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BACKGROUND:Twenty-five million people in the United States have limited English proficiency (LEP); this growing and aging population experiences worse outcomes when hospitalized. Federal requirements that hospitals provide language access services are very challenging to implement in the fast-paced, 24-hour hospital environment. OBJECTIVE:To determine if increasing access to professional interpreters improves hospital outcomes for older patients with LEP. DESIGN:Natural experiment on a medicine floor of an academic hospital. PARTICIPANTS:Patients age 50 years or above discharged between January 15, 2007 and January 15, 2010. EXPOSURE:Dual-handset interpreter telephone at every bedside July 15, 2008 to Mar 14, 2009. OUTCOME MEASURES:Thirty-day readmission, length of stay, estimated hospital expenditures. RESULTS:Of 8077 discharges, 1963 were for LEP, and 6114 for English proficient patients. There was a significant decrease in observed 30-day readmission rates for the LEP group during the 8-month intervention period compared with 18 months preintervention (17.8% vs. 13.4%); at the same time English proficient readmission rates increased (16.7% vs. 19.7%); results remained significant in adjusted analyses. This improved readmission outcome for the LEP group was not maintained during the subsequent postintervention period when the telephones became less accessible. There was no significant intervention impact on length of stay in either unadjusted or adjusted analyses. After accounting for interpreter services costs, the estimated 119 readmissions averted during the intervention period were associated with estimated monthly hospital expenditure savings of $161,404. CONCLUSIONS:Comprehensive language access represents an important, high value service that all medical centers should provide to achieve equitable, quality healthcare for vulnerable LEP populations.

BACKGROUND:Limited English-proficient patients suffer poorer quality of care and outcomes. Interpreters can ameliorate these disparities; however, evidence is lacking on the quality of different interpretation modes. OBJECTIVE:Compare accuracy of interpretation for in-person (IP) professional, professional videoconferencing (VC), and ad hoc (AH) interpretation. DESIGN:A cross-sectional study of transcribed audiotaped primary care visits. SUBJECTS:Subjects included 32 Spanish-speaking Latino patients and 14 clinicians. MEASURES:Independent coding of transcripts by 4 coders (2 were internists) for accurate and inaccurate interpretation instances. Unit of analysis was a segment of continuous speech or text unit (TU). Two internists independently verified inaccurate interpretation instances and rated their clinical significance as clinically insignificant, mildly, moderately, or highly clinically significant. RESULTS:Accurate interpretation made up 70% of total coded TUs and inaccurate interpretation (errors) made up 30%. Inaccurate interpretation occurred at twice the rate for AH (54% of coded TUs) versus IP (25%) and VC (23%) interpretation, due to more errors of omission (P<0.001) and answers for patient or clinician (P<0.001). Mean number of errors per visit was 27, with 7.1% of errors rated as moderately/highly clinically significant. In adjusted models, the odds of inaccurate interpretation were lower for IP (OR=0.25, 95% CI, 0.19, 0.33) and VC (OR=0.31; 95% CI, 0.17, 0.56) than for AH interpreted visits; the odds of a moderately/highly clinically significant error were lower for IP (OR=0.25; 95% CI, 0.06, 0.99) than for AH interpreted visits. CONCLUSIONS:Inaccurate language interpretation in medical encounters is common and more frequent when untrained interpreters are used compared with professional IP or through VC. Professional VC interpretation may increase access to higher quality medical interpretation services.

BackgroundLanguage barriers disrupt communication and impede informed consent for patients with limited English proficiency (LEP) undergoing healthcare procedures. Effective interventions for this disparity remain unclear.ObjectiveAssess the impact of a bedside interpreter phone system intervention on informed consent for patients with LEP and compare outcomes to those of English speakers.DesignProspective, pre-post intervention implementation study using propensity analysis.SubjectsHospitalized patients undergoing invasive procedures on the cardiovascular, general surgery or orthopedic surgery floors.InterventionInstallation of dual-handset interpreter phones at every bedside enabling 24-h immediate access to professional interpreters.Main MeasuresPrimary predictor: pre- vs. post-implementation group; secondary predictor: post-implementation patients with LEP vs. English speakers. Primary outcomes: three central informed consent elements, patient-reported understanding of the (1) reasons for and (2) risks of the procedure and (3) having had all questions answered. We considered consent adequately informed when all three elements were met.Key ResultsWe enrolled 152 Chinese- and Spanish-speaking patients with LEP (84 pre- and 68 post-implementation) and 86 English speakers. Post-implementation (vs. pre-implementation) patients with LEP were more likely to meet criteria for adequately informed consent (54% vs. 29%, p = 0.001) and, after propensity score adjustment, had significantly higher odds of adequately informed consent (AOR 2.56; 95% CI, 1.15–5.72) as well as of each consent element individually. However, compared to post-implementation English speakers, post-implementation patients with LEP had significantly lower adjusted odds of adequately informed consent (AOR, 0.38; 95% CI, 0.16–0.91).ConclusionsA bedside interpreter phone system intervention to increase rapid access to professional interpreters was associated with improvements in patient-reported informed consent and should be considered by hospitals seeking to improve care for patients with LEP; however, these improvements did not eliminate the language-based disparity. Additional clinician educational interventions and more language-concordant care may be necessary for informed consent to equal that for English speakers.

Background: Effective communication at hospital discharge is necessary for an optimal transition and to avoid adverse events. We investigated the association of a language barrier with patient understanding of discharge instructions. Methods: Spanish-speaking, Chinese-speaking, and English-speaking patients admitted to 2 urban hospitals between 2005 and 2008, comparing patient understanding of follow-up appointment type, and medication category and purpose between limited English-proficient (LEP) and English-proficient patients. Results: Of the 308 patients, 203 were LEP. Rates of understanding were low overall for follow-up appointment type (56%) and the 3 medication outcomes (category 48%, purpose 55%, both 41%). In unadjusted analysis, LEP patients were less likely than English-proficient patients to know appointment type (50% vs. 66%; P=0.01), medication category (45% vs. 54%; P=0.05), and medication category and purpose combined (38% vs. 47%; P=0.04), but equally likely to know medication purpose alone. These results persisted in the adjusted models for medication outcomes: LEP patients had lower odds of understanding medication category (odds ratio 0.63; 95% confidence interval, 0.42—0.95); and category/purpose (odds ratio 0.59; 95% confidence interval, 0.39—0.89). Conclusions: Understanding of appointment type and medications after discharge was low, with LEP patients demonstrating worse understanding of medications. System interventions to improve communication at hospital discharge for all patients, and especially those with LEP, are needed.

BackgroundThere are many interventions to facilitate seamless continuity of care for patients in transition from hospital back to primary care; however, disparities remain in readmission rates for vulnerable populations, especially African-Americans.ObjectivesWe set out to investigate the association of race and ethnicity with 30-day readmission in our urban academic setting and to identify factors that could be leveraged in primary care to address disparities in hospitalizations.Methods/ApproachUsing data originally collected for quality improvement purposes, we evaluated 30-day readmission rates for our primary care patients (January 1, 2013–September 30, 2014) by race and ethnicity, adjusting for demographic and clinical characteristics. Then, using inductive and deductive methods, we coded semi-structured interviews with 24 African-American primary care patients who were discharged from the Medicine or Cardiology service at our tertiary care hospital during the study period.Key ResultsAfrican-Americans had the highest readmission rate (21.7%) and a higher adjusted odds of readmission (1.37; 95% CI 1.04–1.81) compared to Whites. Five major themes emerged as having potential to be leveraged in primary care to help prevent multiple hospitalizations: (1) dependable patient-physician relationships, (2) healthcare coordination across settings, (3) continuity with one primary care provider (PCP), (4) disease self-management, and (5) trust in resident physicians. Participants also made several recommendations to keep patients like themselves from returning to the hospital: increased time to tell their story during their primary care visit, more direct patient-physician communication during the visit, and improved access between visits.ConclusionsWhile African-American patients in our practice experience higher rates of hospital readmissions than their White counterparts, they emphasize the significance of their PCP relationship and communication to enhance disease management and prevent hospitalizations. Ongoing efforts are needed to establish and implement best practice communication trainings for patients at increased risk of hospitalization, particularly for resident physicians.

BackgroundEthnic minorities who present with mental health symptoms in primary care are less likely to receive treatment than non-Hispanic whites; language barriers may magnify this disparity.ObjectiveWe examined the contributions of ethnicity, gender, and English proficiency to unmet mental health need.DesignCross-sectional study.ParticipantsChinese and Latino primary care patients with a preferred language of English, Cantonese, Mandarin, or Spanish.Main MeasuresParticipants were interviewed within 1 week of a primary care visit and asked whether in the prior year they (1) needed help with emotional or mental health symptoms and (2) had seen a primary care physician or a mental health professional for these symptoms. Among those who reported “mental health need,” we defined “unmet mental health need” as no reported use of services for these symptoms. Regression models explored independent and interaction effects among ethnicity, gender, and English proficiency, on the two outcomes.Key ResultsAmong 1149 participants (62% women; 262 Chinese, with English proficiency [EP], 532 Chinese, with limited English proficiency [LEP], 172 Latino with EP; and 183 Latino with LEP), 33% reported mental health need. Among Chinese, but not Latino, participants, those with LEP were more likely than those with EP to report mental health need (AOR 2.55, 95% CI 1.73–3.76). Women were more likely to report mental health need than men (AOR 1.35, 1.03–1.79) regardless of ethnicity or English proficiency. Among participants reporting mental health need, 41% had unmet mental health need. Men with LEP, compared with those with EP, were more likely to have unmet mental health need regardless of ethnicity (AOR 2.53, 1.06–6.04).ConclusionsWe found high levels of mental health symptoms and unmet mental health need in both Chinese and Latino primary care patients. These results affirm the need to implement depression screening and targeted treatment interventions for patient subgroups at highest risk of untreated symptoms, such as men with LEP.

Limited English proficiency is associated with decreased access to ambulatory care, however, it is unclear if this disparity leads to increased use of emergency departments (EDs) for low severity ambulatory care sensitive conditions (ACSCs). We sought to determine the association between the patient's preferred language and hospital utilization for ACSCs. We conducted a retrospective cohort study of all ED visits in New Jersey in 2013 and 2014. The primary outcome was hospital admission for acute ACSCs, chronic ACSCs, and fractures (a nonambulatory care sensitive control condition). Secondary outcomes included intensive care unit (ICU) utilization and length of stay. Mixed-effect regression models estimated the association between preferred language (English vs. non-English) and study outcomes, controlling for demographics, comorbidities, and hospital characteristics. We examined 201,351 ED visits for acute ACSCs, 251,193 visits for chronic ACSCs, and 148,428 visits for fractures, of which 13.5%, 11.1%, and 9.9%, respectively, were by non-English speakers. In adjusted analyses, non-English speakers were less likely to be admitted for acute ACSCs [-3.1%; 95% confidence interval (CI), -3.6% to -2.5%] and chronic ACSCs (-2.3%; 95% CI, -2.8% to -1.7%) but not fractures (0.4%; 95% CI, -0.2% to 1.0%). Among hospitalized patients, non-English speakers were less likely to receive ICU services but had no difference in length of stay. These findings suggest non-English-speaking patients may seek ED care for lower acuity ACSCs than English-speaking patients. Efforts to decrease preventable ED and increase access to ambulatory care use should consider the needs of non-English-speaking patients.

Background Language concordance can increase access to care for patients with language barriers and improve patient health outcomes. However, systematically assessing and tracking physician non-English language skills remains uncommon in most health systems. This is a missed opportunity for health systems to maximize language-concordant care. Objective To determine barriers and facilitators to participation in non-English language proficiency assessment among primary care physicians. Design Qualitative, semi-structured interviews. Participants Eleven fully and partially bilingual primary care physicians from a large academic health system with a language certification program (using a clinician oral proficiency interview). Approach Interviews aimed to identify barriers and facilitators to participation in non-English language assessment. Two researchers independently and iteratively coded transcripts using a thematic analysis approach with constant comparison to identify themes. Key Results Most participants were women ( N = 9; 82%). Participants reported proficiency in Cantonese, Mandarin, Russian, and Spanish. All fully bilingual participants ( n =5) had passed the language assessment; of the partially bilingual participants ( n =6), four did not test, one passed with marginal proficiency, and one did not pass. Three themes emerged as barriers to assessment participation: (1) beliefs about the negative consequences (emotional and material) of not passing the test, (2) time constraints and competing demands, and (3) challenging test format and structure. Four themes emerged as facilitators to increase assessment adoption: (1) messaging consistent with professional ethos, (2) organizational culture that incentivizes certification, (3) personal empowerment about language proficiency, and (4) individuals championing certification. Conclusions To increase language assessment participation and thus ensure quality language-concordant care, health systems must address the identified barriers physicians experience and leverage potential facilitators. Findings can inform health system interventions to standardize the requirements and process, increase transparency, provide resources for preparation and remediation, utilize messaging focused on patient care quality and safety, and incentivize participation.

ABSTRACT BACKGROUND Professional interpreter use improves the quality of care for patients with limited English proficiency (LEP), but little is known about interpreter use in the hospital. OBJECTIVE Evaluate interpreter use for clinical encounters in the hospital. DESIGN Cross-sectional. PARTICIPANTS Hospitalized Spanish and Chinese-speaking LEP patients. MAIN MEASURES Patient reported use of interpreters during hospitalization. KEY RESULTS Among 234 patients, 57% reported that any kind of interpreter was present with the physician at admission, 60% with physicians during hospitalization, and 37% with nurses since admission. The use of professional interpreters with physicians was infrequent overall (17% at admission and 14% since admission), but even less common for encounters with nurses (4%, p < 0.0001). Use of a family member, friend or other patient as interpreter was more common with physicians (28% at admission, 23% since admission) than with nurses (18%, p = 0.008). Few patients reported that physicians spoke their language well (19% at admission, 12% since admission) and even fewer reported that nurses spoke their language well (6%, p = 0.0001). Patients were more likely to report that they either “got by” without an interpreter or were barely spoken to at all with nurses (38%) than with physicians at admission (14%) or since admission (15%, p < 0.0001). CONCLUSIONS Interpreter use varied by type of clinical contact, but was overall more common with physicians than with nurses. Professional interpreters were rarely used. With physicians, use of ad hoc interpreters such as family or friends was most common; with nurses, patients often reported, “getting by” without an interpreter or barely speaking at all.

The prevalence of functional impairment is increasing among middle-aged adults and is associated with adverse health outcomes. Primary care providers (PCPs) and geriatricians may have important insights about optimal approaches to caring for these patients, but little is known about their perspectives. To examine PCPs' and geriatricians' perspectives on clinical needs and optimal approaches to care for middle-aged patients with functional impairment. Qualitative study using semi-structured interviews. PCPs and geriatricians from outpatient practices in the San Francisco Bay area. Interviews focused on characteristics and care needs of middle-aged patients with functional impairment and models of care to address these needs. We analyzed interviews using hybrid deductive-inductive qualitative thematic analysis. Clinicians (14 PCPs, 15 geriatricians) described distinct characteristics of functional impairment in middle-aged versus older adults, such as different rates of onset, but similar clinical needs. Despite these similar needs, clinicians identified age-specific barriers to delivering optimal care to middle-aged patients. These included system-level challenges such as limited access to insurance and social services; practice- and clinician-level barriers including inadequate clinician training; and patient-level factors including less access to family caregivers and perceptions of stigma. To overcome these challenges, clinicians suggested clinical approaches including addressing health-related social needs within healthcare systems; implementing practice-based models that are multi-disciplinary, team-based, and coordinated; training clinicians to effectively manage functional impairment; and expanding community-based services and supports to help patients navigate the medical system. Identified needs, challenges, and solutions were generally similar across geriatricians and PCPs. Clinicians face challenges in delivering optimal care to middle-aged patients who have functional impairments similar to their older counterparts but lack access to services and supports available to older people. These findings suggest the importance of increasing access to care models that address functional impairment regardless of age.