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Chu JN, Wong J, Bardach NS, Allen IE, Barr-Walker J, Sierra M, Sarkar U, Khoong EC. Association between language discordance and unplanned hospital readmissions or emergency department revisits: a systematic review and meta-analysis. BMJ Qual Saf 2023:bmjqs-2023-016295. [PMID: 38160059 DOI: 10.1136/bmjqs-2023-016295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 10/25/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND AND OBJECTIVE Studies conflict about whether language discordance increases rates of hospital readmissions or emergency department (ED) revisits for adult and paediatric patients. The literature was systematically reviewed to investigate the association between language discordance and hospital readmission and ED revisit rates. DATA SOURCES Searches were performed in PubMed, Embase and Google Scholar on 21 January 2021, and updated on 27 October 2022. No date or language limits were used. STUDY SELECTION Articles that (1) were peer-reviewed publications; (2) contained data about patient or parental language skills and (3) included either unplanned hospital readmission or ED revisit as one of the outcomes, were screened for inclusion. Articles were excluded if: unavailable in English; contained no primary data or inaccessible in a full-text form (eg, abstract only). DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data using Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping reviews guidelines. We used the Newcastle-Ottawa Scale to assess data quality. Data were pooled using DerSimonian and Laird random-effects models. We performed a meta-analysis of 18 adult studies for 28-day or 30-day hospital readmission; 7 adult studies of 30-day ED revisits and 5 paediatric studies of 72-hour or 7-day ED revisits. We also conducted a stratified analysis by whether access to interpretation services was verified/provided for the adult readmission analysis. MAIN OUTCOMES AND MEASURES Odds of hospital readmissions within a 28-day or 30-day period and ED revisits within a 7-day period. RESULTS We generated 4830 citations from all data sources, of which 49 (12 paediatric; 36 adult; 1 with both adult and paediatric) were included. In our meta-analysis, language discordant adult patients had increased odds of hospital readmissions (OR 1.11, 95% CI 1.04 to 1.18). Among the 4 studies that verified interpretation services for language discordant patient-clinician interactions, there was no difference in readmission (OR 0.90, 95% CI 0.77 to 1.05), while studies that did not specify interpretation service access/use found higher odds of readmission (OR 1.14, 95% CI 1.06 to 1.22). Adult patients with a non-dominant language preference had higher odds of ED revisits (OR 1.07, 95% CI 1.004 to 1.152) compared with adults with a dominant language preference. In 5 paediatric studies, children of parents language discordant with providers had higher odds of ED revisits at 72 hours (OR 1.12, 95% CI 1.05 to 1.19) and 7 days (OR 1.02, 95% CI 1.01 to 1.03) compared with patients whose parents had language concordant communications. DISCUSSION Adult patients with a non-dominant language preference have more hospital readmissions and ED revisits, and children with parents who have a non-dominant language preference have more ED revisits. Providing interpretation services may mitigate the impact of language discordance and reduce hospital readmissions among adult patients. PROSPERO REGISTRATION NUMBER CRD42022302871.
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Affiliation(s)
- Janet N Chu
- Medicine, University of California San Francisco, San Francisco, California, USA
| | - Jeanette Wong
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Naomi S Bardach
- Pediatrics, University of California San Francisco, San Francisco, California, USA
- Philip R Lee Institute for Health Policy Studies, San Francisco, California, USA
| | - Isabel Elaine Allen
- Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Jill Barr-Walker
- Zuckerberg San Francisco General Hospital and Trauma Center Library, San Francisco, California, USA
| | - Maribel Sierra
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Tendo, San Francisco, California, USA
| | - Urmimala Sarkar
- Medicine, University of California San Francisco, San Francisco, California, USA
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Elaine C Khoong
- Medicine, University of California San Francisco, San Francisco, California, USA
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
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Teeple S, Smith A, Toerper M, Levin S, Halpern S, Badaki-Makun O, Hinson J. Exploring the impact of missingness on racial disparities in predictive performance of a machine learning model for emergency department triage. JAMIA Open 2023; 6:ooad107. [PMID: 38638298 PMCID: PMC11025382 DOI: 10.1093/jamiaopen/ooad107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/15/2023] [Accepted: 12/06/2023] [Indexed: 04/20/2024] Open
Abstract
Objective To investigate how missing data in the patient problem list may impact racial disparities in the predictive performance of a machine learning (ML) model for emergency department (ED) triage. Materials and Methods Racial disparities may exist in the missingness of EHR data (eg, systematic differences in access, testing, and/or treatment) that can impact model predictions across racialized patient groups. We use an ML model that predicts patients' risk for adverse events to produce triage-level recommendations, patterned after a clinical decision support tool deployed at multiple EDs. We compared the model's predictive performance on sets of observed (problem list data at the point of triage) versus manipulated (updated to the more complete problem list at the end of the encounter) test data. These differences were compared between Black and non-Hispanic White patient groups using multiple performance measures relevant to health equity. Results There were modest, but significant, changes in predictive performance comparing the observed to manipulated models across both Black and non-Hispanic White patient groups; c-statistic improvement ranged between 0.027 and 0.058. The manipulation produced no between-group differences in c-statistic by race. However, there were small between-group differences in other performance measures, with greater change for non-Hispanic White patients. Discussion Problem list missingness impacted model performance for both patient groups, with marginal differences detected by race. Conclusion Further exploration is needed to examine how missingness may contribute to racial disparities in clinical model predictions across settings. The novel manipulation method demonstrated may aid future research.
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Affiliation(s)
- Stephanie Teeple
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19143, United States
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21218, United States
- Clinical Decision Support Solutions, Beckman Coulter, Brea, CA 92821, United States
| | - Matthew Toerper
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21218, United States
- Clinical Decision Support Solutions, Beckman Coulter, Brea, CA 92821, United States
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21218, United States
- Clinical Decision Support Solutions, Beckman Coulter, Brea, CA 92821, United States
| | - Scott Halpern
- Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Oluwakemi Badaki-Makun
- Department of Pediatric Emergency Medicine, Johns Hopkins University, Baltimore, MD 21218, United States
| | - Jeremiah Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21218, United States
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Teeple S, Chivers C, Linn KA, Halpern SD, Eneanya N, Draugelis M, Courtright K. Evaluating equity in performance of an electronic health record-based 6-month mortality risk model to trigger palliative care consultation: a retrospective model validation analysis. BMJ Qual Saf 2023; 32:503-516. [PMID: 37001995 PMCID: PMC10898860 DOI: 10.1136/bmjqs-2022-015173] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 03/08/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE Evaluate predictive performance of an electronic health record (EHR)-based, inpatient 6-month mortality risk model developed to trigger palliative care consultation among patient groups stratified by age, race, ethnicity, insurance and socioeconomic status (SES), which may vary due to social forces (eg, racism) that shape health, healthcare and health data. DESIGN Retrospective evaluation of prediction model. SETTING Three urban hospitals within a single health system. PARTICIPANTS All patients ≥18 years admitted between 1 January and 31 December 2017, excluding observation, obstetric, rehabilitation and hospice (n=58 464 encounters, 41 327 patients). MAIN OUTCOME MEASURES General performance metrics (c-statistic, integrated calibration index (ICI), Brier Score) and additional measures relevant to health equity (accuracy, false positive rate (FPR), false negative rate (FNR)). RESULTS For black versus non-Hispanic white patients, the model's accuracy was higher (0.051, 95% CI 0.044 to 0.059), FPR lower (-0.060, 95% CI -0.067 to -0.052) and FNR higher (0.049, 95% CI 0.023 to 0.078). A similar pattern was observed among patients who were Hispanic, younger, with Medicaid/missing insurance, or living in low SES zip codes. No consistent differences emerged in c-statistic, ICI or Brier Score. Younger age had the second-largest effect size in the mortality prediction model, and there were large standardised group differences in age (eg, 0.32 for non-Hispanic white versus black patients), suggesting age may contribute to systematic differences in the predicted probabilities between groups. CONCLUSIONS An EHR-based mortality risk model was less likely to identify some marginalised patients as potentially benefiting from palliative care, with younger age pinpointed as a possible mechanism. Evaluating predictive performance is a critical preliminary step in addressing algorithmic inequities in healthcare, which must also include evaluating clinical impact, and governance and regulatory structures for oversight, monitoring and accountability.
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Affiliation(s)
- Stephanie Teeple
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Kristin A Linn
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott D Halpern
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nwamaka Eneanya
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Katherine Courtright
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Zeidan AJ, Smith M, Leff R, Cordone A, Moran TP, Brackett A, Agrawal P. Limited English Proficiency as a Barrier to Inclusion in Emergency Medicine-Based Clinical Stroke Research. J Immigr Minor Health 2023; 25:181-189. [PMID: 35652977 DOI: 10.1007/s10903-022-01368-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 04/08/2022] [Accepted: 05/04/2022] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Amy J Zeidan
- Department of Emergency Medicine, Emory University School of Medicine, 80 Jesse Hill Junior Drive S#, 30303, Atlanta, GA, USA.
| | | | - Rebecca Leff
- Department of Emergency Medicine, Mayo Clinic, New York, USA
| | - Alexis Cordone
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Tim P Moran
- Department of Emergency Medicine, Emory University School of Medicine, 80 Jesse Hill Junior Drive S#, 30303, Atlanta, GA, USA
| | | | - Pooja Agrawal
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
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Moorthie S, Peacey V, Evans S, Phillips V, Roman-Urrestarazu A, Brayne C, Lafortune L. A Scoping Review of Approaches to Improving Quality of Data Relating to Health Inequalities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15874. [PMID: 36497947 PMCID: PMC9740714 DOI: 10.3390/ijerph192315874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/21/2022] [Accepted: 11/25/2022] [Indexed: 06/17/2023]
Abstract
Identifying and monitoring of health inequalities requires good-quality data. The aim of this work is to systematically review the evidence base on approaches taken within the healthcare context to improve the quality of data for the identification and monitoring of health inequalities and describe the evidence base on the effectiveness of such approaches or recommendations. Peer-reviewed scientific journal publications, as well as grey literature, were included in this review if they described approaches and/or made recommendations to improve data quality relating to the identification and monitoring of health inequalities. A thematic analysis was undertaken of included papers to identify themes, and a narrative synthesis approach was used to summarise findings. Fifty-seven papers were included describing a variety of approaches. These approaches were grouped under four themes: policy and legislation, wider actions that enable implementation of policies, data collection instruments and systems, and methodological approaches. Our findings indicate that a variety of mechanisms can be used to improve the quality of data on health inequalities at different stages (prior to, during, and after data collection). These findings can inform us of actions that can be taken by those working in local health and care services on approaches to improving the quality of data on health inequalities.
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Affiliation(s)
- Sowmiya Moorthie
- Cambridge Public Health, Interdisciplinary Research Centre, University of Cambridge, Cambridge CB2 OSZ, UK
| | - Vicki Peacey
- Cambridgeshire County Council, Alconbury, Huntingdon PE28 4YE, UK
| | - Sian Evans
- Local Knowledge Intelligence Service (LKIS) East, Office for Health Improvements and Disparities, UK
| | - Veronica Phillips
- Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, UK
| | - Andres Roman-Urrestarazu
- Cambridge Public Health, Interdisciplinary Research Centre, University of Cambridge, Cambridge CB2 OSZ, UK
| | - Carol Brayne
- Cambridge Public Health, Interdisciplinary Research Centre, University of Cambridge, Cambridge CB2 OSZ, UK
| | - Louise Lafortune
- Cambridge Public Health, Interdisciplinary Research Centre, University of Cambridge, Cambridge CB2 OSZ, UK
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Gore A, Truche P, Iskerskiy A, Ortega G, Peck G. Inaccurate Ethnicity and Race Classification of Hispanics Following Trauma Admission. J Surg Res 2021; 268:687-695. [PMID: 34482009 DOI: 10.1016/j.jss.2021.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 06/25/2021] [Accepted: 08/04/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Race and ethnicity are associated with disparate trauma outcomes. This study seeks to characterize accuracy of trauma registry classification of patient race and ethnicity and to identify factors associated with misclassification. METHODS A prospective observational study of patients admitted to an urban Level 1 trauma center was conducted over a 6-mo period. Race and ethnicity data recorded in the trauma registry were compared to patients' self-identifying data obtained through in-person interviews. Logistic regression determined rates of discordant race and ethnicity between trauma registry and patient self-identification processes, and identified factors independently associated with misclassification. RESULTS A total of 444 patients were recruited. 98 (22%) self-identified as Hispanic/Latino. 45 patients self-identifying as Hispanic (45.9%) had inaccurately recorded ethnicity in the trauma registry. There was an increased odds of ethnicity misclassification in younger patients (OR 0.97, P < 0.01) and Spanish-only speakers (OR 11.80, P < 0.001). A decreased odds was found in males (OR 0.43, P < 0.05). No factors increased odds of racial misclassification, while dual English/Spanish speakers (OR 0.05, P < 0.01) wereas found to have decreased odds. Neither ethnicity nor race misclassification was associated with clinical variables. New racial self-identification was observed with 75% of patients who self-identified ethnically as Hispanic also self-identifying racially as Hispanic. CONCLUSIONS Hispanic trauma patients have racial and ethnic misclassifications regardless of clinical status. Racial and ethnic identification is not sufficiently captured by current standardized questionnaires. Accuracy of hospital level racial data is important for local and national policies to address trauma disparities.
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Affiliation(s)
- Ankita Gore
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Paul Truche
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
| | - Anton Iskerskiy
- Rutgers School of Graduate Studies, New Brunswick, New Jersey
| | - Gezzer Ortega
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory Peck
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, New Brunswick, New Jersey.
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Medical Spanish in US Medical Schools: a National Survey to Examine Existing Programs. J Gen Intern Med 2021; 36:2724-2730. [PMID: 33782890 PMCID: PMC8390604 DOI: 10.1007/s11606-021-06735-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Most medical schools offer medical Spanish education to teach patient-physician communication skills with the growing Spanish-speaking population. Medical Spanish courses that lack basic standards of curricular structure, faculty educators, learner assessment, and institutional credit may increase student confidence without sufficiently improving skills, inadvertently exacerbating communication problems with linguistic minority patients. OBJECTIVE To conduct a national environmental scan of US medical schools' medical Spanish educational efforts, examine to what extent existing efforts meet basic standards, and identify next steps in improving the quality of medical Spanish education. DESIGN Data were collected from March to November 2019 using an IRB-exempt online 6-item primary and 14-item secondary survey. PARTICIPANTS All deans of the Association of American Medical Colleges member US medical schools were invited to complete the primary survey. If a medical Spanish educator or leader was identified, that person was sent the secondary survey. MAIN MEASURES The presence of medical Spanish educational programs and, when present, whether the programs met four basic standards: formal curricular structure, faculty educator, learner assessment, and course credit. KEY RESULTS Seventy-nine percent of medical schools (125 out of 158) responded to either or both the primary and/or secondary surveys. Among participating schools, 78% (98/125) of medical schools offered medical Spanish programming; of those, 21% (21/98) met all basic standards. Likelihood of meeting all basic standards did not significantly differ by location, school size, or funding type. Fifty-four percent (53/98) report formal medical Spanish curricula, 69% (68/98) have faculty instructors, 57% (56/98) include post-course assessment, and 31% (30/98) provide course credit. CONCLUSIONS Recommended next steps for medical schools include formalizing medical Spanish courses as electives or required curricula; hiring and/or training faculty educators; incorporating learner assessment; and granting credit for student course completion. Future studies should evaluate implementation strategies to establish best practice recommendations beyond basic standards.
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Ortega P, Shin TM, Martínez GA. Rethinking the Term "Limited English Proficiency" to Improve Language-Appropriate Healthcare for All. J Immigr Minor Health 2021; 24:799-805. [PMID: 34328602 PMCID: PMC8323079 DOI: 10.1007/s10903-021-01257-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2021] [Indexed: 11/28/2022]
Abstract
The concept of limited English proficiency (LEP) presents significant challenges when applied to the healthcare needs of the diverse and growing multilingual population in the U.S. We expound on the following ways in which the concept of LEP is problematic: the ethnocentric notion of a "primary language," the ambiguous idea of "limited ability," and the deficit-oriented construct of "language assistance." We provide examples that illustrate the negative healthcare impact of LEP terminology, including the unaccounted-for complexities of health communication within the concept of "primary language," the "limited abilities" of health professionals whose language skills are often unassessed, and the ignored role of "language assistance" resources such as interpreters as essential collaborators. Finally, we propose rethinking LEP by (a) reframing patient language using the term non-English language preference and (b) assessing health professional non-English language skills. These actionable strategies have the potential to improve language-appropriate healthcare for diverse populations.
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Affiliation(s)
- Pilar Ortega
- Departments of Medical Education and Emergency Medicine, University of Illinois College of Medicine, 808 S. Wood Street, MC 591, Chicago, IL, 60612, USA.
| | - Tiffany M Shin
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Glenn A Martínez
- Department of Modern Languages and Literatures, University of Texas at San Antonio, San Antonio, TX, USA
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Rajaram A, Thomas D, Sallam F, Verma AA, Rawal S. Accuracy of the Preferred Language Field in the Electronic Health Records of Two Canadian Hospitals. Appl Clin Inform 2020; 11:644-649. [PMID: 32998169 DOI: 10.1055/s-0040-1715896] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND The collection of race, ethnicity, and language (REaL) data from patients is advocated as a first step to identify, monitor, and improve health inequities. As a result, many health care institutions collect patients' preferred languages in their electronic health records (EHRs). These data may be used in clinical care, research, and quality improvement. However, the accuracy of EHR language data are rarely assessed. OBJECTIVES This study aimed to audit the accuracy of EHR language data at two academic hospitals in Toronto, Ontario, Canada. METHODS The EHR language was compared with a patient's stated preferred language by interview. Language was dichotomized to English or non-English. Agreement between language documented in the EHR and patient-reported preferred language was calculated using sensitivity, specificity, and positive predictive value (PPV). RESULTS A total of 323 patients were interviewed, including 96 with a stated non-English preferred language. The sensitivity of the EHR for English-language preference was high at both hospitals: 100% at hospital A with a PPV of 88%, and 99% at hospital B with a PPV of 85%. However, the sensitivity of the EHR for non-English preference differed greatly between the two hospitals. The sensitivity was 81% with a PPV of 100% at hospital A and the sensitivity was 12% with a PPV of 60% at hospital B. CONCLUSION The accuracy of the EHR for identifying non-English language preference differed greatly between the hospitals studied. Language data must be accurate for it to be used, and regular quality assurance is required.
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Affiliation(s)
- Akshay Rajaram
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Daniel Thomas
- School of Medicine, University College Cork, Cork, Ireland
| | - Faten Sallam
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Amol A Verma
- Li Ka Shing Centre for Healthcare Analytics Research and Training and Division of General Internal Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shail Rawal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of General Internal Medicine, University Health Network, Toronto, Ontario, Canada
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Liao L, Chung S, Altamirano J, Garcia L, Fassiotto M, Maldonado B, Heidenreich P, Palaniappan L. The association between Asian patient race/ethnicity and lower satisfaction scores. BMC Health Serv Res 2020; 20:678. [PMID: 32698825 PMCID: PMC7374891 DOI: 10.1186/s12913-020-05534-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/13/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patient satisfaction is increasingly being used to assess, and financially reward, provider performance. Previous studies suggest that race/ethnicity (R/E) may impact satisfaction, yet few practices adjust for patient R/E. The objective of this study is to examine R/E differences in patient satisfaction ratings and how these differences impact provider rankings. METHODS Patient satisfaction survey data linked to electronic health records from two large outpatient centers in northern California - a non-profit organization of community-based clinics (Site A) and an academic medical center (Site B) - was collected and analyzed. Participants consisted of adult patients who received outpatient care at Site A from December 2010 to November 2014 and Site B from March 2013 to August 2014, and completed Press-Ganey Medical Practice Survey questionnaires (N = 216,392 (Site A) and 30,690 (Site B)). Self-reported non-Hispanic white (NHW), Black, Latino, and Asian patients were studied. For six questions each representing a survey subdomain, favorable ratings were defined as top-box ("very good") compared to all other categories ("very poor," "poor," "fair," and "good"). Using multivariable logistic regression with provider random effects, we assessed whether the likelihood of giving favorable ratings differed by patient R/E, adjusting for patient age and sex. RESULTS Asian, younger and female patients provided less favorable ratings than other R/E, older and male patients. After adjustment, Asian patients were less likely than NHW patients to provide top-box ratings to the overall assessment question "likelihood of recommending this practice to others" (Site A: Asian predicted probability (PP) 0.680, 95% confidence interval (CI): 0.675-0.685 compared to NHW PP 0.820, 95% CI: 0.818-0.822; Site B: Asian PP 0.734, 95% CI: 0.733-0.736 compared to NHW PP 0.859, 95% CI: 0.859-0.859). The effect sizes for Asian R/E were greater than the effect sizes for older age and female sex. An absolute 3% decrease in mean composite score between providers serving different percentages of Asian patients translated to an absolute 40% drop in national ranking. CONCLUSIONS Patient satisfaction scores may need to be adjusted for patient R/E, particularly for providers caring for high panel percentages of Asian patients.
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Affiliation(s)
- Lillian Liao
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, USA
- Columbia University Vagelos College of Physicians and Surgeons, 50 Haven Avenue Box #B-26, New York, NY10032 USA
| | - Sukyung Chung
- Palo Alto Medical Foundation Research Institute, Palo Alto, USA
| | - Jonathan Altamirano
- Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, USA
| | - Luis Garcia
- Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, USA
| | - Magali Fassiotto
- Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, USA
| | - Bonnie Maldonado
- Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, USA
| | - Paul Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, USA
| | - Latha Palaniappan
- Department of Medicine, Stanford University School of Medicine, Stanford, USA
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Ortega P, Diamond L, Alemán MA, Fatás-Cabeza J, Magaña D, Pazo V, Pérez N, Girotti JA, Ríos E. Medical Spanish Standardization in U.S. Medical Schools: Consensus Statement From a Multidisciplinary Expert Panel. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:22-31. [PMID: 31365394 DOI: 10.1097/acm.0000000000002917] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Medical Spanish (MS) education is in growing demand from U.S. medical students, providers, and health systems, but there are no standard recommendations for how to structure the curricula, evaluate programs, or assess provider performance or linguistic competence. This gap in medical education and assessment jeopardizes health care communication with Hispanic/Latino patients and poses significant quality and safety risks. The National Hispanic Health Foundation and University of Illinois College of Medicine convened a multidisciplinary expert panel in March 2018 to define national standards for the teaching and application of MS skills in patient-physician communication, establish curricular and competency guidelines for MS courses in medical schools, propose best practices for MS skill assessment and certification, and identify next steps needed for the implementation of the proposed national standards. Experts agreed on the following consensus recommendations: (1) create a Medical Spanish Taskforce to, among other things, define educational standards; (2) integrate MS educational initiatives with government-funded research and training efforts as a strategy to improve Hispanic/Latino health; (3) standardize core MS learner competencies; (4) propose a consensus core curricular structure for MS courses in medical schools; (5) assess MS learner skills through standardized patient encounters and develop a national certification exam; and (6) develop standardized evaluation and data collection processes for MS programs. MS education and assessment should be standardized and evaluated with a robust interinstitutional medical education research strategy that includes collaboration with multidisciplinary stakeholders to ensure linguistically appropriate care for the growing Spanish-speaking U.S. population.
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Affiliation(s)
- Pilar Ortega
- P. Ortega is clinical assistant professor, Departments of Emergency Medicine and Medical Education, University of Illinois College of Medicine, Chicago, Illinois; ORCID: http://orcid.org/0000-0002-5136-1805. L. Diamond is assistant attending, Department of Psychiatry and Behavioral Sciences, Immigrant Health and Cancer Disparities Service, Hospital Medicine Service, Memorial Sloan Kettering Cancer Center, New York, New York. M.A. Alemán is professor, Department of Medicine, University of North Carolina School of Medicine, and director, Comprehensive Advanced Medical Program of Spanish, Chapel Hill, North Carolina. J. Fatás-Cabeza is associate professor, Department of Spanish and Portuguese, and director, Undergraduate Translation and Interpretation Program, University of Arizona, Tucson, Arizona. D. Magaña is assistant professor, Department of Literature, Languages and Cultures, University of California, Merced, Merced, California. V. Pazo is instructor, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, and course director, Medical Spanish, Harvard University, Boston, Massachusetts. N. Pérez is director, School of Medicine Special Programs and Hispanic Center of Excellence, University of Texas Medical Branch, Galveston, Texas. J.A. Girotti is assistant professor, Department of Medical Education, and director, Hispanic Center of Excellence, University of Illinois College of Medicine, Chicago, Illinois. E. Ríos is president, National Hispanic Health Foundation, Washington, DC
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Garcia LC, Chung S, Liao L, Altamirano J, Fassiotto M, Maldonado B, Heidenreich P, Palaniappan L. Comparison of Outpatient Satisfaction Survey Scores for Asian Physicians and Non-Hispanic White Physicians. JAMA Netw Open 2019; 2:e190027. [PMID: 30794297 PMCID: PMC6484609 DOI: 10.1001/jamanetworkopen.2019.0027] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
IMPORTANCE Patient satisfaction scores are used to inform decisions about physician compensation, and there remains a lack of consensus regarding the need to adjust scores for patient race/ethnicity. Previous research suggests that patients prefer physicians of the same race/ethnicity as themselves and that Asian patients provide lower satisfaction scores than non-Hispanic white patients. OBJECTIVE To examine whether Asian physicians receive less favorable patient satisfaction scores relative to non-Hispanic white physicians. DESIGN, SETTING, AND PARTICIPANTS This population-based survey study used data from Press Ganey Outpatient Medical Practice Surveys collected from December 1, 2010, to November 30, 2014, which included 149 775 patient survey responses for 962 physicians. Every month, 5 patients per physician were randomly selected to complete a satisfaction survey after an outpatient visit. Hierarchical multivariable logistic regression was used to examine the association between Asian race/ethnicity of the physician and racial/ethnic concordance of the patient with the probability of receiving the highest score on the survey item rating the likelihood to recommend the physician. Statistical analysis was performed from April 2 to August 27, 2018. EXPOSURES Physician characteristics included race/ethnicity, sex, years in practice, and proportion of Asian patient responders. Patient characteristics included race/ethnicity, sex, age, and language spoken. MAIN OUTCOMES AND MEASURES The highest score (a score of 5 on a 1-5 Likert scale, where 1 indicates very poor and 5 indicates very good) on the survey item rating the likelihood to recommend the physician on the Press Ganey Outpatient Medical Practice Survey. RESULTS Of the 962 physicians in this study, 515 (53.5%) were women; physicians had a mean (SD) of 19.9 (9.1) years of experience since graduating medical school; 573 (59.6%) were white, and 350 (36.4%) were Asian. In unadjusted analyses, the odds of receiving the highest score on the survey item rating the likelihood to recommend the physician were lower for Asian physicians compared with non-Hispanic white physicians (odds ratio, 0.78; 95% CI, 0.72-0.84; P < .001). This association was not significant after adjusting for patient characteristics, including patient race/ethnicity. However, Asian patients were less likely to give the highest scores relative to non-Hispanic white patients (odds ratio, 0.56; 95% CI, 0.54-0.58; P < .001), regardless of physician race/ethnicity. CONCLUSIONS AND RELEVANCE This study suggests that Asian physicians may be more likely to receive lower patient satisfaction scores because they serve a greater proportion of Asian patients. Patient satisfaction scores should be adjusted for patient race/ethnicity.
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Affiliation(s)
- Luis C. Garcia
- Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, California
| | - Sukyung Chung
- Palo Alto Medical Foundation Research Institute, Palo Alto, California
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Lily Liao
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Jonathan Altamirano
- Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, California
| | - Magali Fassiotto
- Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, California
| | - Bonnie Maldonado
- Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, California
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Paul Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Latha Palaniappan
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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Chung S, Mujal G, Liang L, Palaniappan LP, Frosch DL. Racial/ethnic differences in reporting versus rating of healthcare experiences. Medicine (Baltimore) 2018; 97:e13604. [PMID: 30558033 PMCID: PMC6320096 DOI: 10.1097/md.0000000000013604] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Asians are reported to have poorer healthcare experience than non-Hispanic Whites (NHWs), but the sources of the differences are not understood. One explanation is Asian's reluctance to choose extreme responses in survey. We thus sought to compare NHW-Asian differences in responses to healthcare experience surveys when asked to report versus rate their experiences. Patients of an outpatient care system in 2013 to 2014 in the United States were studied. Patient experience surveys were sent after randomly selected clinic visits. Responses from 6 major Asian subgroups and NHWs were included (N = 61,115). The surveys used a combined questionnaire of Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) and Press Ganey surveys. CG-CAHPS questions are framed as "reporting" and Press Ganey questions as "rating" of experiences. We compared the proportion of favorable (or top box) responses to 2 related questions, one from CG-CAHPS and another from Press Ganey, and assessed racial/ethnic differences when using each of the 2 related questions, using a Pearson chi-squared test for independence. All Asian subgroups were less likely to select top box than NHWs for all questions. The Asian-NHW differences in 'rating" questions were larger than the difference in related "reporting" questions. Of those who chose top box to CG-CAHPS questions (e.g., "Yes" on a question asking "Waited < 15 minutes"), their responses to related Press Ganey questions varied widely: 47% to 57% of Asian subgroups versus 67% of NHWs rated wait time as "Very good." The extent of racial/ethnic differences in patient-reported experiences varies based on how questions are framed. The observed poorer experiences by Asians are in part explained by their worse rating of similar objectively measurable experiences.
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Affiliation(s)
- Sukyung Chung
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA
| | - Gabriella Mujal
- Department of Health Administration, Saint Louis University, St Louis, MO
| | - Lily Liang
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA
| | | | - Dominick L. Frosch
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA
- Department of Medicine, University of California Los Angeles, Los Angeles, CA
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Ortega P. Spanish Language Concordance in U.S. Medical Care: A Multifaceted Challenge and Call to Action. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:1276-1280. [PMID: 29877912 DOI: 10.1097/acm.0000000000002307] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Patient-physician language discordance within the growing Spanish-speaking patient population in the United States presents a significant challenge for health systems. The Civil Rights Act, an Executive Order, and federal standards establish legal requirements regarding patients' legal right to access medical care in their language of origin and to culturally and linguistically appropriate services, and national competency standards for undergraduate and graduate medical education and licensing examinations support the importance of patient-physician communication. However, no requirements or guidelines currently exist for medical Spanish educational resources, and there is no standardized process to assess the competency of medical students and physicians who use Spanish in patient care. Relatedly, existing data regarding current medical Spanish educational resources are limited, and Spanish proficiency evaluations are often based on self-assessments. Future efforts should use a multifaceted approach to address this complex challenge. A standardized process for Spanish-language-concordant medical care education and quality assurance should incorporate the validation of medical Spanish educational resources, competency requirements for medical usage of Spanish, an incentivized certification process for physicians who achieve medical Spanish competency, and health system updates that include routine collection of language concordance data and designation of Hispanic-serving health centers.
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Affiliation(s)
- Pilar Ortega
- P. Ortega is assistant professor, Departments of Emergency Medicine and Medical Education, College of Medicine, University of Illinois at Chicago, Chicago, Illinois; ORCID: http://orcid.org/0000-0002-5136-1805
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Magaña López M, Bevans M, Wehrlen L, Yang L, Wallen GR. Discrepancies in Race and Ethnicity Documentation: a Potential Barrier in Identifying Racial and Ethnic Disparities. J Racial Ethn Health Disparities 2016; 4:10.1007/s40615-016-0283-3. [PMID: 27631381 PMCID: PMC5342943 DOI: 10.1007/s40615-016-0283-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/17/2016] [Accepted: 08/18/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Data collection on race and ethnicity is critical in the assessment of racial disparities related to health. Studies comparing clinical and administrative data show discrepancies in race documentation and attribution. METHODS Self-reported data from two studies were compared to demographics in the electronic health record (EHR) extracted from the Biomedical Translational Research Information System (BTRIS) repository. McNemar and Bhapkar analyses were conducted to quantify the agreement of ethnicity and race between self-reported and EHR data. Pearson's chi-square tests were used to explore the relationship between acculturation, length of time in the USA, country of residence, and how individuals self-reported their race. RESULTS The sample (n = 280) was predominantly female (52.1 %), with a mean age of 47 (SD ± 13.74), mean years in the USA were 12.8 (SD ± 11.67) and the majority were born outside of the USA. (55.6 %). Those who self-identified as Hispanic (n = 208) scored a mean of 5.5 (SD ± 3.07) on the short acculturation scale (SAS) that ranges 4 to 20; lower scores indicate less acculturation. A significant difference was found between the way race is reported in the electronic medical record and self-reported data among those people who identified as Hispanic, with significant differences in the white (p < 0.0001) and other (p < 0.0001) categories. CONCLUSIONS The misclassification of race is most frequent in those individuals who self-identified as Hispanic. As the Hispanic population in the USA continues to grow, understanding the factors that affect the way that individuals from this heterogeneous population self-report race may provide important guidance in tailoring care to address health disparities.
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Affiliation(s)
- M. Magaña López
- National Institutes of Health (NIH), Clinical Center, 10 Center Drive, Room 2B01, Bethesda, MD 20892 USA
| | - M. Bevans
- National Institutes of Health (NIH), Clinical Center, 10 Center Drive, Room 2B01, Bethesda, MD 20892 USA
| | - L. Wehrlen
- National Institutes of Health (NIH), Clinical Center, 10 Center Drive, Room 2B01, Bethesda, MD 20892 USA
| | - L. Yang
- National Institutes of Health (NIH), Clinical Center, 10 Center Drive, Room 2B01, Bethesda, MD 20892 USA
| | - G. R. Wallen
- National Institutes of Health (NIH), Clinical Center, 10 Center Drive, Room 2B01, Bethesda, MD 20892 USA
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Pu J, Zhao B, Wang EJ, Nimbal V, Osmundson S, Kunz L, Popat RA, Chung S, Palaniappan LP. Racial/Ethnic Differences in Gestational Diabetes Prevalence and Contribution of Common Risk Factors. Paediatr Perinat Epidemiol 2015; 29:436-43. [PMID: 26201385 PMCID: PMC6519933 DOI: 10.1111/ppe.12209] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The White House, the American Heart Association, the Agency for Healthcare Research and Quality, and the National Heart, Lung and Blood Institute have all recently acknowledged the need to disaggregate Asian American subgroups to better understand this heterogeneous racial group. This study aims to assess racial/ethnic differences in relative contribution of risk factors of gestational diabetes mellitus (GDM) among Asian subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese), Hispanics, non-Hispanic blacks, and non-Hispanic whites. METHODS Pregnant women in 2007-2012 were identified through California state birth certificate records and linked to the electronic health records in a large mixed-payer ambulatory care organisation in Northern California (n = 24 195). Relative risk and population attributable fraction (PAF) for specific racial/ethnic groups were calculated to assess the contributions of advanced maternal age, overweight/obesity (Centers for Disease Control and Prevention (CDC) standards and World Health Organization (WHO)/American Diabetes Association (ADA) body mass index cut-offs for Asians), family history of type 2 diabetes, and foreign-born status. RESULTS GDM was most prevalent among Asian Indians (19.3%). Relative risks were similar across all race/ethnic groups. Advanced maternal age had higher PAFs in non-Hispanic whites (22.5%) and Hispanics (22.7%). Meanwhile family history (Asian Indians 22.6%, Chinese 22.9%) and foreign-borne status (Chinese 40.2%, Filipinos 30.2%) had higher PAFs in Asian subgroups. Overweight/obesity was the most important GDM risk factor for non-Hispanic whites, Hispanics, Asian Indians, and Filipinos when the WHO/ADA cut-off points were applied. Advanced maternal age was the only risk factor studied that was modified by race/ethnicity, with non-Hispanic white and Hispanic women being more adversely affected than other racial/ethnic groups. CONCLUSIONS Overweight/obesity, advanced maternal age, family history of type 2 diabetes, and foreign-borne status are important risk factors for GDM. The relative contributions of these risk factors differ by race/ethnicity, mainly due to differences in population prevalence of these risk factors.
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Affiliation(s)
- Jia Pu
- Research Institute, Palo Alto Medical Foundation, Palo Alto, CA
| | - Beinan Zhao
- Research Institute, Palo Alto Medical Foundation, Palo Alto, CA
| | - Elsie J. Wang
- School of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Vani Nimbal
- Research Institute, Palo Alto Medical Foundation, Palo Alto, CA
| | - Sarah Osmundson
- Lucile Packard Children’s Hospital, Stanford University School of Medicine, Stanford, CA
| | - Liza Kunz
- Research Institute, Palo Alto Medical Foundation, Palo Alto, CA
| | - Rita A. Popat
- Division of Epidemiology, Department of Health Research and Policy, School of Medicine, Stanford University, Stanford, CA
| | - Sukyung Chung
- Research Institute, Palo Alto Medical Foundation, Palo Alto, CA
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de Silva KL, Tsai PJS, Kon LM, Hiraoka M, Kessel B, Seto T, Kaneshiro B. Third and fourth degree perineal injury after vaginal delivery: does race make a difference? HAWAI'I JOURNAL OF MEDICINE & PUBLIC HEALTH : A JOURNAL OF ASIA PACIFIC MEDICINE & PUBLIC HEALTH 2014; 73:80-83. [PMID: 24660124 PMCID: PMC3962033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Severe perineal injury (third and fourth degree laceration) at the time of vaginal delivery increases the risk of fecal incontinence, chronic perineal pain, and dyspareunia.1-5 Studies suggest the prevalence of severe perineal injury may vary by racial group.6 The purpose of the current study was to examine rates of severe perineal injury in different Asian and Pacific Islander subgroups. A retrospective cohort study was performed among all patients who had a vaginal delivery at Queens Medical Center in Honolulu, Hawai'i between January 1, 2002 and December 31, 2003. Demographic and health related variables were obtained for each participant. Maternal race/ethnicity (Japanese, Filipino, Chinese, other Asian, Part-Hawaiian/Hawaiian, Micronesian, other Pacific Islander, Caucasian, multiracial [non-Hawaiian], and other) was self-reported by the patient at the time admission. The significance of associations between racial/ethnic groups and demographic and health related variables was determined using chi-square tests for categorical variables and analysis of variance for continuous factors. Multiple logistic regression was performed to adjust for potential confounders when examining severe laceration rates. A total of 1842 subjects met inclusion criteria. The proportion of severe perineal lacerations did not differ significantly between racial groups. In the multiple logistic regression analysis, operative vaginal delivery was related to both race and severe perineal laceration. However, despite adjusting for this variable, race was not associated with an increased risk of having a severe laceration (P = .70). The results of this study indicate the risk of severe perineal laceration does not differ based on maternal race/ethnicity.
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Affiliation(s)
- Kanoe-Lehua de Silva
- Department of Obstetrics, Gynecology and Women's Health, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (KDS, PST, MH, B. Kessel, B. Kaneshiro)
| | - Pai-Jong Stacy Tsai
- Department of Obstetrics, Gynecology and Women's Health, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (KDS, PST, MH, B. Kessel, B. Kaneshiro)
| | - Leanne M Kon
- Department of Obstetrics, Gynecology and Women's Health, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (KDS, PST, MH, B. Kessel, B. Kaneshiro)
| | - Mark Hiraoka
- Department of Obstetrics, Gynecology and Women's Health, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (KDS, PST, MH, B. Kessel, B. Kaneshiro)
| | - Bruce Kessel
- Department of Obstetrics, Gynecology and Women's Health, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (KDS, PST, MH, B. Kessel, B. Kaneshiro)
| | - Todd Seto
- Department of Obstetrics, Gynecology and Women's Health, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (KDS, PST, MH, B. Kessel, B. Kaneshiro)
| | - Bliss Kaneshiro
- Department of Obstetrics, Gynecology and Women's Health, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (KDS, PST, MH, B. Kessel, B. Kaneshiro)
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Abstract
AIM Human involvement in the collection and entering of information into a database leads to a degree of error. The aim of this study was to assess the concordance between two individuals blinded from each other who independently collected information on the same set of patients and entered it into a colorectal neoplasia database. METHOD A colorectal research nurse and a surgeon independently maintained an electronic database on all new patients admitted with colorectal neoplasia under the surgeon over a 5-year period. Twenty-three key endpoints were selected from the database in order to determine the agreement between the two observers. The κ statistic (for nominal and ordinal data) and the concordance correlation coefficient (for interval data) were used to determine the level of agreement between the two data sets. RESULTS Both observers recorded 432 new referrals during this period. There was only complete concordance between the two databases with respect to the number of new patients and returns to theatre within 30 days. Nonetheless, there was almost perfect concordance between the two data sets for a majority of the endpoints. The most important areas of variance were in the length of stay (κ=0.78), the American Society of Anesthesiology grade (κ=0.41), emergency surgery (κ=0.36), nodal staging (κ=0.54) and time to recurrence (κ=0.77). CONCLUSION This study highlights a number of important areas of data inaccuracy in a prospective colorectal database. The inaccuracies were due to observer bias, issues of data interpretation, or just difficulty in collecting the information accurately.
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Affiliation(s)
- C Platell
- Colorectal Cancer Unit, St John of God Hospital, Subiaco, WA, Australia.
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Holland AT, Palaniappan LP. Problems with the collection and interpretation of Asian-American health data: omission, aggregation, and extrapolation. Ann Epidemiol 2012; 22:397-405. [PMID: 22625997 DOI: 10.1016/j.annepidem.2012.04.001] [Citation(s) in RCA: 169] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 03/31/2012] [Accepted: 04/06/2012] [Indexed: 11/30/2022]
Abstract
Asian-American citizens are the fastest growing racial/ethnic group in the United States. Nevertheless, data on Asian American health are scarce, and many health disparities for this population remain unknown. Much of our knowledge of Asian American health has been determined by studies in which investigators have either grouped Asian-American subjects together or examined one subgroup alone (e.g., Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese). National health surveys that collect information on Asian-American race/ethnicity frequently omit this population in research reports. When national health data are reported for Asian-American subjects, it is often reported for the aggregated group. This aggregation may mask differences between Asian-American subgroups. When health data are reported by Asian American subgroup, it is generally reported for one subgroup alone. In the Ni-Hon-San study, investigators examined cardiovascular disease in Japanese men living in Japan (Nippon; Ni), Honolulu, Hawaii (Hon), and San Francisco, CA (San). The findings from this study are often incorrectly extrapolated to other Asian-American subgroups. Recommendations to correct the errors associated with omission, aggregation, and extrapolation include: oversampling of Asian Americans, collection and reporting of race/ethnicity data by Asian-American subgroup, and acknowledgement of significant heterogeneity among Asian American subgroups when interpreting data.
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Affiliation(s)
- Ariel T Holland
- Health Policy Research, Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
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