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When patients and physicians speak the same language, it may improve the quality and safety of care delivered. We sought to determine whether patient–physician language concordance is associated with in-hospital and postdischarge outcomes among home care recipients who were admitted to hospital. We conducted a population-based study of a retrospective cohort of 189 690 home care recipients who were admitted to hospital in Ontario, Canada, between 2010 and 2018. We defined patient language (obtained from home care assessments) as English (Anglophone), French (Francophone) or other (allophone). We obtained physician language from the College of Physicians and Surgeons of Ontario. We defined hospital admissions as language concordant when patients received more than 50% of their care from physicians who spoke the patients’ primary language. We identified in-hospital (adverse events, length of stay, death) and post-discharge outcomes (emergency department visits, readmissions, death within 30 days of discharge). We used regression analyses to estimate the adjusted rate of mean and the adjusted odds ratio (OR) of each outcome, stratified by patient language, to assess the impact of language-concordant care within each linguistic group. Allophone patients who received language-concordant care had lower risk of adverse events (adjusted OR 0.25, 95% confidence interval [CI] 0.15–0.43) and in-hospital death (adjusted OR 0.44, 95% CI 0.29–0.66), as well as shorter stays in hospital (adjusted rate of mean 0.74, 95% CI 0.66–0.83) than allophone patients who received language-discordant care. Results were similar for Francophone patients, although the magnitude of the effect was smaller than for allophone patients. Language concordance or discordance of the hospital admission was not associated with significant differences in postdischarge outcomes. Patients who received most of their care from physicians who spoke the patients’ primary language had better in-hospital outcomes, suggesting that disparities across linguistic groups could be mitigated by providing patients with language-concordant care.

Background Language barriers can impact health care and outcomes. Valid and reliable language data is central to studying health inequalities in linguistic minorities. In Canada, language variables are available in administrative health databases; however, the validity of these variables has not been studied. This study assessed concordance between language variables from administrative health databases and language variables from the Canadian Community Health Survey (CCHS) to identify Francophones in Ontario. Methods An Ontario combined sample of CCHS cycles from 2000 to 2012 (from participants who consented to link their data) was individually linked to three administrative databases (home care, long-term care [LTC], and mental health admissions). In total, 27,111 respondents had at least one encounter in one of the three databases. Language spoken at home (LOSH) and first official language spoken (FOLS) from CCHS were used as reference standards to assess their concordance with the language variables in administrative health databases, using the Cohen kappa, sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV). Results Language variables from home care and LTC databases had the highest agreement with LOSH (kappa = 0.76 [95%CI, 0.735–0.793] and 0.75 [95%CI, 0.70–0.80], respectively) and FOLS (kappa = 0.66 for both). Sensitivity was higher with LOSH as the reference standard (75.5% [95%CI, 71.6–79.0] and 74.2% [95%CI, 67.3–80.1] for home care and LTC, respectively). With FOLS as the reference standard, the language variables in both data sources had modest sensitivity (53.1% [95%CI, 49.8–56.4] and 54.1% [95%CI, 48.3–59.7] in home care and LTC, respectively) but very high specificity (99.8% [95%CI, 99.7–99.9] and 99.6% [95%CI, 99.4–99.8]) and predictive values. The language variable from mental health admissions had poor agreement with all language variables in the CCHS. Conclusions Language variables in home care and LTC health databases were most consistent with the language often spoken at home. Studies using language variables from administrative data can use the sensitivity and specificity reported from this study to gauge the level of mis-ascertainment error and the resulting bias.

Background Appropriate use of medication is a key indicator of the quality of care provided in long-term care (LTC). The objective of this study was to determine whether resident-facility language concordance/discordance is associated with the odds of potentially inappropriate prescribing of antipsychotics (PIP-AP) in LTC. Methods We conducted a population-based, retrospective cohort study of LTC residents in Ontario, Canada from 2010 to 2019. We obtained resident language from standardized resident assessments, and derived facility language by determining the proportion of residents belonging to each linguistic group within individual LTC homes. Using linked administrative databases, we identified all instances of PIP-AP during a 1-year follow-up period. PIP-AP was defined using the STOPP-START criteria, which have previously been shown to predict adverse clinical events such as emergency department (ED) visits and hospitalizations. The association between linguistic factors and PIP-AP was assessed using adjusted multivariable logistic regression analysis. Results We identified 198,729 LTC residents consisting of 162,814 Anglophones (81.9%), 6,230 Francophones (3.1%), and 29,685 Allophones (14.9%). The odds of PIP-AP of were higher for both Francophones (aOR 1.15, 95% CI 1.08–1.23) and Allophones (aOR 1.11, 95% CI 1.08–1.15) when compared to Anglophones. When compared to English LTC homes, French LTC homes had greater odds of PIP-AP (aOR 1.12, 95% CI 1.05–1.20), while Allophone homes had lower odds of PIP-AP (aOR 0.82, 95% CI 0.77–0.86). Residents living in language-discordant LTC homes had higher odds of PIP-AP when compared to LTC residents living in language-concordant LTC homes (aOR 1.07, 95% CI 1.04–1.10). Conclusion This study identified linguistic factors related to the odds of PIP-AP in LTC, suggesting that the linguistic environment may have an impact on the quality of care provided to residents.

Background Patients who live in minority language situations are generally more likely to experience poor health outcomes, including harmful events. The delivery of healthcare services in a language-concordant environment has been shown to mitigate the risk of poor health outcomes related to chronic disease management in primary care. However, data assessing the impact of language-concordance on the risk of in-hospital harm are lacking. We conducted a population-based study to determine whether admission to a language-discordant hospital is a risk factor for in-hospital harm. Methods We used linked administrative health records to establish a retrospective cohort of home care recipients (from 2007 to 2015) who were admitted to a hospital in Eastern or North-Eastern Ontario, Canada. Patient language (obtained from home care assessments) was coded as English (Anglophone group), French (Francophone group), or other (Allophone group); hospital language (English or bilingual) was obtained using language designation status according to the French Language Services Act . We identified in-hospital harmful events using the Hospital Harm Indicator developed by the Canadian Institute for Health Information. Results The proportion of hospitalizations with at least 1 harmful event was greater for Allophones (7.63%) than for Anglophones (6.29%, p  <  0.001) and Francophones (6.15%, p  <  0.001). Overall, Allophones admitted to hospitals required by law to provide services in both French and English ( bilingual hospitals ) had the highest rate of harm (9.16%), while Francophones admitted to these same hospitals had the lowest rate of harm (5.93%). In the unadjusted analysis, Francophones were less likely to experience harm in bilingual hospitals than in hospitals that were not required by law to provide services in French ( English-speaking hospitals) (RR = 0.88, p  = 0.048); the opposite was true for Anglophones and Allophones, who were more likely to experience harm in bilingual hospitals (RR = 1.17, p  <  0.001 and RR = 1.41, p  <  0.001, respectively). The risk of harm was not significant in the adjusted analysis. Conclusions Home care recipients residing in Eastern and North-Eastern Ontario were more likely to experience harm in language-discordant hospitals, but the risk of harm did not persist after adjusting for confounding variables.

Dynamic CT angiography (dCTA) contrast extravasation, known as the \"dynamic spot sign\", can predict hematoma expansion (HE) in intracerebral hemorrhage (ICH). Recent reports suggest the phase of spot sign appearance is related to the magnitude of HE. We used dCTA to explore the association between the phase of spot sign appearance and HE, clinical outcome, and contrast extravasation rates. We assessed consecutive patients who presented with primary ICH within 4.5 hours from symptom onset who underwent a standardized dCTA protocol and were spot sign positive. The independent variable was the phase of spot sign appearance. The primary outcome was significant HE (either 6 mL or 33% growth). Secondary outcomes included total absolute HE, mortality, and discharge mRS. Mann-Whitney U, Fisher's exact test, and logistic regression were used, as appropriate. Of the 35 patients with spot signs, 27/35 (77%) appeared in the arterial phase and 8/35 (23%) appeared in the venous phase. Thirty patients had follow-up CT scans. Significant HE was seen in 14/23 (60.87%) and 3/7 (42.86%) of arterial and venous cohorts, respectively (p = 0.67). The sensitivity and specificity in predicting significant HE were 82% and 31% for the arterial phase and 18% and 69% for the venous phase, respectively. There was a non-significant trend towards greater total HE, in-hospital mortality, and discharge mRS of 4-6 in the arterial spot sign cohort. Arterial spot signs demonstrated a higher median contrast extravasation rate (0.137 mL/min) compared to venous spot signs (0.109 mL/min). Our exploratory analyses suggest that spot sign appearance in the arterial phase may be more likely associated with HE and poorer prognosis in ICH. This may be related to higher extravasation rates of arterial phase spot signs. However, further studies with larger sample sizes are warranted to confirm the findings.

Background The COVID-19 pandemic disproportionately affected frail individuals, especially those living in long-term care (LTC) homes. This study examined the role of linguistic factors on COVID-19 related outcomes in LTC homes. Methods We performed a population-based, retrospective cohort study of residents living in LTC homes in Ontario, Canada who were diagnosed with COVID-19 between March 31, 2020 and March 31, 2021. Resident language, obtained from LTC assessments, was used to classify residents into one of the three linguistic groups: Anglophone (English), Francophone (French), and allophone (other language). Language of the LTC home was determined using a person-time representation of the languages spoken by residents within each LTC home. We defined LTC facilities as French homes when Francophone residents contributed more than 25% of the person-days, and allophone homes when allophone residents contributed more than 50% of the person-days. Residents whose language corresponded to the language of the LTC home in which they were living were said to have received language-concordant care , while all other residents were said to have received language-discordant care. The outcomes of this study were ED visits, hospitalizations, and mortality within 90 days. Results We included a total of 26,829 LTC residents (20,315 Anglophones, 1,032 Francophones, and 5,482 allophones) living in 572 LTC homes (502 English, 28 French, 42 allophone) who were diagnosed with COVID-19. LTC residents who lived in language-discordant homes were more likely to have ED visits (adjusted HR 1.12, 95% CI 1.01–1.25) and hospitalizations (adjusted HR 1.15, 95% CI 1.02–1.29) when compared to LTC residents who lived in language-concordant homes. Residents-facility language discordance was not associated with overall mortality (adjusted HR 1.00, 95% CI 0.91–1.10) or in hospital mortality (adjusted HR 1.04, 95% CI 0.88–1.23). Conclusion Residents living in language-discordant LTC facilities experienced more ED visits and hospitalizations following diagnosis of COVID-19. The findings of this study highlight the importance of providing frail, vulnerable individuals with linguistically concordant care.

Background Prior studies have demonstrated the negative impact of language barriers on access, quality, and safety of healthcare, which can lead to health disparities in linguistic minorities. As the population ages, those with multiple chronic diseases will require increasing levels of home care and long-term services. This study described the levels of multimorbidity among recipients of home care in Ontario, Canada by linguistic group. Methods Population-based retrospective cohort of 510,685 adults receiving home care between April 1, 2010, to March 31, 2018, in Ontario, Canada. We estimated and compared prevalence and characteristics of multimorbidity (2 or more chronic diseases) across linguistic groups (Francophones, Anglophones, Allophones). The most common combinations and clustering of chronic diseases were examined. Logistic regression models were used to explore the main predictors of ‘severe’ multimorbidity (defined as the presence of five or more chronic diseases). Results The proportion of home care recipients with multimorbidity and severe multimorbidity was 92% and 44%, respectively. The prevalence of multimorbidity was slightly higher among Allophones (93.6%) than among Anglophones (91.8%) and Francophones (92.4%). However, Francophones had higher rates of cardiovascular and respiratory disease (64.9%) when compared to Anglophones (60.2%) and Allophones (61.5%), while Anglophones had higher rates of cancer (34.2%) when compared to Francophones (25.2%) and Allophones (24.3%). Relative to Anglophones, Allophones were more likely to have severe multimorbidity (adjusted OR = 1.04, [95% CI: 1.02–1.06]). Conclusions The prevalence of multimorbidity among Ontarians receiving home care services is high; especially for whose primary language is a language other than English or French (i.e., Allophones). Understanding differences in the prevalence and characteristics of multimorbidity across linguistic groups will help tailor healthcare services to the unique needs of patients living in minority linguistic situations.

Background Hospitalizations carry considerable risks for frail, elderly patients; this is especially true for patients with dementia, who are more likely to experience delirium, falls, functional decline, iatrogenic complications, and infections when compared to their peers without dementia. Since up to two thirds of patients in long-term care (LTC) facilities have dementia, there is interest in identifying factors associated with transitions from LTC facilities to hospitals. The purpose of this study was to investigate the association between dementia status and incidence of hospitalization among residents in LTC facilities in Ontario, Canada, and to determine whether this association is modified by linguistic factors. Methods We used linked administrative databases to establish a prevalent cohort of 81,188 residents in 628 LTC facilities from April 1st 2014 to March 31, 2017. Diagnoses of dementia were identified with a previously validated algorithm; all other patient characteristics were obtained from in-person assessments. Residents’ primary language was coded as English or French; facility language (English or French) was determined using language designation status according to the French Language Services Act . We identified all hospitalizations within 3 months of the first assessment performed after April 1st 2014. We performed multivariate logistic regression analyses to determine the impact of dementia and resident language on the incidence of hospitalization; we also considered interactions between dementia and both resident language and resident-facility language discordance. Results The odds of hospitalization were 39% lower for residents with dementia compared to residents without dementia (OR 0.61, 95% CI 0.57–0.65). Francophones had lower odds of hospitalization than Anglophones, but this difference was not statistically significant (OR 0.91, 95% CI 0.81–1.03). However, Francophones without dementia were significantly less likely to be hospitalized compared to Anglophones without dementia (OR 0.71, 95% CI 0.53–0.94). Resident-facility language discordance did not significantly affect hospitalizations. Conclusions Residents in LTC facilities were generally less likely to be hospitalized if they had dementia, or if their primary language was French and they did not have dementia. These findings could be explained by differences in end-of-life care goals; however, they could also be the result of poor patient-provider communication.

Lorsque les patients et les médecins parlent la même langue, cela peut améliorer la qualité et la sécurité des soins. Nous avons voulu vérifier si la concordance linguistique patient–médecin est associée à des résultats en milieu hospitalier et posthospitaliers chez les bénéficiaires de soins à domicile qui doivent être hospitalisés. Nous avons procédé à une étude de population auprès d’une cohorte rétrospective de 189 690 bénéficiaires de soins à domicile qui ont été admis à l’hôpital en Ontario, au Canada, entre 2010 et 2018. Nous avons défini la langue des patients (obtenue à partir des évaluations pour les soins à domicile) comme anglaise (anglophones), française (francophones) ou autre (allophones). Nous avons obtenu la langue des médecins auprès de l’Ordre des médecins et chirurgiens de l’Ontario. Nous avons déterminé que les hospitalisations se déroulaient dans un milieu de concordance linguistique lorsque les patients recevaient plus de 50 % de leurs soins de la part de médecins s’exprimant dans la même langue qu’eux (langue principale). Nous avons défini les paramètres en milieu hospitalier (événements indésirables, durée du séjour, décès) et posthospitaliers (consultations aux services des urgences, réadmissions hospitalières, décès dans les 30 jours suivant le congé). Nous avons utilisé des analyses de régression logistique pour estimer la moyenne ajustée et le rapport des cotes (RC) ajusté de chaque paramètre, stratifié en fonction de la langue des patients pour évaluer l’impact des soins linguistiquement concordants dans chaque groupe linguistique. Les patients allophones qui ont reçu des soins linguistiquement concordants plutôt que discordants présentaient un risque moindre d’événements indésirables (RC ajusté 0,25, intervalle de confiance [IC] de 95 % 0,15–0,43) et de décès en milieu hospitalier (RC ajusté 0,44, IC de 95 % 0,29–0,66), et leurs séjours ont été moins longs (moyenne ajustée 0,74, IC de 95 % 0,66–0,83). Les résultats ont été similaires pour les patients francophones, quoiqu’à un degré moindre. La concordance ou la discordance linguistique des hospitalisations n’a pas été associée à des différences significatives sur le plan des paramètres posthospitaliers. Les patients ayant reçu la majeure partie de leurs soins de médecins s’exprimant dans la même langue qu’eux (langue principale) ont eu de meilleurs résultats en milieu hospitalier, ce qui suggère que les disparités entre les groupes linguistiques pourraient être atténuées en offrant aux patients des soins linguistiquement concordants.

We have proposed that three scientific criteria are important for the ethical justification of randomized clinical trials (RCTs): (1) they should be designed around a clear hypothesis; (2) uncertainty should exist around that hypothesis; (3) that uncertainty should be as established through a systematic review. We hypothesized that the majority of a sample of recently published RCTs would not explicitly incorporate these criteria, therefore rendering them potentially unjustified on scientific grounds. Cross-sectional analysis of all RCTs published in the New England Journal of Medicine and the Journal of the American Medical Association in 2015. Each article and protocol was reviewed for: (1) a clearly stated central hypothesis; (2) references to “equipoise,” or “consensus;” (3) some indication of evidentiary uncertainty; (4) a meta-analysis or systematic review surrounding the hypothesis or study question. We included 208 RCT articles and 199 protocols. Among combined articles and protocols, 76% had a clearly stated hypothesis, 99% referenced some form of uncertainty, and 54% cited a relevant systematic review or meta-analysis. Only 44% of combined texts contained all three scientific criteria. There were few references to “equipoise” (10%) or “consensus” (11%), and those references to equipoise were most often inconsistent with accepted definitions. The majority of RCTs (56%) did not meet the three scientific criteria described previously and therefore may be scientifically and therefore ethically unjustified. We recommend that “equipoise,” “clinical equipoise,” and “lack of consensus” be abandoned as scientific criteria for RCTs and be replaced by an expectation that RCTs have a clearly stated, meaningful hypothesis around which uncertainty has been established through a systematic review of the literature.