgroup analyses by social network and age were used to explore the heterogeneity.

FINDINGS

395 subjects were successfully recruited and randomized. 10 subjects did not meet the inclusion criteria and therefore, 385 eligible subjects (150 in the treatment group and 235 in the control group) were analyzed. The intervention significantly reduced their total healthcare costs (average treatment effect (ATE) = -1.26, 95% CI = -2.39, -0.14, p = 0.028) and total out-of-pocket (OOP) healthcare costs (ATE = -1.29, 95% CI = -2.37, -0.20, p = 0.021) in the 20-month follow-up. To be exact, it reduced self-medication costs (ATE = -0.82, 95% CI = -1.49, -0.15, p = 0.016) and OOP self-medication costs (ATE = -0.84, 95% CI = -1.46, -0.21, p = 0.009). Subgroup analysis showed that the impacts on self-medication costs and OOP self-medication costs varied by social network (ATE for self-medication costs = -0.26, 95% CI = -0.50, -0.01, p = 0.041; ATE for OOP self-medication costs = -0.27, 95% CI = -0.52, -0.01, p = 0.038). The impacts also varied by age groups (ATE for self-medication costs = -0.22, 95% CI = -0.40, -0.04, p = 0.019; ATE for OOP self-medication costs = -0.17, 95% CI = -0.29, -0.04, p = 0.010). There were no adverse events or side effects during the trial.

INTERPRETATION

Hearing aid use significantly lowered self-medication costs and total healthcare costs, but had no impacts on inpatient or outpatient services utilization or costs. The impacts were manifested among people with active social network or younger age. It can be speculated that the intervention may be adapted to other similar settings in developing countries to reduce healthcare costs.

FUNDING

P.H. reports grants from National Natural Science Foundation of China (No. 71874005) and Major Project of the National Social Science Fund of China (No. 21&ZD187).

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR1900024739.

Barriers in Healthcare for Latinx Patients with Limited English Proficiency-a Narrative Review

Latinx (includes Hispanics and is the non-gendered term for Latino/Latina which is a person of Latin American origin or descent) constitutes the largest racial and ethnic minority group in the United States (US). Many members of this group report limited English proficiency, experience discrimination, feel distrust in the healthcare setting, and face poorer health outcomes than non-Latinx Whites. As healthcare systems assess internal structures of care, understanding the experiences of Latinx patients may inform strategies to improve care. This narrative review describes studies that assessed the experiences of Latinx patients with limited English proficiency (LEP) in the inpatient and outpatient settings in the US. We searched PubMed for studies published between January 1, 1990, and March 2021. We reviewed all citations and available abstracts (n = 429). We classified study titles (n = 156) as warranting detailed consideration of the original article. Limited English proficiency is a well-documented challenge reported by Latinx patients seeking care in the outpatient setting, resulting in mistrust of healthcare organizations and clinicians. The effects of LEP overlap substantially with challenges related to patients' immigration status, cultural traditions, and socioeconomic needs. Use of professional interpretation rather than ad hoc interpretation improves trust and satisfaction. There is no consensus about the most effective mode of delivering professional interpretation (in person, telephonic, video conferencing), although rapid simultaneous telephone translation is a promising modality. Increasing awareness of the barriers to effective communication, improving skills in communicating through translators, and increasing the amount of time spent with patients may improve communication and trust more than structural changes like mode of translation or bedside rounding. Cultural fluency training, standardized language training for providers, and incentive pay for fluency are also deserving of further consideration.

Exploring the Factors that Influence Ethical Spanish Use among Medical Students and Solutions for Improvement

IssueThere is a need for greater access to Spanish language services in United States healthcare. One approach to increasing language concordant care is the use of second language skills by healthcare staff. The desire to use second language skills may have unintended consequences when individuals step beyond their language abilities and can cause more harm than do good for limited-English proficiency patients. Medical students are in a unique position that places them at increased risk for inappropriately using second language skills. Evidence: The use of qualified healthcare interpreters has been shown to mitigate some of the disparities seen with limited-English proficiency patients including poorer healthcare outcomes, less access to care, and lower patient satisfaction. In spite of this knowledge, studies have demonstrated the phenomenon of residents and physicians "getting by" without the use of an interpreter, even when they recognized that their language competency was insufficient to provide high quality care. Regardless of language ability, medical students are asked to engage in conversations with Spanish speaking patients that are beyond their level of language competency. Students vary in their perceived language ability and level of comfort engaging in different clinical scenarios with limited-English proficiency patients. Implications: Students are in a unique position of vulnerability to pressures to use second language skills in situations that step beyond their abilities. We explore how hierarchy intensifies previously established factors, including a lack of adequate training or evaluation and other structural barriers, in contributing to medical students' inappropriate use of Spanish with limited-English proficiency patients. We propose an approach that includes student education, standardization of clinic rules regarding interpretation, and comprehensive faculty development to address this important patient care issue.

Politics, Pandemics, and Trauma: Understanding and Addressing Latino Health Needs Through a Culturally-Informed Lens

Latino communities in the United States (U.S.) have long endured trauma due to multiple intersecting social and political forces. New restrictive immigration policies since 2016 and the COVID-19 pandemic have each created novel stressors for Latino communities, while escalating the risk of mental health disorders and highlighting the communities' vulnerabilities. The effects of these stressors have been particularly pronounced in southeastern states, such as Tennessee and Georgia, due to their state-level anti-immigrant legislation. Yet, we lack sufficient data to understand how these factors present among Latinos seeking services. To focus attention on the specific experiences of Latino communities living in the U.S. Southeast, the authors analyzed the perspectives of 44 service providers working with these communities in the region using qualitative data collected in an online survey administered during the COVID-19 pandemic and while President Trump's exclusionary immigration policies were in force. Four themes were identified: (1) Latino communities' strengths; (2) impact of the Trump administration on Latino communities; (3) impact of COVID-19's on Latino communities; and (4) strategies to enhance service delivery in Latino communities. Results provide meaningful data to inform micro- and macro-level service delivery in two exclusionary policy states and beyond. Findings suggest future research should include other new immigrant destinations and explore perceptions of Latino community members.

Health care interpreter use in an inpatient rehabilitation setting: examining patterns of use and associated clinical outcomes

PURPOSE

Professional interpreters can improve healthcare quality and outcomes when there is language discordance between patients and health care providers. Multidisciplinary rehabilitation relies on nuanced communication; however, the use of interpreters in rehabilitation is underexplored. This study aimed to examine patterns of health care interpreter use in an inpatient rehabilitation setting.

METHODS

A retrospective cohort study was conducted including patients admitted for subacute rehabilitation during 2019-2020 identified as having limited English proficiency. Patterns of interpreter use (professional and "ad hoc") and rehabilitation outcomes were evaluated via medical record review.

RESULTS

Eighty-five participants were included. During inpatient rehabilitation (median 17 [12-28] days), most clinical interactions (95%) occurred without an interpreter present. Patterns of interpreter use were variable; with greater use of ad hoc versus professional interpreters (received by 60% versus 49% of the cohort, respectively). Those who interacted with a professional interpreter had a longer length-of-stay, larger Functional Independence Measure (FIM) gain, and lower rate of hospital readmission six months post-discharge. The number of professional interpreter sessions correlated positively with FIM gain.

CONCLUSIONS

Access to professional interpreters in inpatient rehabilitation was variable, with some patients having no or minimal access. These findings provide preliminary evidence that professional interpreter use may be associated with clinical rehabilitation outcomes. Implications for rehabilitationProfessional health care interpreters can be used to overcome language barriers in rehabilitation.In an inpatient rehabilitation setting, professional interpreters appeared to be underutilized, with many patients having no or minimal access to interpreters.Use of ad hoc, untrained interpreters and informal communication strategies was common during rehabilitation.Use of professional interpreters appeared to be associated with favorable rehabilitation outcomes.

Interpreter Use and Patient Satisfaction in the Otolaryngology Outpatient Clinic

Background

Communication between providers and patients is essential to patient care and to the patient-physician relationship. It plays a significant role in both measurable and perceived quality of care. This study explores the satisfaction of English-speaking and limited English proficiency (LEP) patients with English-speaking providers, focusing on the correlation between patients’ primary language and the use of interpreter services on patients’ visit satisfaction.

Methodology

This study was designed to have a sample size sufficient to detect a 10% difference in the primary outcome, overall visit satisfaction, between language-concordant patients and LEP patients in the interpreter and no interpreter groups, assuming a two-tailed alpha of 0.05 and power of 80%. All collected data were analyzed using the Statistical Package for the Social Sciences software, version 25 (IBM Corp, Armonk, NY, USA), and significance was determined if p <0.05.

Results

Of the total 209 patients, 65 utilized professional interpreter services, nine used an ad-hoc interpreter, and 135 did not require an interpreter. Patients who used an interpreter demonstrated lower visit satisfaction compared with patients who did not (p < 0.001). Patients expressed significantly greater preference for in-person interpreter (mean = 9.73) or a family member (mean = 9.44) compared to telephone services (mean = 8.50) (p = 0.002). The overall satisfaction scores did not significantly differ between different interpreter types (p = 0.157).

Conclusions

LEP patients experienced lower visit satisfaction compared to language-concordant patients. The data suggest that perceived quality of communication was a factor in these lower satisfaction reports. While LEP patients did prefer in-person interpreters, there was no significant difference in overall visit satisfaction between different types of interpreters.

Disparities in Pediatric Emergency Department Length of Stay and Utilization Associated With Primary Language

OBJECTIVE

The aim of the study was to investigate the association between primary language and length of stay (LOS) in the pediatric emergency department (ED) within the context of known disparities impacting healthcare experiences and outcomes for patients with language barriers.

METHODS

We conducted a retrospective cohort study of consecutive encounters of patients presenting to, and discharged from, an urban pediatric ED from May 2015 through April 2018. Encounters were grouped into English primary language (EPL), Spanish (SPL), and other (OPL). Mean LOS comparisons were stratified by Emergency Severity Index (ESI). Bivariate and multivariate analyses were used to examine the relationship between LOS and variables, including age, sex, race/ethnicity, insurance, and time of presentation.

RESULTS

A total of 139,163 encounters were included. A higher proportion of SPL and OPL encounters were characterized as lower ESI acuity compared with EPL. Significantly longer LOS for SPL and OPL encounters was observed in the 2 lower acuity strata. The ESI 4-5 stratum demonstrated the greatest LOS disparity between EPL, SPL, and OPL (94 vs 103 vs 103 minutes, respectively, P < 0.001). In the highest acuity stratum, ESI 1-2, there was a nonsignificant trend toward longer LOS among EPL encounters (P = 0.08). The multivariate model accounted for 24% of LOS variance, but effect sizes were small for all variables except for ESI and age.

CONCLUSIONS

Patients with Spanish or other non-EPL who were triaged to lower acuity ESI levels experienced longer LOS in the pediatric ED than English-speaking counterparts. They also used the ED more frequently for low acuity issues, possibly reflecting disparities in access to primary care.

Perception of the use of a telephone interpreting service during primary care consultations: A qualitative study with allophone migrants

Objectives

The language barrier prevents allophone migrant patients from accessing healthcare when arriving in a country, and interpreters are often needed to help them to be understood. This study aimed to understand perceptions and experiences of allophone migrant patients who used a telephone-interpreting service during primary care consultations.

Study design

A qualitative study using semi-structured interviews was undertaken between September 2019 and January 2020. Interviews were transcribed and analysed using thematic analysis framework.

Setting

Allophone migrant patients from an accommodation centre for asylum-seekers who used a telephone-interpreting service during primary care consultations with a general practitioner.

Participants

A purposive sample of allophone migrant patients (n = 10).

Results

From the semi-structured interviews, we identified three themes: (1) multi-level difficulties of being an allophone migrant in the primary care pathway (i.e., before, during, and after the consultation); (2) the key role of the interpreter in the doctor-patient relationship, participating in improving the patient’s management by establishing a climate of trust between the two; and (3) advantages and limitations of the TIS. However, even if a telephone-interpreting service is very helpful, allowing quick access to interpreters speaking the allophone patient’s native language, certain situations would require the interpreter to see the patient to better guide the doctor during the consultation.

Conclusion

Telephone-interpreting services enable improving communication and comprehension between allophone migrant patients and doctors. Nevertheless, the interpreter may sometimes need to physically see the patient to better guide the doctor. To do so, interpreting services using videoconferencing deserve wider development.

Multivariable Analysis of Patient Satisfaction in the Pediatric Emergency Department

BACKGROUND

Published data on predictive factors associated with parent satisfaction from care in a pediatric emergency department (ED) visit are limited to be descriptive and obtained from small data sets. Accordingly, the purpose of this study was to determine both modifiable and nonmodifiable demographic and operational factors that influence parental satisfaction using a large and ethnically diverse site data set.

METHODS

Data consist of responses to the National Research Council (NRC) survey questionnaires and electronic medical records of 15,895 pediatric patients seen in a pediatric ED between the ages of 0 and 17 years discharged from May 2018 to September 2019. Bivariate, χ2, and multivariable logistic regression analyses were carried out using the NRC item on rating the ED between 0 and 10 as the primary outcome. Responses were coded using a top-box approach, a response of "9" or "10" represented satisfaction with the facility, and every other response was indicated as undesirable. Demographic data and NRC questionnaire were used as potential predictors.

RESULTS

Multivariable regression analysis found the following variables as independent predictors for positive parental rating of the ED: Hispanic race/ethnicity (odds ratio [OR], 1.285), primary language Spanish (OR, 2.399), and patients who had government-sponsored insurance (OR, 1.470). Those survey items with the largest effect size were timeliness of care (OR, 0.188) and managing discomfort (OR, 0.412).

CONCLUSIONS

Parental rating of an ED is associated with nonmodifiable variables such as ethnicity and modifiable variables such as timeliness of care and managing discomfort.

Healthcare Provider Perspectives Regarding Use of Medical Interpreters During End-of-Life Conversations With Limited English Proficient Patients

BACKGROUND

Healthcare providers increasingly care for patients with Limited English Proficiency (LEP). There is limited research evaluating healthcare provider utilization practices, attitudes, perceived benefits and barriers regarding the use of medical interpreters in end of life (EOL) and goals of care (GOC) conversations.

OBJECTIVES

To elicit healthcare providers' opinions of the role, factors that impact decisions to use medical interpreters and perceived utility of using medical interpreters when conducting EOL and GOC conversations with LEP patients and their families.

DESIGN

Cross-sectional survey of internal medicine trainees and attending physicians from a U.S. medical center.

RESULTS

A total of 117 surveys were collected with a response rate of 51%. In-person medical interpreters received higher ratings with regard to their helpfulness compared to telephone medical interpreters during EOL and GOC conversations. Being an attending physician and having received training in the use of a medical interpreter predicted higher composite scores reflecting greater awareness of the roles of medical interpreters and endorsement of best communication practices. In-person interpreters were viewed by a subset of participants as "standard of care" during EOL and GOC conversations.

CONCLUSION

Having more years in practice and receiving training in the use of medical interpreters correlated with more favorable attitudes toward the role of medical interpreters and positive communication practices. Incorporating early training in the use of medical interpreters could help enhance communication practices and outcomes during EOL and GOC conversations with LEP patients.

The Impact of Diagnostic Decisions on Patient Experience in the Pediatric Emergency Department

OBJECTIVE

Patient experience serves as both a subjective measure of value-based health care delivery and a metric to inform operational decision making. The objective of this study was to determine if specific diagnostic and therapeutic interventions affect patient experience scores for children seen in the emergency department.

METHODS

We performed a retrospective observational study in the emergency department of a large quaternary care children's hospital on patients who were discharged to home and later completed a National Research Corporation Health patient experience survey. We matched the survey results to electronic health record (EHR) data and were able to extract demographics, operational metrics, and order information for each patient. We performed multiple logistic regression analyses to determine the association of image acquisition, laboratory test ordering, medication administration, and discharge prescribing with likelihood to recommend the facility as our measure of patient experience.

RESULTS

Of the 4103 patients who met inclusion criteria for the study, 75% strongly recommended the facility. Longer wait times were associated with lower patient experience scores [odds ratio (OR) per waiting room hour increase, 0.72; 95% confidence interval (CI), 0.65-0.81]. Significant diagnostic factors associated with higher patient experience included magnetic resonance imaging ordering (OR, 2.38; 95% CI, 1.00-5.67), x-ray ordering (OR, 1.19; 95% CI, 1.00-1.42), and electrocardiogram ordering (OR, 1.62; 95% CI, 1.07-2.44). Of the treatment factors studied, only antibiotic prescribing at discharge was found to have a significant positive association with patient experience (OR, 1.32; 95% CI, 1.08-1.63).

CONCLUSION

The positive association between more intensive diagnostic workups and patient experience could have implications on the utility of patient experience scores to evaluate pediatric care teams. Consideration should be taken to interpret patient experience scores in the context of compliance with approaches in evidence-based medicine.

Non-English Primary Language Is Associated with Short-Term Outcomes After Supratentorial Tumor Resection

BACKGROUND

Despite research indicating that patients with non-English primary language (NEPL) have increased hospital length of stay (LOS) for craniotomies, there is a paucity of neurosurgical research examining the impact of language on short-term outcomes. This study sought to evaluate short-term outcomes for patients with English primary language (EPL) and NEPL admitted for resection of a supratentorial tumor.

METHODS

Using the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project New Jersey State Inpatient Database, this study included patients 18-90 years old who underwent resection of a supratentorial primary brain tumor, meningioma, or brain metastasis from 2009 to 2017. The primary outcomes were total, preoperative, and postoperative LOS. Secondary outcomes were complications, mortality, and discharge disposition. Univariable and multivariable analyses compared Spanish primary language (SPL), non-English non-Spanish (NENS) primary language, and EPL groups.

RESULTS

A total of 7324 patients were included: 2962 with primary brain tumor, 2091 with meningioma, and 2271 with brain metastasis. Patients with SPL (n = 297) were younger and more likely to have noncommercial insurance, lower income, and fewer comorbidities. Patients with NENS (n = 257) had similar age and comorbidities to the EPL group but had a greater proportion of noncommercially insured and low-income patients (P < 0.001). Multivariable analysis showed that patients with NENS had increased postoperative LOS (adjusted incidence rate ratio, 1.10; P = 0.008) and higher odds of a complication (adjusted odds ratio, 1.36; P = 0.015), and patients with SPL had higher odds of being discharged home (adjusted odds ratio, 1.55; P = 0.017).

CONCLUSIONS

Patients with NEPL have different short-term outcomes after supratentorial tumor resection that varies based on primary language. More research is needed to understand the mechanisms driving these findings and to clarify unique experiences for different populations with NEPL.

Increasing Frequency of Interpreting Services is Associated With Shorter Peri-operative Length of Stay

BACKGROUND

Patients with limited English proficiency have barriers to accessing care. Rather than a binary use or no use, this study uses granular data on frequency of interpreting services to determine if this frequency is associated with differences in peri-operative length of stay for patients with limited English proficiency.

MATERIALS AND METHODS

This is a cross sectional study on length of stay for peri-operative admissions of at least one night during 2018, for patients who used medical interpreting services in an academic medical center in Boston, Massachusetts. The participants are split into quartiles of ascending number of interpreting events per day. The exposure for the primary outcome is the frequency of interpreting events per day during peri-operative admission. The primary study outcome measurement is peri-operative length of stay in days.

RESULTS

There was a statistically significant decrease in length of stay for patients in the highest two quartiles of interpreting service frequency, compared to the lowest quartile: quartile 2 trended shorter by 1.4 d (95% CI -4.5 to 1.7, P = 0.37), quartile 3 was 4.2 d shorter (95% CI -7.6 to -0.7, P = 0.02), and quartile 4 was 4.6 d shorter (95% CI -8.1 to -1.1, P = 0.01).

CONCLUSIONS

More frequent interpreting services per day during peri-operative admission are associated with shorter length of stay in adjusted analysis. The findings merit further study in an intervention to increase use of interpreting services for surgical patients with limited English proficiency to study the impact of increased frequency of culturally competent care.

Latino Immigrant Service Provision in Tennessee and Georgia: Provider Perceptions

Latinos and Latino immigrants are increasingly settling in new immigrant destinations, such as Tennessee and Georgia, that have historically lacked sufficient infrastructure for delivery of culturally and linguistically competent health and social services. This cross-sectional survey study was designed to assess providers' (n = 109) perspectives of the service provision landscape in each state. Descriptive analyses and t-tests (by state) were conducted to explore service concerns, access barriers, and organizational capacity to address concerns and barriers. Among most prevalently reported concerns were income/wages and fear of deportation. Key access barriers included language, lack of driver's license and insurance, and fear of deportation. Most (63%) organizations had sufficient Spanish language proficiency, though building trust was a notable barrier within 58% of organizations. Results provide meaningful data to inform existing strengths and service gaps in two exclusionary policy states. Future research should include perspectives of Latino community members.

A Mixed-Methods Investigation into Patients' Decisions to Attend an Emergency Department for Chronic Pain

OBJECTIVE

This study explored factors that underpin decisions to seek emergency department (ED) care for chronic noncancer pain in patients identifying as culturally and linguistically diverse (CALD) or Australian born.

DESIGN AND METHODS

This mixed-methods study was underpinned by the Behavioral Model of Health Services Use conceptual framework. Consenting consecutive patients attending the ED for a chronic pain condition were recruited to a CALD (n = 45) or Australian-born (n = 45) cohort. Statistical comparisons compared the demographic, pain, health literacy, and episode of care profiles of both cohorts. Twenty-three CALD and 16 Australian-born participants consented to an audio-recorded semi-structured interview (n = 24) or focus group (n = 5 focus groups) conducted in their preferred language. Interviews were translated and transcribed into English for analysis using applied thematic analysis, guided by the conceptual framework. Data were triangulated to investigate the patterns of ED utilization and contributing factors for both cohorts.

RESULTS

ED attendance was a product of escalating distress, influenced by the degree to which participants' perceived needs outweighed their capacity to manage their pain. This interaction was amplified by the presence of predisposing factors, including constrained social positions, trauma exposure, and biomedical health beliefs. Importantly, experiences varied between the two cohorts with higher degrees of pain catastrophizing, lower health literacy, and greater social challenges present for the CALD cohort.

CONCLUSION

This study highlights the role contextual factors play in amplifying pain-related distress for CALD and Australian-born patients with chronic pain. The findings support a need for health care providers to recognize features of higher vulnerability and consider streamlining access to available support services.

Health Care Disparities and the Future of Pancreatic Cancer Care

There have been tremendous advances in the diagnosis and treatment of pancreatic cancer in the past decade, yet we are failing to achieve equitable outcomes for all patient populations. Disparities exist in the incidence, diagnosis, treatment, and outcomes of patients with pancreatic cancer. Inequities are based on racial and ethnic group, sex, socioeconomic status, and geography. To address disparities, future steps must focus on research methods, including collection and methodology, and policy measures, including access, patient tools, hospital incentives, and workforce diversity. Through these comprehensive efforts, we can begin to rectify inequitable care for treatment of patients with pancreatic cancer.

Utility of mobile technology in medical interpretation: A literature review of current practices

OBJECTIVES

Language barriers limit healthcare access. However, professional interpretation usage is infrequent due to high cost and poor interpreter availability. Healthcare-oriented mobile applications are becoming more accepted and may help alleviate this burden. This literature review aims to better understand the utility of mobile technology in healthcare interpretation. Specifically, the objective of this review is to synthesize the feasibility, outcome, and challenges of implementing technological medical interpretation services.

PATIENT INVOLVEMENT

No patients were involved for this review.

METHODS

In December 2019, MEDLINE (Ovid) was systematically searched according to PRISMA guidelines. All articles discussing the utility of technology in healthcare interpretation encounters were included.

RESULTS

Two major themes emerged: 1) comparing video and phone interpretation with in-person interpretation and 2) assessing direct translation software in healthcare settings. Phone and video interpretation help reduce overall patient wait-times. Both patients and clinicians preferred in-person or video interpretation over interpretation by phone. Chief benefits of using direct translation software include immediate access, low costs, and sustainability. Several studies discussed potential translation inaccuracies and the importance of having professional interpreters in medico-legal discussions.

CONCLUSION

Mobile applications may be used to facilitate access to medical interpreters with high clinician and patient satisfaction. Direct in-app translations facilitate access but risk inaccuracies with important medico-legal considerations.

PRACTICAL VALUE

Mobile applications are available at low costs and can improve access to interpreters though video and phone calls. Mobile software can also provide direct translation and facilitate clinical care. Clinicians should prioritize face-to-face encounters with professional medical interpreters, whenever possible. In a time of social distancing amidst the current COVID-19 pandemic, there is crucial value in elucidating the best telehealth interpretation practices.

Satisfaction With Telephone Versus In-Person Interpretation Services in Limited English-Proficient Urogynecology Patients: A Randomized Controlled Trial

OBJECTIVE

The objective of this study was to determine if in-person interpreters improve patient satisfaction scores compared with phone interpreters for urogynecology office visits in limited English proficient (LEP) patients.

METHODS

Portuguese and Spanish LEP subjects were randomized to phone or in-person interpreter, and a 14-item questionnaire was administered with 3 subscales assessing the primary outcome of patient satisfaction with the interpreter, physician, and nursing. Subject demographics, English proficiency, overall health status, and yearly household income were recorded. Sample size calculations indicated that a mean difference of 12 in satisfaction scores could be detected with 44 subjects per arm. Analysis was conducted using descriptive statistics, and comparisons between the intervention versus control group were analyzed using Fisher exact test, Wilcoxon rank sum test, and linear regression.

RESULTS

We enrolled and randomized 106 subjects, and 82 subjects completed the study. There was a statistically significant difference in subject satisfaction between randomization groups, favoring in-person interpreters. In the as-treated analysis, the median satisfaction score for the phone interpreter group was 92.9 and 100 for in-person interpreter group (P < 0.001). Linear regression adjusted for English proficiency showed that there was a difference between median scores of 7.14 (P = 0.002).

CONCLUSIONS

Portuguese and Spanish LEP patients experienced higher satisfaction scores for urogynecology office visits when in-person interpreters are used compared with a phone interpreter. Although we found a statistically significant difference between these groups, the clinical significance of our finding is less clear. This topic should continue to be investigated for the field of urogynecology and further studies are needed.

Language Preference and Risk of Primary Cesarean Delivery: A Retrospective Cohort Study

OBJECTIVES

While some medical indications for cesarean delivery are clear, subjective provider and patient factors contribute to the rising cesarean delivery rates and marked disparities between racial/ethnic groups. We aimed to determine the association between language preference and risk of primary cesarean delivery.

METHODS

We conducted a retrospective cohort study of nulliparous, term, singleton, vertex (NTSV) deliveries of patients over 18 years old from 2011-2016 at an academic medical center, supplemented with data from the Massachusetts Department of Public Health. We used modified Poisson regression with robust error variance to calculate risk ratios for cesarean delivery between patients with English language preference and other language preference, with secondary outcomes of Apgar score, maternal readmission, blood transfusion, and NICU admission.

RESULTS

Of the 11,298 patients included, 10.3% reported a preferred language other than English, including Mandarin and Cantonese (61.7%), Portuguese (9.7%), and Spanish (7.5%). The adjusted risk ratio for cesarean delivery among patients with a language preference other than English was 0.85 (95% CI 0.72-0.997; p = 0.046) compared to patients with English language preference. No significant differences in risk of secondary outcomes between English and other language preference were found.

DISCUSSION

After adjusting for confounders, this analysis demonstrates a decreased risk of cesarean delivery among women who do not have an English language preference at one institution. This disparity in cesarean delivery rates in an NTSV population warrants future research, raising the question of what clinical and social factors may be contributing to these lower cesarean delivery rates.

"Are They Saying It How I'm Saying It?" A Qualitative Study of Language Barriers and Disparities in Hospice Enrollment

CONTEXT

Language barriers contribute significantly to disparities in end-of-life (EOL) care. However, the mechanisms by which these barriers impact hospice care remains underexamined.

OBJECTIVES

To gain a nuanced understanding of how language barriers and interpretation contribute to disparities in hospice enrollment and hospice care for patients with limited English proficiency.

METHODS

Qualitative, individual interviews were conducted with a variety of stakeholders regarding barriers to quality EOL care in diverse patient populations. Interviews were audiorecorded and transcribed verbatim. Data were coded using NVivo 11 (QSR International Pty Ltd., Melbourne, Australia). Three researchers analyzed all data related to language barriers, first individually, then in group meetings, using a grounded theory approach, until they reached consensus regarding themes. Institutional review board approval was obtained.

RESULTS

Twenty-two participants included six nurses/certified nursing assistants, five physicians, three administrators, three social workers, three patient caregivers, and two chaplains, self-identifying from a variety of racial/ethnic backgrounds. Three themes emerged regarding language barriers: 1) structural barriers inhibit access to interpreters; 2) variability in accuracy of translation of EOL concepts exacerbates language barriers; and 3) interpreters' style and manner influence communication efficacy during complex conversations about prognosis, goals of care, and hospice. Our theoretical model derived from the data suggests that Theme 1 is foundational and common to other medical settings. However, Theme 2 and particularly Theme 3 appear especially critical for hospice enrollment and care.

CONCLUSION

Language barriers present unique challenges in hospice care because of the nuance and compassion required for delicate goals of care and EOL conversations. Reducing disparities requires addressing each level of this multilayered barrier.

Treating immigrant patients in psychiatric emergency rooms

We examine whether patient variables (geographic origin, gender, Spanish language proficiency) and subjective clinician aspects in emergency department psychiatric encounters (diagnostic certainty, clinician's comfort level with patient) are associated with diagnosis and the use of coercive measures. Using a descriptive cross-sectional design, we recorded 467 visits (400 foreign-born and 67 native-born patients) in hospital psychiatry emergency rooms (ERs) in Barcelona between 2007 and 2015. We first assessed the association of patient variables and subjective clinician aspects of psychiatric encounters with service use outcomes and with mental illness diagnosis. Fitted logistic models predicted the likelihood of service use outcomes and estimated the propensity of receiving each diagnosis. The null model evaluated the role of patient's geographical origin, while the full model evaluated the additional roles of patient's gender and language, the clinician's assessment of the influence of culture in diagnosis, and clinician comfort with two outcomes: patient's diagnosis and use of coercive measures in the ER. Women were less likely to receive coercive measures or intramuscular medications compared to men. Significant ethnic/racial and gender differences were found in receiving certain diagnoses. Additionally, a patient's lower Spanish proficiency was correlated with a higher probability of receiving a psychosis diagnosis. The clinician's level of diagnostic certainty was also positively correlated with increasing clinician-reported comfort with patient. Overall, ethnic factors and the subjective aspects of psychiatric encounters were found to influence diagnosis and the use of coercive measures. Cultural competency programs and interpreter services within psychiatric ER settings should thus be required.

"If at Least the Patient Could Not Be Forgotten About": Communication in the Emergency Department as a Predictor of Patient Satisfaction

Press Ganey survey data are used by institutions to understand patient experiences in the emergency department (ED). The present mixed-methods retrospective cohort study examined the effects of hallway placement, pain management reporting, communication approaches, time spent in the ED, and other demographic variables on predicting satisfaction ratings of doctors, nurses, and overall ED care. A total of 4940 patient responses between January 1, 2012, and December 31, 2017, were analyzed from 2 EDs associated with an academic institution and tertiary care center. Consensus coding was used to qualitatively capture patient responses that relate to communication issues pertaining to care/empathy and understandings of ED procedures. After controlling for multiple factors, hallway placement, pain management, and understanding of ED procedures were associated with higher odds of negative ratings for doctors, nurses, and overall assessment. Issues with patient communication, particularly regarding understanding of ED procedures, were found to be a strong predictor of negative ratings of doctors, nurses, and overall care. These findings point to the improvements in communication as a potential point of intervention in mitigating negative patient experiences.